HomeMy WebLinkAbout0125 WINTERGREEN CIRCLE - Health J
125 Wintergreen Circle
Osterville'. P
A = 119 071
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a
L '`'TOWN OF BARNS TABLE
LOCATION (IL. SEWAGE# ZQZO
VILLAGEOSTE9V(ILC— ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO. 6a r 3• 0t,"e G. )OR- 77
SEPTIC TANK CAPACITY 100O ZO.
LEACHING FACILITY.(type) 500 A&3.CI+Amg (size) ZSX 12.83
NO.OF BEDROOMS 3
OWNER -)PtyVke-S S La-p 2E14 P<wr
PERMIT DATE: a( I 2g zn COMPLIANCE DATE: 10� O
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility do ® 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
C a
ks
.Z to
3 9 3
2 42.3 q 3 39.(o 33.3 g
9 3(e 31. 4
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.41 38.5
9t.� - �It•1
i
No. 26 ;O v r/ Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Rppl.tatlon for Misposal *pstem Construction i3Prmit
Application for a Permit to Construct( ) Repair()6) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 1 aS UWi.WtevN 6 je- Owner's Name,Address,and Tel.No.
OShrvil%e. MAI ouss �5� —776-1300
Assessor's Map/Parcel jig �qM I S V f t'��k A/ tt-
Installer's Name,Address,and Tel.No. �( MNIV6 �, Designer's Name,Address,and Tel.No. S� 73-0377
RO)D rA % DiA . Trx(� S08-g77-8977 TL dKV Crotnbtcry 01py WM h-q
Type of Building:
Dwelling No.of Bedrooms *3 Lot Size 10221 10, sq.ft. Garbage Grinder( )
Other Type of Building R45144"z,\ No.of Persons Showers( ) Cafeteria( )
Other Fixtures 2
Design Flow(min.required) '5 o gpd Design flow provided y� gpd
Plan Date gill Number of sheets 1 Revision Date
Title Size of Septic Tank 1000 6 cA n Type of S.A.S. A C,6- L.-e&c, ,:nNq Ckc,,nbA4S
Description of Soil (VI e tV vy% r%dA she t0��✓1
Nature of Repairs or Alterations(Answer when applicable) neW D--90Y e ��SU� be,1100 f'Q-64$'-j�
�Q &Y-6� if)1 1000 g6tk n Se,Q1=1,C k-Ctn k
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. Q
Signed Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. a-o ;1-o �� � Date Issued
4 .t p�)
:2O '3 615 ��+ ���, Fee
'• j Entered in computer: /
4 THE COMMONWEALTH OF MASSACHUSETTS
Q - PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ftplitation for -Misposal *pStem Construction Permit
Application for a Permit to Construct( ) Repair y) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
4
Location Address or Lot No. Owner's'Name,Address,and Tel.No.
OSferv11%a fn)Pv oabss-
Assessor's Map/Parcel t �q M .j V t rQnn S��7,6'�. 0
Installer's Name,Address,and Tel.No. tt3 W jN jVow Designer's Name,Address,and Tel.No. S L9- ;2 7?a-O 9J77
Robo Z VV2 . Tel(- SOSJ77 K77 ,Tc- f F a859 cron'twfy Ploy waReham
Type of Building: /� $
Dwelling No.of Bedrooms J Lot Size 122�p� o� sq.ft. Garbage Grinder( )
Other Type of Building R4.5-deAJ ,c,\ No.of Persons Showers.,( . ) Cafeteria( ) �-
__ Other Fixtures
Design Flow(min.required) 33o gpd Design flow provided gpd
Plan Date �{ ,�Q�p Number of sheets I Revision Date
Title
Size of Septic Tank o Type of S.A.S. proc"4 1-c+ar nc ti.�.M�J•�RS
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) new --90X ) . Ulf don pre-C4S�-
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction w4 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 c , , 1'1 Date '7=� y
Application Disapproved by Date
for the following reasons
Permit No. C) X-c.) — .,, - Date Issued:.;
JIV
y ,
----------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
GO BARNSTABLE, MA§SAtHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system,Constructed( ) Repaired( ) Upgraded(K)
Abandoned( )by 20100 r Q • 00 2
at ��4— )1A4C f4Qn 1 1L, QS6rVl11Q has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. ;0,�O -305 dated
Installer (tQflj, r( $ G V Q Tn� Designer i
#bedrooms Approved design flow 3 7 gpd
The issuance of this permit shall n�t be.construed as a guarantee that the system will f�unctto
_Ma 'ee
Date �(�� �-�. Inspector
------------- -------- - ----------.--. -:,::
No: 2v ?o•3 0j FeeC/
THE COMMONWEALTH OF MASSACHUSETTS
;-� PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Misposal 6pstem Construction Permit
Permission is hereby granted to Construct( ) Repair( ) Upgrade(x) Abandon( )
System located at I:kr,: W%4t 2hr yr\ Clock a4 cu16 01 a M&
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 Approved by
i
Town of Barnstable
Regulatory Services,
Richard V.Scali, Interim Director w ,
t aaRi WAB e
Public Health Division
'°rEer " Thomas McKean, Director '
200 Main Street,Hyannis,MA 02601 Z_
X
Office: 508-862-4644 Fax: 508-790-6304 ray
Installer,& Designer Certification Form
Date: 10-3-20 Sewage Permit# ZOZO -30S Assessor's Map\Parcel 119/71
Designer: Enn tine-ecin5, . Installer: Robert B. Our Co., Inc._(RBO)
Address: Z85y Croe&erry *Oja waj Address: 363 Whites Path
gnat Waft ltaM } Nib _d 253 8 South Yarmouth,MA
On ?� RBO .was issued a perinit to install a
(date - -) (tnsta-ter)
septic system at_125 Wintergreen Circle based on a design drawn.by
(address)
71C 605ii0eeCid1 TY1C dated 9-111-20
(designer)
X 1 certify that the septic system referenced above was installed substantially according
to the design, which may include minor approved changes such as lateral relocation of
the distribution box and/or septic tank. Strip out.(if required) was inspected and the
soils were found satisfactory.
I certify that the septic system referenced above was installed with .major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical.relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow. Strip out(if.required) was inspected and the soils
were found satisfactory.
I certify that the system referenced above was constructed i iance with the terms
of the BA approval letters(if applicable) `j,,,,rKC
�As
o���P S9cyo
w� JOWL R,
CHURCHILL Jit H
(Installer's ature): CML
.41
- p
�F
(D ner's Signature (Affx De` 1 p Here)
PL SE RETURN TO ARNSTABLE PUBLIC HEALTH DI
SION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BAR.iSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
QASeptic\Designer Certification Form Rev 8-14-13.doe
I
TOWN OF BARNSTABLE_Z,-
+
LOCATION ��� CNAt'q(PZ^ Glrc._ SEWAGE #
I -=
VILLAGE o sr ry.IL ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY I C TJI� GAI
(� ' ire_ �•,I.
LEACHING FACILITY: (type) t + 6 X(y (size)
NO.OF BEDROOMS
BUILDER OR OWNER M)GP1 rQ� l �10
PERMITDATE: 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 leachi g facility) Feet
Furnished by Z/�S(��.y`+On �DrC,
I
W -
OD
y V
TOWN OF BARNSTABLE
.LOCATION I !il/dl+ SEWAGE#
Vi'LAGE,,, 9 �-s ASSESSOR'S MAP &LOT a '
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER ��'®fl/,� '�l�l�lsf/Ke
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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LdCATION SEWAGE PERMIT NQ.
VILLAGE
INSTALLER NAME 8 ADDRESS
� SUILDER OR 0w ER
DA T E PERMIT ISS" E, hv
DAT E COMPLIANCE ISSUED �J/g/
6LIfK 7�
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No.......'.............. .................
TM-COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7 _AF;,-- --------
.............OF.........
Appliration for Dispaiial Workii Tomummin Vamit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
... ........
.........................................................
Location-Address or . 4
...i..�..7......I.At�...........
C)L.�;..... j
.5........... ...............
d
Ow 10 L MW ........................
----------------- ................... .. .. .......
Ins a Address
Type of- ;ttiild -7 Size ...Sq. feet
U 2
Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder
Other—Type of Building ............................ No. of persons............................ Showers Cafeteria
PL4
04 Other fi5tu es .....................................................................................................................................................
< L I _,Z
.......................
Design Flow................. gallons per person per day. Total daily flow............................................gallons.
1:4 Septic Tank—Liquid capacity.1pep.-gallons Length_�17... Width................ Diameter-______--_______ Depth.....__......_..
Disposal Trench—No..................... Width_....__............. Total Length.._.. ........_..Total leaching area....................sq. ft.
Seepage Pit No ------------ Diameter...._P7:--------- Depth below inlet.....- �........ Total leaching areazo_.45.sq. ft.
Z Other Distribution box (vl) Dosing tank ( )
Performed by...O.Ag 14,Y_....M3jec Percolation Test Results Date......................
Test Pit No. 1.... -____minutes per inch Depth of Test pit......1y....... Depth to ground water..!V.001r-�7----
fxq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......_____.___......__.
................)..................... 4------------- -----------**"*------------------------------ ................
0 Description of Soil.............0. ...........7T.V. tT
............. .............I........................
----------------------*-----------*------------------------------------------------------------------------------------------------------------------------------------------------------------
........................................................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
................................ .................................................................................................................................
Agreement:
The undersigned agrees to install the foredescribed IndivAal Sewage Disposal System in accordance with
the provisions of TAITA!L- 5 of the State Sanitary Code—The u d signed further agrees not to place the system in
operation until a Certificate of Compliance has bee i u d,b oar health.
Signed---..- ................................... .....)?)//- --- ------ --
t
ApplicationApproved By------------- ........ .4 .......................................... ........ .. ... ...-----------
Date
Application Disapproved for the following reasons. ............................................................................................................
........................................................................................................................................................................................................
Date
PermitNo............. ................. Issued.......................................................
Date
No. ...... ......`:.... FE$.•.........._............
TFof COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
L,TH
� .. -OF........ 11.i2. ..� !'1 ��e ..............................
Appliration for Dispniiai Workii Tomi#rurtion Permit
Application is hereby made for a Permit to Construct (✓ ) or Repair ( ) an Individual Sewage Disposal
System at:
� , -
. �.1.11r1%]?<_r ice,�_ G E i! ;: t ( f Z\/!-� -T............ .......... ....
- ----- .
Location-Address or Lot No. 'S
'.: �............... 5. .... ?.....LETN... .`.. .......
...----•-.. ---
Ow r off..............f.. .........L. ---Address r
Je-
Iasta ler Address
dType of Building Size Lot__4�./_Z.1_.Z-:_._.Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures -----------------------•--•----• -----"--------------------- ------
•---------------------------
W Design Flow..............?_` ........................gallons per person per day. Total daily flow.......... ...................
WSeptic Tank—Liquid capacityVM..gallons Length�_P--___ Width................ Diameter--------------.. Depth................
x Disposal Trench—No.--..--•----•--_--•-- Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No......)------------- Diameter----�_2------------ Depth below inlet.... ......... Total leaching areal-,_&_&.sq. ft.
Z Other Distribution box (✓ ) Dosing tank ( )
'-' Percolation Test Results Performed -------------------- - G, - 7�- .........
Date------•----------------
,aa Test Pit No. 1... .......minutes per inch Depth of Test Pit.....1. ........... Depth to ground water.?Uu! ..
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.-.__-_-___--__-----___-
R,' •--•••....................••-•••-••..I.....--•--•.... ---........-•---•---•--......-----I---------......--•------•----•----••-----•-•-........--••••--.••---
O Description of Soil. r�- .- IV � -5 1��5 1••l.-f +......................1 Iv_.�..a/ `�lV.D-
W -••---•---•------ ----------•------"----------------•-"----------------"..._........----"-""-----•---------"--"---....._......------------...---•--"------•--------"----"---------•-----•-..........--•-
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Indio' I ial Sewage Disposal System in accordance with
the provisions of'ITLL 5 of the State Sanitary Code— The rsigned further agrees not to place the system in
operation until a Certificate of Compliance has be '?issued by,,l/t oa�rd f health. /
Signed-
�v ate^
� Date
Application Approved B =t .......................................................... `_� '�' - -----•---
APplieation Disapproved for the following reasons•i, -----------------••-------------------------------------------------------------------•-.---.-•-------
....-•-------•--••----•...-•-•-••--•---•-•--•--•----•--•-----•-----•--•••---•---•-•-----•--•-•-......•••.-•--••-•••----•-----••---•------•-••----••--••--•-•---•-•-•••••-•-----------•••--•••......---•-
Date
PermitNo.......................................................... Issued-.......................................................
Date
S
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
'".........OF...", : ./G/..... .::.. ...................
C�rr�i�irtt#e u$ ��a�t��i�nr�e
T IS IS TO CERTIFY, That the Individual Sewage Disposal System constructed - or Repaired ( )
�c r r .. v� • -------•------•------•-••---•----...--•--•-----•-••-.....
by r b ra- = ....... .. `p�" --� -I- C A
� Inst�er J f ��}
at..........k�.. . / �• �-t�-t� '--1� .£ _.. ',i.Y..rC_,.�c ..... Lam••-.? t`I
has been installed in accordance with the provisions of TITLE�,r�of .The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.__-__--__----_--j_�'f--•--__----_- dated................................................'',
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. ,,�� /'
DATE.......................................11101d�--�----------------- Inspector.------/'�.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
t1- % 5✓ "` ,,�,p''`.................OF.. ., .. ''4j:f.P'� ..
No......................... FEE..... .............
i n 1 kii Tuntrnrt#ion ermit
h b
tip fPermission is - i to C truct or Re air ( ) an Individual Sewage Disposal System��
at Noon .e?�.�.-_.......
..............................................................
Street
as shown on the application for Disposal Works Construction Permit No..................'_,Dated................................._........
r
----•........................... Board of Health
- DATE................................................................................ �/'
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
MeT
SITE PLAt
CA-
! K..40
14 In
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VIoT - v�, o
40
low G.A �pCIG Tm.
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of tmd4s
WILLIAM M, �\e
WARWICI( o'
ci n
No. 19771 a
V. 9��'iSTERtia 2 �,
p°1ia �D S U R �a���
REGISTERED 4 AND SURVEYOR
44
ZONE �� d �l ba+. R
v��, ,�l,a�i.e,�._,, ,,,,a• .
PLAN REF. . .. _ ,_ ..
BENCH MARK DATUM " o ' d, , 'A.�rJAK 0 A$,$PC.,�"0, '
st`;
DOMESTIC ytATER S4URGE •°•T� sod / fly f .L. 00l6T
FLOOD ZONE.
- Y
1 .lip
� S
►y LEACHING BASIN SECTION NOT TO SCALE sheevl z �� z
COVER
�-
FART)! F/L L BRICK AND NORTAR COURSES AS REeo. TO BRING
COVER TO GRADE
I4VL S„FLOW L INC __ . p'=f(y"TO WASHED PEAS TONE FREE OF IRONS,
PIPt 'T; FINES AND DUST IN PLACE
514" TO /%p WASHED CRUSHED STONE FREE OF
` r '•OPENING W/TH 4%8" IRONS, FINES AND DUST IN PLACE
;
•�� OUTER D/ANETER'
AND IJ/q" INSIDE
DIAMETER I CONCRETE TO BE 4000 PSI 28 DAYS
` '`• ; ' 2. REINFORCED WITH 6"x 6° NO. 6 GA. W.W.M.
tp 3. 2'AND 4� SECTIONS ARE AVAILABLE FOR
n GREATER DEPTH REQUIREMENTS
6'0" �I---� 4, NUMBER OF PITS REQUIRED o�
M 8. I 12 NOTE: EXCAVATE TO ELEVATION OR
EFFECTIVE DIAMETER
(Nor ro EXCEED 3 TINES EFFECTIVE DEPTH) LOWER AS REQUIRED TO REMOVE ALL
WATER TABLE LOAM AND CLAY BENEATH PIT. REPLACE
CNo�E� EXCAVATED MATERIAL WITH CLEAN
TYPICAL PROFILE GRAVEL TO DESIGNED GRADE.
5 /B"STD. LT. WGL at MN COVER
4610
j 4"8/T.FIBER PIPE
.,`.: 4"C.I PIPE OUTLET LEVEL
TIGHT JOINT
DWELLING FLOW LINE TO FIRST JOINT
00 0 10. 1 to
GD C.I. TEE Z ��110 1 l 1 008 00 1 1
STD. PRECAST CO NC. D/ST. BOX TO BE 1 I
CFI• : 3 1 1 0 00 00 1 1 1 1 ,
. 7j.(� •, �!• �1J,�0 1 t
I&OAL.SEPTIC TAN INSTALLED ON LEVEL,
p 000 00 0 1 11 .1
STABLE BASE 1 I 1 0 00 00 1.1 1 1
�"SEPTIC TANK TO BE 1 10 000 00 1 1 1 I
11p100I001 ► .
/HSTT LLEVFL, 11100
00STABLE BASE. ip0P00
0 0 1 1-LEACHING BASIN Ip ! O 0 ABASE TO BE L EVEL 1 1 1 , LV
SOIL AND PERC. DATA
PERC. RATE LZ MIN. /IN. „ TEST PIT NO. r-?l .(o TEST PIT NO. 2
� To(��sv13�o11� 0u
TEST BY : R 3
WITNESSED, BY: X.00 ►� -r� -r ��!✓apJ ��N r=
TEST PIT GR. EL. �� sp•tiD
DATE
DESIGN DATA GENERAL NOTES
'BEDROOMS NO HEAVY EQUIPMENT TO RUN OVER SYSTEM.
DISPOSAL SEPTIC TANK, DIST. BOX AN LEACHING BASINS TO BE STANDARD
EST. TOTAL DAILY EFFL. �PD. PRECAST REINFORCED CONCRETE UNITS.
SEPTIC TANK GAL. ALL :SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE
TO REVISED TITLE 5 OF THE STATE ENVIRONMENTAL CODE,
` SIDEWALL AREA �' yGAL./SQ.FT. MINIMUM REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF
BOTTOM AREA I.O GAL./SQ.FT. SANITARY SEWAGE EFFECTIVE ON JULY to 1977.
LEACHING REQUIRED 2 SQ.FT. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD
ACTUAL LEACHING AREA OF HEALTH.
��g—SQ.FT. AT -COMPLETION OF CONSTRUCTION, PRIOR TO BACKFILLING, THE
BOARD OF HEALTH SHALL BE NOTIFIED FOR INSPECTION.
PITCH ALL SEWER LINES I/ql / FT. UNLESS INDICATED OTHERWISE.
t
"aFrH: 'r SEW GE ®ISPOSA L SYSTEM
V
o"r WART
IIV I.Y�/ il- L�O�.C1
E. -p- O
MORAN Z, �p I � w 11j-c I=et---f j L(gz_L�
(t23417�Q
J� O�Sc,ScF:iiG�4� OGi'1' �L v 1 LL—�� /vl ►�.Gi `�
SCALE As s DicarEo ®.4rC 7
i WAI. M .WARWtCK 8 ASSOC., INC.
i r
80X 801 •NQRrH M4404/TM
jI MASS. WWI - 565-2638
j PROFESSIONAL EAIGINEER
6
L d"7C AT ION SEWAGE PERMIT NO.
4074 / C�f�z (�Y(�Yco�d� ; �. 9S/
1 VI,LLACE
INSTALLER' NAIRE A ADDRESS
� B U I L D E R OR 0 NER
+p e f
DA T E P E R N I T ISSt`E4
DATE COMPLIANCE ISSUED
C
J� 1
�\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS .
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEIVED
JON 15 2004
TLE $ TOWN OF BARNSTABLE
HEALTH DEPT.*
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION ®1
a
Property Address: 125 Wintergreen Circle ��dd
O s to ry i l l a
d`dN
Owner's Name: Marilyn Baker
Owner's Address: MAP a
Date of Inspection: a --D PARCEL
LOB I----
Name of Inspector:(please print) W' 1 1 jam 1'_ • Robinson Sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P 0 Box 1 089
Centerville, MA
Telephone Number: (508) 775-8776_
CERTIFICATION STATEMENT
i certify that 1 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 15340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: w I Date: 0 �
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heathy -
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 scat to the system owner and copies.sent to the.buyer,if applicable,and the approtting
authority.
Notes and Comments
"'`This report only describes conditions at the time or 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 or use.
Title 5 Inspection Form 6/15/2000 page I
Page 2 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 125 Wintergreen Circle
Osterville
Owner: Marilyn Baker
Date of Inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Syst/p(n Passes:
1-0 1 have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.if"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
•A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to-broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due.to broken or obstncted pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is I:movcd
ND explain:
f
~` Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 125 Wintergreen Circle
Osterville
Owner: Marilyn .Baker'
Date of Inspection: . Z- '-0 1-/
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 iling to protect public health,safety or the environment.
1 System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
sys em 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 frofi 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 tree from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of I I ,
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 125 Wintergreen Circle
Osterville
Owner: Marilyn Baker
Date of Inspection: -2--6 e9
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all"inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than'/,day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within I00.feet of a surface water supply or tributary to a surface
water supply.
l(cYcsfNo)
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 fet 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 (lie presence of ammonia
nitrogen and nitrate bitrogen 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.]
The system fails.1 have determined that one or more ofthe 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.
Large Systems:
be considered a large system the system must serve a faci!ity with a design flow of 10,000 gpd to 15,000
g d.
Yo``u must indicate either"yes"or"no"to each of the following:
(Tlie following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If y u have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"y s"in Section D above the large system has faded.The O'Amer ar operator of any large system considered a
si nificant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
1 . 04.The system owner should contact the appropriate regional office of the Department.
4
I
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 125 Wintergreen Circle
s ervi e
Owner: Marilyn Baker
Date of Inspection:
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes —o
Pumping information was provided by the owner,occupant,or Board of Health
t//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 NIA)
✓_ Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out.?
Were all system components,excluding the SAS,located on site?
_�_ Were the septic tank manholes uncovered,opened,"and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
_ ✓Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes . no
Existing information.For example,a plan at the Board of Health.
_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance.
is unacceptable)[310 CUR 15.302(3)(b)]
5
Page 6 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 125 Wintergreen Circle
Osterville
Owner: Marilyn Bak _r
Date of Inspection: 4 —'I—oL/
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):. Number of bedrooms(actual):1
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Number of current residents:
Does residence have a garbage grinder(yes or no): 2
U
Is laundry on a separate sewage system(yes or no):�D [if yes separate inspection required]
Laundry system inspected(yes or no�0
Seasonal use:(yes or no):40
Water meter readings,if available(last 2 years usage(gpd)): 2 0 03 - 81 , 00 0
Sump pump(yes or no):�0 2002 — 36,000
Last date of occupancy: L—'7"O of
COMMERCIAL/I STRIAL
Type of establishment:
Design flow(based on 3 10 CMR 15.203): gpd
Basis of design flow(s ats/persons/sgft,etc.):
Grease trap present(ye s or no):_
Industrial waste holdi tank present(yes or no):_
Non-sanitary waste di charged to the Title 5 system(yes or no):_
Water meter readings,if available:
Last date of occupan /use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):_
If yes,volume pumped:_gallons--How was quantity pumped dcwrmined?
Reason for pumping:
TYJ�`E OF SYSTEM
�j_// Septic tank,distribution box,soil absorption system
_Single cesspool
Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank Attach a copy of the DEP approval
_Other(describe):
Approximate age of all co pone ts,date installed(if known)and source of information:
9 C/
Were sewage odors detected when arriving at the site(yes or no):,d..-(J
6
F
Page 7 of
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 125 wi nterareen Circle
0st ervi 1 1 e
Owner: r
Date of Inspection: iV'7 4-1.
BUILDING SEWER n ate on site plan)
Depth below grade:
Materials of construction: cast iron —40 PVC—other(explain):
Distance from private Ovate supply well or suction line:
Comments(on condition f joints,venting,evidence of leakage,etc.):
SEPTIC TANK: !/(locate on site plan)
Depth below grade:
Material of construction:::�`uncrete metal fiberglass
_other(explain) _ — g _Polyethylene
If tank is metal list age:— Is age confirmed-by a Certificate of Compliance(yes or no):—(attach a copy of
certificate)
Dimensions:_ w L :a Q o
Sludge depth:_ oL—3
Distance from top of sludge to bottom of outlet tee or baffle: 3 6
Scum thickness: C2
Distance from top of scum to top of outlet tee or baffle:, /0 d
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined:_ 6 for -- e O u n :S
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
O 6C) 0 s,1—I�
S V
GREASE TRAP: (locate on site plan)
Depth below grade:
Material of construe ion:_concrete metal fiberglass—polyethylene—other
(explain): — —
Dimensions:
Scum thickness:
Distance from top f Scum to top of outlet tee or baffle:
Distance from bot m of scum to bottom of outlet tee or baffle:
Date of last pump ng:
Comments(on p tping recontrnendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to oud t invert,evidence of leakage,etc.):
7
Page 8 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 125 Wintergreen Circle
Osterville
Owner: Ma; rl yn Baker
Date of Inspection:
TIGHT or HOLDING 11 LNK: (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: Tamin
allons
Design Flow. allons/day
Alarm present
Alarm level: rking order(yes or no):
Date of last p
Comments(c float switches,etc.):
DISTRIBUTION BOX: if resent must be o ened e( p p )(local on site plan)
Depth of liquid level above outict invert: t�
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.): ,)
PUi11P CHAMBER: (locate on site plan)
Pumps in working o der(yes or no):
Alarms in%working rdcr(yes or no):
Comments(note a ndition of pump chamber,condition of pumps and appurtenances,etc.):
8
I
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:125 Wintergreen Circle
Osterville
Owner: Mari 1 Yn Raikar
Date of Inspection: -?— LJ
SOIL ABSORPTION SYSTEM(SAS): l/ (locate on site plan,cxcavation'not required)
If SAS not located explain why:
Type d
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): o
v-v e 4 S I a P-
CESSPOOLS: (cesspool must a 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 o no):
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,si s of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 1 l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 125 Wintergreen Circle
Osterville
Owner: Marilyn Baker
Date of Inspection: ?—
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at]east two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
G�
� b
3 �
3 �
10
r .
.Page-11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: - 125 Wintergreen Circle
Osterville
Owner. Marilyn
Date.ofbspection:
SITE EXAM
Slope
Surface water
Check cellar.
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established round water elevation:
/'��
11
6
�.
3
i
�*� •,r"`ter �_ �D
a ar
PrOPOsed POOI
.. ,,.
Fencing is in r will
4 i be to code. D or
` SepticsvSte alarms evil
Vol
installed all entry
y 14' doors to the pool area
44
freom the house
amo
3r 1
>. v4.1� " fr 13.
t f
CO
✓a `�
G ► �` � 100,Vv
40
40,
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVZ OFF 1, ENTAL AFFAIRS
g DEPARTME f ENVIR.PN L PROTECTION
ONE WINTER S tf' T..OS `�'(g�l/,��2108 292.5500
CT ��YC w
TOwlv 16 OF ��`�r TRUDY CO I
Governor WILLIAN1 F WELD H�ITy FPTTW, 4A Sccrctar
ARGEO PAUL CELLUCCI DAVID B STRUW
Lt.Govemor SUBSURFACE SEWAGE D,11, RASA 1 ECTION FORM Commissionc
CERTIFICATION
Gerome Burke
Property Address: 125 Wintergreen 4:9cle Ost Ma Address of Owner: 1 1 5 Oak Hill Drive
Date of Inspection: 9/29/97 (If different) Sharon Ma 02067
Name of Inspector: ,Tngpph P macomber Jr.
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: Joseph P Macomber & Son Inc.
Mailing Address: BOX 66 Centerville Ma 02632
Telephone Number: ( 5 0 8) 7 7 5—3 3 3 A
CERTIFICATION STATEMENT
I cenify 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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
i
(✓ Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails D
Inspector's Signature: �j Date: 9�
The System Inspectd shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system 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 Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
AI SYSTEM PASSES:
�e 5 I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria,not evaluated are indicated below.
COMMENTS:
BJ SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate ye , no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection, or
I the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web: http://www.magnet state,ma us/Oep
Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Properly Address: 25 Wintergreen Circle Osterville Ma
Owner: Gerome Burke
Date of Inspection: 9/30/97
B) SYSTEM CONDITIONALLY PASSES (continued)
ND_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the
Board of Health). Describe observations:
11 broken pipe(s) are replaced
,tfk obstruction is removed
np�1 f4f-T distribution box is levelled or replaced
►v'1r The system required pumping more than four 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
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
-Nu— Conditions exist which require funher evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well
r k7F The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid).
3) 1OTHER
�fII
(rw1sod P&ge 7.0f 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 125 Wintergreen Circle Osterv''ile Ma
Owner: Gerome Burke
Date of Inspection: 9/3 O/9 7
D) SYSTEM FAPLS:
Yo must rndica a el:- et "Yes" or "No" as to each of the following:
�D I have determined that the system violates one or more of the following failure criteria as defined in 310 CmR 15.303 The bass
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
Backup of sewage into facility or system component due to an 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 inven due to an overloaded or clogged SAS or cesspool
Liquid depth m4s44,peol is less than 6" below inven or available volume is less than 1/2 day flow.
Required pumping more th 4 times in the last year NOT due to clogged or obstructed pipe(s)
Number of times pumped
_ V Any portion of the Spoil Absorption System, cesspool or privy is below the high groundwater elevation
LT
_ r Any ponwn of a cvr5T7abt or privy is within 100 feet of a surface water supply or tributary to a surface water supply
lE
Any poni0n of a c V
/ r»-NPJUl.tor privy is within a Zone I of public well.
v Any portion of a ceKpvoltor privy is within 50 feet of a private water supply well.
_ ✓_ Any portion of a I or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, artach copy of well water analysis for
coliform bacteria, volatile organ icbcompounds, ammonia nitrogen and nitrate nitrogen.
Q LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
9s No
the system is within 400 feet of a surface drinking water supply
I _ 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 11 of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information
Ir.vi..d 04/25/97) P.9. 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
ti
Property Address:125 Wintergreen Circle Osterville Ma
Owner: Gerome burke
Date of Inspection: 9/3 0/9 7
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
_ Pumping information was provided by the owner, occupant, or Board of Health.
ZNone of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
✓� _ The site was inspected for signs of breakout.
All system components, luding-the-Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
/ — The size and location of the Soil Absorption System on the site has been determined based on:
(L/ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (15.302(3)(b))
(revised 04/25/97) Pegs 4 of 10
61
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 125 Wintergreen Circle Ostervilkle Ma
Owner: Gerome Burke
Date of Inspection: 9/3 0/9 7
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 0 d./bedroom for S.A.S.
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or no): is
Laundry connected to system (yes or no):,
Seasonal use (yes or no): 5
Water meter readings, if available (last two (2) year usage (gpd):
Sump Pump (yes or no):&L
Last date of occupancy:ypL
COMMERCI,AUINDUSTRIAL: f
Type of establishment:_ A
ft
Design flow:0A gallons/day
Grease trap present: (yes or no)gp
Industrial Waste Holding Tank present: (yes or no)A
Non-sanitary waste discharged to the Title S system: (yes or no)M
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe) Alt
Last date of occupancy: oia
h;GENERAL INFORMATION
PUMPING RECORDS and source I information:
System pumped as pan of inspection: (yes or no)YO
If yes, volume pumped: gallons
Reason for pumping:
TYPE�f SYSTEM
�/ Septic tank/distribution box/soil absorption system
Single cesspool
IL0 Overflow cesspool'
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
IVZ I/A Technology etc. Copy of up to date contract
Chher .
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at tie site: (yes or no)d—
(revised 04/25/97) Page 5 o1 10
• j �
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM,?INFORMATION (continued)
Property Address:125 Wintergreen Circle Osterville�Ma
Owner: Gerome Burke
Date of Inspection: 9/3 0/9 7
BUILDING SEWER:
(Locate on site plan)
�l
Depth below grade:35
Material of construction: _ cast iron 1/ 40 PVC _ other (explain)
Distance from private water supply well or suction line
Diameter kyik
Comments: (condition of joints, venting, evidence of leakage, etc.)
n/ft
SEPTIC TANK:_
(locate on site plan)
r, lI
Depth below grade:
Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age (r_ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions: M �In'h�o"W ,50 H
Sludge depth -ft46-
Distance from top of sludge to bosom of outlet tee or baffle: uCL
Scum thickness: :iju—
Distance from top of scum to top of outlet tee or baffle: ka(12-
Distance from bonom o'• scum to bosom of outlet tee or baffle:4f4 Q
How dimensions were determined: P1 e6 k)fCd
Comments
(recommendation for pumping, condition of inlet and outlet lees or baffles, depth of liquid level in relation to outlet inverl, structural
integrity, evidence of leakage, etc.) e 2
6r .e r S s r
P
GREASE TRAP:ff
(locate on site plan)
Depth below grade:
Material of construction: _,concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions: NH
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bosom of cum to bosom of outlet tee or baffler
Date of last pumping:
Comments:
(recommendation for pumping, condilio of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(rsvlsod 04/25/97) Psg• 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: ;I 25 Wintergreen Circle Ostervi'`lle Ma
Owner: Gerome Burke
Date of Inspection: 9/3 0/9 7
TIGHT OR HOLDING TANK:NWf (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan;
Depth below grade:.
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions: ff
Capaciry: gallons
Design flow: gallons/day
Alarm level: Alarm in working order _ Yes; _ No
Date of previous pumping: _
Comments.
(condition of inlet tee, condit on of alarm nd float switches, et )
�r l�obfn� inns arr- IID_��n�
DISTRIBUTION BOX:
(locate on site plan.)
Depth of liquid level above outlet invert: /VD
Comments:
(note if level and distributio is qual, evidence of sol ds carryover evidence of leakage into or out of box, etc.) f.
C f )
PUMP CHAMBER:.
(locate on site plan)
Pumps in working order: (Yes or No) 1
Alarms in working order (Yes or No)
Comments:
(note���4 of pump chamber, condition of pumps and appurtenances, etc.) PUM CAWLL IV)t
(revls•d 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: °�
125 Wintergreen Circle 9 c e Osterville Ma
Owner:
Gerome Burke
Date of Inspection: 9/3 0/9 7 /
SOIL ABSORPTION SYSTEM (SAS):✓_ /O00 qa ( r ) X8_
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to,�e present, explain:
Type:
leaching pits, number: ,
leaching chambers, number:0
leaching galleries, number:=
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number�:0
Alternative system:
Name of Technology:
Comments:
(note condition of soil, $i ns of hydraulic failur level of ponding, condition of vegetation, etc.)
L , 1 v D
i
CESSPOOLS:UP
(locate on site plan)
Number and configuration: r
Depth-top of liquid to inlet invert: yff
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool: A/Fir
Materials of construction:
Indication of groundwater: LrT /
inflow (cesspool must be pumped as pan of inspection) 6:550DOL5 C/(f
Comments:
(note condition o soil, signs of hydraulic failure, level of pondin , condition of vegetation, etc.)
t C Ps,, �/� n rC� no p2 �f
PRIVY: 6J..1
(locate on site plan) ,�/
Materials of construction: /V A Dimensions:
Depth of solids_
Comments:
(note ndition of soil, signs of hydr ulic failure, level of ponding, condition of vegetation, etc.)
r n o L
trevlsed 04/25/97) Page 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1 2'5 Wintergreen Circle Osterville ma
Owner: Gerome burke
Date of Inspection: 9/3 0/9 7
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties °o at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
0.
I
(wined 04/25/91) Page 9 of 10
SUBSURFACE SEWAGE DISP(: L SYSTEM INSPECTION FORM
I'..: C
SYSTEM JNFOI: .. . ION (continued)
Property Address: 125 Wintergreen Circle Osterville 'Na
Owner: Gerome Burke
Date of Inspection: 9/3 0/9 7
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater 0&.ation:
Obtained from Design Plans on record
bservation of Sit utting property observation hole, baserrmtnh sump etc.)
L---�—Determine it from local conditions
I
L-`--Check with local Board of health
Check FEMA Maps
ZCheck pumping records
V Cfieck local excavators, installers
Use USGS Data
Describe in your own words how you established the High Grounciv/a•erElevation. (Must be completed)
�F
(revis-d 04/25/97) F&C. of 10
.t r+�r+�nr�+r .'r'��'nii+RT!'f•'t.T1:•.T+1T1:w�T'nn'1TRTL ".'..'mv Tn '."�i�ii-v�mT�-r.—.--- . ._
TOWN OF .BARNSTABLE WARD OF HEALTH
SUUSURFACF SFHACF DISPOSAL SYSTEM IN8I1FCTION FORM - PART D CERTIFICATION;
�� �...-_...�..... -� !.�.T.r!�1'rt:m T T.nIT1 r�.Tn•��•.'t^l.1Pf7 tf1Ti"'TrT4•Rf��v nT"r� R.++n Trii"r't rv-m'+r.-.� -r-rt.-. r- - _
-TYPE OR PRINT CI.EARLY-
PROPEl7TY INSPECTED
STREET ADDRESS 125 Wintergreen Circle Osterville Ma 02632
ASSESSORS MAP , BLOCK AND PARCEL #
OWNER' s NAME Gerome Butke
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P. Macomber Jr .
COMPANY NA"IE Joseph P. Macomber & 'Son , Inc .
COMPANY ADDRESS Box 66 Centerville , Ma . 02632-0066
5trvvt Town or Clty 9 1 P
COMPANY TE:,EPIIONC (508 775 -3338 FAX ( 508 ) 790 _1 578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposci-1 system nt,
this Address and that the information reported is true , accurate , and
complete as of the time of .-inspection . The inspection was performed and anv
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one :
XXXXXXXXXX Systeci PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
healLh or the environment as defined in 310 CMR 15 . 303 . Any fai )(ire
criteria not evaluated are as stated in the FAILURE CRITCRIA sectio!) o .r
this form .
System FAILED \
The inspection which I have con acted has found that the system fails .o
Protect the public health and the environment in accordance with T : , lP
5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form.
Y( I -
1nspector Signature - Date
)no copy of this certification must be provided to the OWNER , the BUYER
( where appl l.ca.ble ) - and the BOARD OF II EALI'!I .
• If the Inspection FAILED , the owner or operator shall upgrade tho oyate -
. ir.hin one dear oC the cute of the inspection , unless allowed or require
otherwise as provided in 310 CFIR 15 . 305 ,
partd . dc
�<
<1G
W
In DU
7 rr7
ti
s
- S
THE COMMONWEALTH OF MASSACITUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
y
Joseph P. Macomber, Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE S SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws . Issued by The Department of Environmental Protection.
)unc 8, 1995
Acting Dircctor of Lhc ion of Witcr Pollution Control
T
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS.
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
t
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A RECEIVED
CERTIFICATION
JUL 252002
Property Address: 125 Wintergreen Circle
Osterville,,MA 02655 TOWN OF BARNSTABLE
Owner's Name: Michael Ho HEALTH DEPT.'
Owner's Address: 13135 Brooks Landing Place
Carmel, IN 46033
Date of Inspection: June 25, 2002
Name of Inspector: (Please Print) James M. Ford
Company Name: James M.Ford.
Mailing Address: P.O. Box 49 Map: 119
Osterville,MA 02655-0049 Parcel 071
Telephone Number: (508) 862-9400
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
N Further Evaluation by the Local Approving Authority
Fa l
Inspector's Signature: Date: _ June 25, 2002
The system inspector shall subracopy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 125 Wintergreen Circle
Osterville^ AM
Owner: Michael Ho
Date of Inspection: June 25,2002
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One.or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is.leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
F
Property Address: 125 Wintergreen Circle
Osterville, MA
Owner: Michael.Yo
Date of Inspection: June 25, 2002
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,sabty 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 is a manner which will protect public health,safety and the environment:
Cesspool or privy i�within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
I
Page 4 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 125 Wintergreen Circle
Osterville, AM
Owner: Michael Ho
Date of Inspection: June 25, 2002
D. System Failure Criteria applicable to all systems:
You must indicate either`yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question.in Section E the system is considered a significant threat,or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 125 Wintergreen Circle
Osterville, M4
Owner: Michael Ho
Date of Inspection: June 25, 2002
Check if the following have been done: You must indicate"yes"or"no"'.as to each of the following:
Yes No
✓ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks
✓ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ _ Was the site inspected for signs of break out?
✓ Were all system components,excluding the SAS, located on site?
✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ?
✓ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface,sewage disposal systems?
The size and-location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
✓ _ Existing information. For example,a plan at the Board of Health.
_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3xb)].
5
I
Page 6 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 125 Wintergreen Circle
Osterville, MA
Owner: Michael Ho
Date of Inspection: June 25, 2002
FLOW CONDITIONS
RESIDENTIAL
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
Number of current residents: 0
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system (yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): Yes
Water meter readings, if available(last 2 years usage(gpd)): 2001 -27,000 gals.; 2006-25,000 gals.
Sump Pump(yes or no): No
Last date of occupancy: Summer use
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): and
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: None on file-per treatment plant
Was system pumped as part of the inspection(yes or no): No
If yes, volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes,attach previous inspection records; if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Nov. 8184-per as built card
Were sewage odors detected when arriving at the site(yes or no): No +
6
Page 7 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 125 Wintergreen Circle
Osterviile, MA
Owner: Michael Ho
Date of Inspection: June 25', 2002
BUILDMG SEWER(locate on site plan)
Depth below grade: Approx. 28"
Materials of construction: _cast iron ✓ 40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: Approx..18"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 Qal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 3"
Distance from top of scum to top of outlet tee or baffle: 10"
Distance from bottom of scum to bottom of outlet tee or baffle: . 10"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tees were present. The liquid level.was even with the outlet invert. Recommend pumping every 3 years.
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene =other
(explain):
Dimensions:
Scum thickness: '
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or.baffle condition, structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 125 wintergreen Circle
Osterville, MA
Owner: Michael Ho
Date of Inspection: June 25, 2002
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
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.):
The D-box was level. There were no signs of solids or leakage.
PUMP CHAMBER: None (Locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 125 Wintergreen Circle
Osterville, AM
Owner: Michael Ho
Date of Inspection: June 25, 2002
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 6'x 6'- 1000 gal.
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
Innovative/alternative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.):
The pit was dry. The scum line was approximately]'up from the bottom. There were no signs of failure The bottom to grade
was approximately 11'. The cover was approximately 2'below grade.
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth -top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
PRIVY: None (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,'signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 125 Wintergreen Circle.
Osterville, MA
Owner: Michael Ho
Date of Inspection: June 25, 2002
Map: 119
Parcel: 071
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.
L _ _
1001 Ay- as
ray- s
3
y
10
i
Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 125 Wintergreen Circle
Osterville, MA
Owner: Michael Ho
Date of Inspection: .Tune 25, 2002
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 28' feet
Please indicate (check) all methods used to determine the high ground water elevation:.
Obtained from system design plans on record- If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
The bottom of the leach pit to grade was approximately 11. Using the Barnstable topographic map and the Cape Cod
Commission water contours maps, the maps were showing approximately 28'+/-to ground water at this site.
r'
This report has been prepared and the system inspected and passed as,of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
- 11
T
14'-0"
———————————————
r-------------
I
� { 11
I aU: C
I I
b 4 GARAGE ADDITION EXISTING GARAGE o GARAGE ADDITION EXISTING GARAGE EXISTING RESIDENCE
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FOUNDATION PLAN FIRST FLOOR PLAN
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JOB: 0244
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m ° WINTERGREEN CIRCLE Grooks
CSTERV I LLE, MA
10 SEAWARD LANE HYANNIS, MA 020001
g SECTION PHONE: 50&-?T5-F631
s •
T.O.F. EL.= 39.0'f FINISH GRADE OVER D-BOX= 34.5'± FINISH GRADE OVER CHAMBERS= 35.3' - 34.5' GENERAL NOTES
PROVIDE EXTENSION RISER SLOPE tcD 2% MIN. OVER SYSTEM 3/4 TO 1-1/2 DOUBLE WASHED
REMOVABLE WATER-TIGHT COVER OVER STONE TO CROWN OF PIPE 1. UNLESS OTHERWISE NOTED ALL SYSTEM COMPONENTS AND CONSTRUCTION
WITH COVER OVER INLET& RISER TO WITHIN 6"OF FINISHED GRADE 4"SCHEDULE 40 PVC INSPECTION PORT WITH ACCESS
FINISH GRADE OUTLET TO WITHIN 6"OF F.G. 0 2"OF 1/8"TO 1/2" DOUBLE WASHED METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE ENVIRONMENTAL
' ' 5" DIA. OUTLET(S) MIN SLOPE 1 /o BOX TO F.G. (SEE NOTE 21) CODE AND ANY APPLICABLE LOCAL RULES.
FND. EL.= 37.5 t F.G. OVER TANK EL. = 3$.O � �- STONE OR GEOTEXTILE FILTER FABRIC
-� --_. -- - 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD OF HEALTH AND THE
�, TOP OF SAS= 32.33� PLACE RISERS ON ALL DESIGN ENGINEER.
PROPOSED 4„ 9 MIN. 9"MIN CHAMBERS WITH 3. 4"SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL BE USED IN DISPOSAL
--EXISTING 4" SCH. 40 PVC 36" MAX. 3'I .5O' 36"MAX- , INLET PIPES TO 6"OF
f'r SEWER PIP �--I SEWER PIPE � BREAKOUT EL= 32.00 FINISHED GRADE SYSTEM UNLESS OTHERWISE NOTED.
6" 3" 3 DROP MAX 3„ 9„ MIN.SL PROVIDE WATERTIGHT ELEVATION =32.00' FOR A DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS. UNLESS A
L=102't 4. TO PREVENT BREAKOUT, THE PROPOSED FINISHED GRADE SHALL NOT BE LESS THAN
-- -- 2" DROP MIN OPE @ 1% c
7
13" 4" PVC IN FROM JOINTS (TYP.) 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S. AND THE TOP OF
14" \'�*33.9't SEPTIC TANK 4" PVC OUT TO 0 0 0 O 0 0 0 0 °° 0 0 O 0 o THE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION.
CONTRACTOR TO PROVIDE -- - • LEACHING FACILITY o0 0 0 0 5. SLOPE ALL SOLID PIPE AT 1.0%MINIMUM.
SPECIFIED DROP BETWEEN oo
INLET AND OUTLET CONTRACTOR „ CONTRACTOR SHALL OUTLET TEE 31 .90' 12"MIN. ,� 31.73' o0 0 0 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL.
l SHALL VERIFY SIZE 48 VERIFY CONDITION OF \ 2 0 0 0 o 0 CDC7 0 0 000 7. LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED PRIOR TO BACK
AND INSPECTION. SYSTEM IS
EXISTING CONDITION OF EXISTAND RING TEES EPLACE AS GAS BAFFLE OVERUSHED MECHANIONE CALLY oQ °° oo oo FILLING WHEN SYSTEM NOT TO BE BACK FILLEDS NEARLY COMPLETE AND READY WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH
I TANK NECESSARY COMPACTED BASE
I 4.0' AND DESIGN ENGINEER.
5 OUTLET DISTRIBUTION BOX $.5 �P) 4.0 (NP') 4.0 8. ELEVATIONS BASED ON APPROXIMATE M.S.L. DATUM. BENCHMARK ELEVATION OF 40.00,
TO BE INSTALLED ON A LEVEL STABLE 25.0' ESTABLISHED ON A NAIL SET IN UTILITY POLE#35A AS SHOWN ON PLAN.
BASE. FIRST TWO FEET OF OUTLET 29.50' GROUND WATER ELEV= < 23.50' 12 83 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION
PIPES TO BE LAID LEVEL. THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE AT
EXISTING 1 ,000 GALLON CONCRETE SEPTIC TANK CROSS SECTION VIEW 2 - 500 GALLON CHAMBERS 5'MIN. i,I-Irlivitti< i;ivL3 v Icv°v 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY DISCREPANCIES
*CONTRACTOR TO VERIFY EXISTING T ,/E !!� TYPICAL CHAMBER PROFILE: TO THE DESIGN ENGINEER.
SEPTI PROFILE. DIS I RIBU1� iON bUA L)LTAIL CHAT, "" °� "TAIL
ELEVATION PRIOR TO ANY WORK& NOT TO SCALE NOT TO SCALE 10. ALL JOINTS WHERE PIPE ENTERS AND EXITS CONC. STRUCTURES SHALL BE MADE WATERTIGHT.
NOTIFY ENGINEER IF DIFFERENT. --------------_-_-- -_ - __ __. __-- ------------------___._-_._ NOTTOSCALE
11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED R ZONING
' r '" .•.• � TEST PIT DATA REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH DETERMINATION FROM
` ` ` PERC NO. TPT-20-177 APPROPRIATE AUTHORITY.
f, I INSPECTOR: David W. Stanton(BOH) 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS LOCATED
I UNDER MORE THAN 3 FEET OF COVER OR LOCATED UNDER PAVEMENT, DRIVES, OR
9 EVALUATOR: Michael Pimentel, EIT, CSE TRAVELED WAYS IN WHICH CASE THEY SHALL WITHSTAND H-20 LOADING.
• `� � C.S.E. APPROVAL DATE:
Oct. 27, 1999
MAP 119 !, r 13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND FINES.
_
i . _ �� - DATE: August 24, 2020
\ LOT 76 *� e'lnett<y TEST PIT#. 1 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND UNSUITABLE
�, • B0gw, MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF LEACHING FACILITY.
9 r r � ELEV TOP= 34.50' REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN COARSE SAND FREE FROM CLAY,
4 FINES OR OTHER UNSUITABLE MATERIAL IN ACCORDANCE WITH 310 CMR 15.255(3).
�. ., it ELEV WATER= <23.50'
rw / / �� �19 S3"F • -- �� :• __ � �� y 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN
�. 8�' i lr ' PERC RATE = SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK.
MAP 119
.c LOCUS
S 16. PROPOSED PROJECT IS LOCATED WITHIN:
LOT 71 �\ t�`
°, DEPTH OF PERC=
o / �`� � V' r i ASSESSOR'S MAP 119 LOT 71
22,212t S.F. a t ��_ TEXTURAL CLASS: 1 -
MAP 119 / ��, \ �� LIS
LOT 1 OG \ J / M !!I OWNER OF RECORD: JAMES SURPRENANT
n. '• ' ;Cd
n ' 0" 34.50' ADDRESS: 125 WINTERGREEN CIRCLE
� C t� 4�� Fill 34.1T OSTERVILLE, MA 02655
�� 1, ,//^ - - ✓ . _ -39- ti \ / mod, ^,��' ii. ls;� Loamy Sand
A/E „ 10Yr 4/1 FEMA FLOOD ZONE X
-EXISTING LEACHING PIT TO BE ", • ' � /2 !t 8 33.83 COMMUNITY PANEL# 25001CO544J
~ • Loamy Sand
PUMPED AND FILLED WITH CLEAN ' .: �� ft j B 10Yr 5/6 17. DEED REFERENCE: BOOK 18968, PAGE 232
SAND &ABANDONED •, J I
N E I f)8t 36" 31.50' 18. PLAN REFERENCE: PLAN BOOK 385, PAGE 97
DECKQ
` 19. ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION.
/ -- -38_ • 20. PROPERTY LINE INFORMATION IS ONLY APPROXIMATE. THIS PLAN I;,TO_ �- BE USED ONLY
't #125 // ✓`� - v\ MAP 143 \� > •'" y N . • FOR SEPTIC SYSTEM UPGRADE. JC ENGINEERING WILL NOT ASSUME ANY LIABILITY
p \ X FOR USES OF THIS PLAN OTHER THAN IT INTENDED PURPOSE.
_ �J�� EXISTING \ l OT 33 Zrl2 It Medium Sand
S S S S
- ' H i idle . .. C 2.5Y 6/6
v4 r 21. A 4" PERFORATED SCH. 40 PVC PIPE SHALL BE PLACED IN A VERTICAL POSITION TO A
3-BEDROOM
W DROOM \\�` m \ 4 s `Y - ;� I •_•t em ,� DEPTH OF THE BOTTOM OF THE SAS 1ND EXTEND TO WITHIN 3"OF FINISH GRADE. A
REMOVABLE THREADED CAP SHALL BE PLACED ON THE TOP TO ALLOW FOR INSPECTIONS.
G�q qPp rTOF=39.0'± \ \ `� A, 22. OWNER/APPLICANT/CONTRACTOR SHALL BE RESPONSIBLE TO OBTAIN ANY AND ALL
�)ECK / u " \ EXISTING 1,000 GALLON LOCUS PLAN REQUIRED PERMITS AND APPROVALS FOR THIS PROJECT.
c OC / ( 3" \ SEPTIC TANK TO BE
37=�--� 5 B ��/ \ UTILIZED IN DESIGN SCALE: 1"= 1000' 132 23.50
f
i/ / EIRESCALE: 1"=20' No Mottling, Standing or Weeping Observed
\ ;
SWING-TIES ! --b 1 PIT A I f .. I= [
,' +`'�%' r- �, DESIGN DATA
\ 15
/E QUO PROPOSED 2-500 DESCRIPTION HC-1 DC-1 PERC NO. TPT-20-177 50x0' EXISTING SPOT GRADE
c i 17" 3 �.: TP 1
/ t 1 \ pQ _n� 34x \ GALLON LEACHING INSPECTOR: David W. Stanton (BOH)
u6, 35x3 �h CHAMBERS w/STONE CORNER OF STONE (1) 25.4' 19.9' NUMBER OF BEDROOMS 3
Tc; ,F• ��� \ r EVALUATOR: Michael Pimentel, EIT, CSE -- - - 50 -- - - EXISTING CONTOUR
CORNER OF STONE(2) 37.2' 27.2' DESIGN FLOW 110 GAUDAY/BEDROOM
j vA���N C.S.E. APPROVAL DATE: 0 PROPOSED CONTOUR
Oct. 27 1999
P 2��•i, / CORNER OF STONE 3 51.0' 47.9' TOTAL DESIGN FLOW 330 GAUDAY August 24, 2020
34x5 O DATE: 9
g" DESIGN FLOW x 200 % = 660 GAUDAY 50 PROPOSED SPOT GRADE
CORNER OF STONE (4) 43.2 44.2 TEST PIT#: 2
T
Li-,Li AREA. ` ` ` ; _ USE EXISTING 1,000 GALLON SEPTIC TANK iAS -- EXISTING GAS LINE
b+ \ PROF' � ELEV TOP= 34.50
�,,,�, w 9" o
35 "` D-BOX" \6 ; ELEV WATER= <23.50' ------ EXISTING OVERHEAD UTILITIES
/ 3 (20" MAP 143
GUvwtIEX- -X-X-X"-"x- f LOT 34 INSTALL 2 - 500 GAL. CHAMBERS w/ AGGREGATE PERC RATE= 2 min./inch
r J !� s
/ S -W -W - EXISTING WATER LINE
`
N860 54' 28"E DECK
� _ •_ _�,, , .x ., 88.95 I , DEPTH OF PERC= "C"soil
-4-._
' ` SIDEWALL CAPACITY TEXTURAL CLASS: 1 TEST PIT LOCATION
39 - ,� (LENGTH + WIDTH) (2 SIDES) (2' HIGH) (0.74 GPD/S.F.) = GAUDAY
'"�' I #125 r'' (25.0'+ 12.83')(2 ) (2' ) (0.74 GPD/S.F.) =112.0 GAUDAY - G EXISTING 1,000 GALLON SEPTIC TANK
1R�FA yYo EXISTING
PROPOSED INSPECTION PORT 3-BEDROOM 0" 34.50'
Benchmark "•�._, � BOTTOM CAPACITY PROPOSED 4" SOLID SCHEDULE 40 PVC PIPE
DWELLING 4„ Fill 3417'
Nail in U.P. #35A (LENGTH x WIDTH) (0.74 GPD/S.F.) = GAUDAY
Elev. =40.00' Loamy Sand PROPOSED DISTRIBUTION BOX
Approx. M.S.L. WINTERGREEN CIRCLE F� (25-0'x 12.83') (0.74 GPD/S.F.) = 237.4 GAL/DAY A/E
10Yr 4/1
�TOF=39.0't 8" 33.83' Q PROPOSED 500 GALLON LEACHING CHAMBER
V DECK TOTALS: B Loamy 10Yr 5/6 d
TOTAL NUMBER OF CHAMBERS 2 36 31.50
REV. DATE BY APP'D. DESCRIPTION
HC-11 �-DCA h^�,�o TOTAL LEACHING CAPACITY TOTAL LEACHING AREA 349.4 GA DAY PROPOSED SEPTIC SYSTEM UPGRADE
Q ? PREPARED FOR:
NOTES: 1)
c
Medium sand ROBERT B. OUR CO., INC.
1.) MAGNETIC MARKING TAPE SHALL BE PLACED ALONG THE TOP EDGE OF ?8, 2.5Y 6/6
EACH SEPTIC SYSTEM COMPONENT. o LOCATED AT
2.) CONTRACTOR SHALL VERIFY SOIL CONDITIONS IN THE LOCATION OF by 2) 125 WINTERGREEN CIRCLE
THE PROPOSED LEACHING FACILITY TO ENSURE CONSISTENCY WITH TEST OSTERVILLE, MA 02655
PIT DATA SHOWN ON THIS PLAN. REPORT TO ENGINEER AND LOCAL �?
BOARD OF HEALTH IF SOILS ARE NOT CONSISTENT WITH TEST PIT DATA. I (4 SCALE: 1 INCH = 20 FT. DATE: SEPTEMBER 11, 2020
132" 23.50'
0 10 20 40 80 FEET
3.) ENTIRE PROPERTY IS LOCATED WITHIN A MASS DEP ZONE 11,WELLHEAD (3 �.9, No Mottling, Standing or Weeping Observed `,A of flags
PROTECTION OVERLAY DISTRICT AND ESTUARINE WATERSHEDS. - --
° " FOR- - ---- O� JOHN LOyG PREPARED BY:
4.) SWING TIES SHOWN ON THIS PLAN ARE PROVIDED ONLY AS A N86 54 28 E RESERVED BOARD O HEALTH USE CHURCHILLJR. m ? JC ENGINEERING, INC.
COURTESY FOR THE INSTALLER. INSTALLER SHALL VERIFY SWING TIE 88.95' °
v N .q�L 7 y 2854 CRANBERRY HIGHWAY
MEASUREMENTS IN THE FIELD PRIOR TO INSTALLING THE SYSTEM. �F EAST WAREHAM, MA 02538
CONTRACTOR SHALL NOTIFY ENGINEER IF MEASUREMENTS APPEAR TO BE SITE PLAN WINTERGREEN CIRCLE Perc rate taken from Application for SST
INCORRECT. Disposal Works Construction Permit No. 508.273.0377
SCALE: 1"=20' 84-451 approved on 10-19-84. Drawn By:By: MCP Designed By:MCP Checked By:JLC JOB No.5287