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HomeMy WebLinkAbout0020 BRIGANTINE AVENUE - Health 20 Brigatine e4veA We, A= 121 k139 4 Marstons Mills iy Y b Commonwealth of Massachusetts �m Title 5 Official Inspection Form F Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4# 20 Brigatine Ave Property Address Elizabeth Walsh Owner Owner's Name information is Ostervi lie �/"1�/-/ Ma 02655 6-13-19 required for 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 A. Inspector Information fillip out forms g on the computer, use only the tab Brett Hickey key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 c Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposa6 system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ❑ Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Brett Hickey " 6-13-19 Inspector'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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 I Commonwealth of Massachusetts �s ,p Title 5 Official Inspection Form io Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 20 Brigatine Ave V� Property Address Elizabeth Walsh Owner Owner's Name information is Osterville Ma 02655 6-13-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System,Passes: Y . ., ❑■ 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: The system was in working order at the time of inspection. 2) 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Brigatine Ave Property Address Elizabeth Walsh Owner Owner's Name information is Osterville Ma 02655 6-13-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): I ❑ 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 ❑i N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts �m Title 5 Official Inspection Form I a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Brigatine Ave Property Address Elizabeth Walsh Owner Owner's Name information is Osterville Ma 02655 6-13-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ 0 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ 0 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 4 of 18 c Commonwealth of Massachusetts `12. Title 5 Official Inspection Form 0Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Brigatine Ave Property Address Elizabeth Walsh Owner Owner's Name information is Osterville Ma 02655 6-13-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ Q Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ 0 Liquid depth in cesspool is less than 6"below invert or available volume is less than '/day flow ❑ a Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Q Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ 0 Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ 0 The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ 0 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. 5) 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 CA. 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 l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 c Commonwealth of Massachusetts r= Title 5 Official Inspection Form i' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I I� 20 Brigatine Ave Property Address Elizabeth Walsh Owner Owner's Name information is Osterville Ma 02655 6-13-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No El ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? 0 ❑ Has the system received normal flows in the previous two week period? ❑ El Have large volumes of water been introduced to the system recently or as part of this inspection? 0 ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ n Was the facility or dwelling inspected for signs of sewage back up? El ❑ Was the site inspected for signs of break out? El ❑ Were all system components, excluding the SAS, located on site? El ❑ 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? ❑ a 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: 0 ❑ Existing information. For example, a plan at the Board of Health. ❑ O 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)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts �m ,p Title 5 Official Inspection Form �= I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I; 20 Brigatine Ave v Property Address Elizabeth Walsh Owner Owner's Name information is Osterville Ma 02655 6-13-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 3 3 Number of bedrooms(design): Number of bedrooms(actual):. 330/GPD DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Description: 1 Number of current residents: Does residence have a garbage grinder? ❑ Yes El No Does residence have a water treatment unit? ❑ Yes 0 No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? ❑ Yes 0 No Seasonaluse? ❑ Yes [g No See below Water meter readings, if available(last 2 years usage(gpd)): Detail: ***2017- 23,000gallons 2018- 34,000gaIIons*** Sump pump? ❑ Yes ❑■ No current Last date of occupancy: Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts �m ,p Title 5 Official Inspection Form Iol Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Brigatine Ave Property Address Elizabeth Walsh Owner Owner's Name information is Osterville Ma 02655 6-13-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner- last pumped 6-7-18 Was system pumped as part of the inspection? ❑ Yes 0 No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form r, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Brigatine Ave Property Address Elizabeth Walsh Owner Owner's Name information is Osterville Ma 02655 6-13-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: El 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): Approximate age of all components, date installed (if known)and source of information: 2016 per COC Were sewage odors detected when arriving at the site? ❑ Yes ❑B No 5. Building Sewer(locate on site plan): 21411 Depth below grade: feet Material of construction: ❑ cast iron ❑■ 40 PVC ❑other(explain): Town water Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 I c Commonwealth of Massachusetts �n Title 5 Official Inspection Form +' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l 20 Brigatine Ave v� Property Address Elizabeth Walsh Owner Owner's Name information is Osterville Ma 02655 6-13-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 11411 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 1 Dimensions: 000gallons 211 Sludge depth: 3411 Distance from top of sludge to bottom of outlet tee or baffle Ot,f Scum thickness NS Distance from top of scum to top of outlet tee or baffle NS Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is not in need of pumping at this time but should be pumped every two years for maintenance. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form I;I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Brigatine Ave L� Property Address Elizabeth Walsh Owner Owner's Name information is Osterville Ma 02655 6-13-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): NA Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u— 20 Brigatine Ave Property Address Elizabeth Walsh Owner Owner's Name information is Osterville Ma 02655 6-13-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 co of current pumping contract(required). Is co attached? Yes No PY P P 9 PY ❑ ❑ 9. Distribution Box(if present must be opened) (locate on site plan): 0" Depth of liquid level above outlet invert 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 in working order at the time of inspection. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Brigatine Ave Property Address Elizabeth Walsh Owner Owner's Name information is Osterville Ma 02655 6-13-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. PumpChamber locate on site plan): ( p ) Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: (2)500 gallon chambers 0 leaching chambers number: ❑ leaching galleries number: ❑ Reaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ !innovative/alternative system Type/name of technology: l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 i c Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Brigatine Ave V� Property Address Elizabeth Walsh Owner Owner's Name information is Osterville Ma 02655 6-13-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The SAS was in working order at the time of inspection. Chambers were dry when viewed. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts +v ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Brigatine Ave v� Property Address Elizabeth Walsh Owner Owner's Name information is Osterville Ma 02655 6-13-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): NA Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Brigatine Ave Property Address Elizabeth Walsh Owner Owner's Name information is Osterville Ma 02655 6-13-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ■❑ hand-sketch in the area below ❑ drawing attached separately 4`w ._ ...:,..... .... s cyst rvaa .k*�a:�r s s...... ,...:; e'i�r':r�^��ta '�>�it: a�.a~1-�r:t.�-��:i :� .�.. :a",.-_ s:".�'a`� e•�g=� ..� :�_.',c"�...r_�.' ....:,..�_- .;... c,.t=1'>AI V .. S".��•xrazt+Kass:3C"t.csrxr '.3�aCY'M^C+�'n-3'a�'".. t�'-7x x Y.,uax,n,�ti>s�ue4r<,rc..�z�•e.xcs'�ra>mc.,es>.3:rr;<a+.�cxrs ,;x>:#z,�.>Ve-..+v.c�a�.F�.>3�=3�� ..�._.._._..__�_��..�_....�s:,t.�, fx'. »xar"'a`»x^Pxx�:zayc.+""=-x'S`0.+'ttY.>uY mc�#staic.aiiry£. �rti^sw._i.is:i„sc_ix+szra.' Rw61nr�rsl'*+wxsxnta•�Y��msY'.:+4".kraw�•i°a-��x+'<'i 4r,�i ................. _._:,,,._� exert., jj ��L�j,;.K�•Yb1.:�K�i?➢'f8f4{BdY'tY��G1M..ti�.Y�:,}(�!4'Y.fi�Q� i3a'51r:; ..,u��fYf..,;.2'�'£32 wr`;S.fil-a: -4c)o!T� Way;_ Al . � t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 r Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Brigatine Ave Property Address Elizabeth Walsh Owner Owner's Name information is Osterville Ma 02655 6-13-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑■ Check Slope FEW Surface water ❑■ Check cellar ❑■ Shallow wells No GW 4' below SAS Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: 0 Obtained from system design plans on record 6-8-16 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: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: A plan on file at the local Board of Health was used to determine high groundwater. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Brigatine Ave Property Address Elizabeth Walsh Owner Owner's Name information is Osterville Ma 02655 6-13-19 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑■ A. Inspector Information: Complete all fields in this section. ❑■ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ❑■ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed 0 D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 } TOWN OF BARNSTABLE LOCATION 2.0 r%gcxr%A'i n c. AVC SEWAGE# Zo IL - 193 VILLAGE M,fY)► 1) 5 ASSESSOR'S MAP&PARCEL 2 IM INSTALLER'S NAME&PHONE NO. C3�.S Fxcxx%k A;o,r\ y'1 - DG S 3 SEPTIC TANK CAPACITY /600 9cJ LEACHING FACILITY:(type) ,5Dp cam)Q (size) 13 x 2$ x Z NO.OF BEDROOMS 3 OWNER t A PERMIT DATE: G-$-f L COMPLIANCE DATE: CJ l uft 6 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) ' Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY Al t3 - 23`2 g3 . yy 2 R EAR No. 1 C Fee �[O THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pphtatlon for -M18 oral *pstem Construction permit Application for a Permit to Construct( ) Repair ) Upgrade( ) Abandon( ) ❑Complete System dividual Components Location Address or Lot No. 0 6 r j p q�fine A -t Owner's Name,Address,and Tel.No. Assessor's Map/Parcel ), — - fq/t �l 6_1izr ish &17 - &94 -_77g i I Installer's Name,Address,and Tel.No. De er's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 33Dgpd Design flow provided 3149 gpd Plan Date� ( � Number of sheets Revision Date Title Size of Septic Tank 000 Q( L Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable)(J (2 16271C1 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 000fH nvironmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Bo alth. Si Date S j Application Approved by Date Application Disapproved by Date for the following reasons Permit No. ((, �(� Date Issued � 6 c ' No. Fee. /v(/ THE COMMONWEALTH rOF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS es 2ppliLatlott for MI8 osaY 6pBte tt Construction Permit Application for a Permit to Construct( )' Repair ) Upgrade( ) Abandon( ) ❑Complete System ( dividual Components Location Address or Lot No. q 0 r 13 an-F nf- Av-t Owner's Name,Address,and Tel.No. (21 ' 19 V. f� L-Iiz4X45h &17 -- &94 -175 Assessor's Map/Parcel ✓V'� Installer's Name,Address,and Tel.No. De 'gner's Name,Address,and Tel.No. BA C3 Excnvcdion SdK- ���- 3 Tlahe�ely Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building Ve",5 1 ) No.of Persons Showers( ) Cafeteria( ) Other Fixtures i Design Flow(min.required) gpd Design flow provided j 'i` gpd Plan Date (P +& ! 16 Number of sheets Revision Date Title Size of Septic Tank /00o CL,l Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) N)A b (2 Q2 600 OU C- .(S 1 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 t e Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Bo of H alth. Si /� 9_ Y_Z'29jDate 4( 51,1 Application Approved by DateCOP- / Application Disapproved by Date for the following reasons J Permit No. G / - K Date Issued "'tip - = --------------------------------------------1----r---------------------------------------- ----- '- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFYY,,that the On-site Sewage Disposal system Constructed( ) Repaired(✓� Upgraded( ) Abandoned( )by -r I_7 X(n V r-A i U 1 at I(1 e V �Oas been'constructed in accordance a / p Alwith the pya 'sions of Title 5' d the for Disposal System Construction Permit No. (�' �0 dated 6/pb Installer_c�p '� r�)/ Designer Q t/ , #bedrooms Approved design flow •3 Q gpd The issuance of this permit shall not be con /ed as a guarantee that the system tll functio, asadeign Date s l/i /'�`-'�! �' Inspector No. Q 6 ` Fee W THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal *Vst m Construction VPrmit Permission is hereby granted to onstruct( ) Repair Upgrade( ) Abandon( ) System located at � 1 A l i(� —A v V _ A/,, 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:Constru(ctiofi mu t 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 • eanxsznai.E. • Public Health Division 639. Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: 1� _Z l& Sewage Permit# Assessor's Map\Parcel 3 l Designer: �_ Installer: CE ��/ _t VC Address: B 8 Address: J!t l ij� G f fiu° 026 yq On 8 �(o 8 Ex(ayafi o was issued a permit to install a (date) (installer) 0 S&'y�1`G� AV�Fseptic system at �� based on a design drawn by n (address) l� !/ (,7e, dated (designer) I 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 ce with the terms of the IAA approval letters (if applicable) iH OF* go DAVID c�N D. a (Installer'are FLAHERlY,JR. C No. 1211 GIST0L NITAR\(Designer (Aix esigner _, p Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. QASeptic\Designer Certification Form Rev 8-14-13.doc Town of B:wxtsiablef P# - o� Department of Regulatory Serykes: Public Health Division- Date- 200MamStreei,;HyaontsMA,P2601. Date.Schedule3 Trine:�. �1 Fee Pd. VU I i Soil Suitability Assessment for Sew a D'posat. (' 'PerfonnedBy.: to . WitnessedByt. vv-. n LOCATION&`GENERAL INQRIGIATION tAcalion Address �v •t��bg ,t_,..� .Owner s Name jv ( " 110/ ,�f t f Address Assessor's Map7Parcel: Fngineer s Name'I' t � Ft' NEW CONSTRUCTION REPAIR // Telephone# f.7'X LandUse' 1 $topes{%}:. V :Surface Stories-- :,. i 17istanceafromi- Opev:Water$ody. R P=ible;WetArea:>�,�_ _. - � � VV R: DnnQingWaterWell//(/()ft'. DrainageWay.. 1 Property Line?�_ft Othei ft,. I 1 SKETCH':(Streefrta ne,dimensionsof.lot exaci locations'of ies(holes&'Pere tests;locate weklands'in[proxit»ity io holes} 1 i Parent;inateriat(geoogie) "�"�"/_,�"�•.'v+ bopttyto,.Bedrock. _ Deptkto Groundwat c Stagding Waiei iii 136le Estimated Seasonal High Groundwwater IF D ,TEItVIItVgTION.FO:It SEASONAZ Used: .I IGH'WATER TABLt Iofetliod Depth:Observed standing m obs.hole: m, 'Depth to sodinWtles: id.. Uapthfoiv ping Fromstdeofo_bs hole: in. :GrodndweterAdjustment ft. Index Well# Reading Date: Index Wei level, Add factor AdJ;Groundwater Leyet i — 1 PERCOL••AT Q :TEST. Date _ T qte Observation Flolc.fi 7N" i "a 7imeaE9 - Depth of_Pere Time-at 67' Stan Pre-sonk..Time @ -End Pre-soak. } / Rate Min,tlnch t SiicSmtability"Assessment,Iize..Passed .. Stte Fs;led:.. ,Addi{ionalTesdngheeded(YJIJ):, O[iginal. Public Health.Division. Observation HOleData To Be Completed on Back`--------- i **�If WC011601ill test is to be conducted within 100)of woland,you MUS(Airst notify the Bai,nstable Conservation Division at least one(1)week prior to beginning: QASCIMICTEeCFORM'DOc. C I Orb �J r ' DEEP OBSERVATION NOC E LOG;' Hale#De h from Soil�Horizon SoiIT@"lure-- 1 x 'soil color, Soil Surface{in:} Utlicr (USDA) (Mutrsell).. Mottling (Strw.'e,Stores,Bnufders.. I I DEEP OBSERVATION HOLE LO.G Elole# � Depth from ,Soil t{or Sod Toxture Sd Color Surfoce(in.) Soil Other (USDA) ,o(Munsell)' Mottling (Structure,Stanes;..Boulders: ..n.i e. %--.ravel . ... I -- € t �EEPOBSERVATION HOLE'LOG Hole# pepth from SotE lior mn Sad Texture Sod Color Surfwe(in.) Sorl.... ,Other ` i {USDA} :(Munsell). Mottling (Structwe,Stones;-Boutders; 1 t s t EEP OBSE'RYATION HOLELOG. Hole# Depth firnnSoil Horizon Soil Texture: Soil Cahr Sod Surfece(m J 'Other { (USDA) (Munsell)- Motiling (Structure,Stones,Boatders. Co�`igt�rxv%Griven' € s `s Flood`Insurance'Rate. n Ma ^ — i AWVe.!iWYearOcddboundary.-No yin; ;Witliin,SQdyearboun;&ry, No" Yes Within lt)pyearpoaftiounclary.No Yes. Denth of Na.turallrOe,�il'rrrrin Pervious%Uterinl Does.at,least fourjfcet .:naturally occurring pervi us inatenal exist;ag all areas observedAro4hd6t the area proposed forlthe-soil absorption syste Cf not what is:the depth of.naturallyoccurring;pe ops.mated I Cerfification ' I certify that on. 07— (date)I have'passed the soil,evahtator examination approved b the Department of En� an nial Protection and that the above ahalysi§ ro y was performed by ro ci>tx tent Huth thexegutredarainin xpertise and x e 'n eserib in 3.10:CMR 1.51017'. I Signature, i gate,.. Y I F I f Q%4FHCPERCFQA�q.D,OC i i L ru ,a m OFFICIAL US r%- Certified Mail Fee ru $ rU Extra Services&Fees(cheekbox,add tee as appropriate) - ❑Return Receipt(hardcopy) $ C ❑Return Receipt(electronic) $ -+ Postmark ❑CertiNed Mail Restricted Delivery $ED O ❑Adutt Signature Required $ X •� C Q ❑Adult Signature Restricted Delivery$ ?� N Postage ru (v r=1 Total Postage and FeesLn rq EliL20� beth Walsh Nrigantine Avenue rville, MA 02655 Certified Mail service provides the following benefits: ■A receipt(this portion of the Certified Mail label). for an electronic return receipt,see a retail ■A unique identifier for your mailpiece. plate for assistance.To receive a duplicate ■Electronic verification of delivery or attempted return receipt for no additional fee,present this delivery. USPS®-postmarked Certified Mail receipt to the ■A record of delivery(including the recipient's retail associate. signature)that is retained by the Postal Service- Restricted delivery service,which provides for a specified period. delivery to the addressee specified by name,or to the addressee's authorized agent. Important Reminders. Adult signature service,which requires the ■You may purchase Certified Mail service with signee to be at least 21 years of age(not First-Class Mail®,First-Class Package Service®, available at retal or Priority Mail®service. Adult signature restricted delivery service,which ■Certified Mail service is notavailable for requires the signee to be at least 21 years of age international mail. and provides delivery to the addressee specified ■Insurance coverage is not available for purchase by name,or to the addressee's authorized agent with Certified Mail service.However,the purchase (not available at retail). of Certified Mail service does not change the ■To ensure that your Certified Mail receipt is insurance coverage automatically included with accepted as legal proof of mailing,R should bear a certain Priority Mail items. USPS postmark If you would like a postmark on j ■For an additional fee,and with a proper this Certified Mall receipt,please present your endorsement on the mailpiece,you may request Certified Mail item at a Post Office-for the following services: postmarking.If you don't need a postmark on this Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion 1 of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply r You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece.: electronic version.For a hardcopy return receipt, complete PS Forth 3811,Domestic Return. ". .. Receipt•attach PS Form 3811 to your mailpiece; IMPORTANT:Save this receipt for your records. Ps Forth 3$00,April 2015(Reverse)PSN 7530-02-000.9047 SENDER: ■ Complete items 1,2,and 3. A Si ature r, S 1 E Print your name and address on the reverse X `(,(/ gent so that we can return the card to you. / ❑Addressee 1 ■ Attach this card to the back of the mailpiece, Re eived (Printed Name) C. D e of D ivery or on the front if space permits: - a f 1. Article Addressed to: D. Is de ivery address different from item 1? Yes Elizabeth Walsh - If YES,enter delivery address below: ❑No 1 20 Brigantine Avenue Osterville, MA 02655 � I -- l 3. Service Type ❑Priority Mail Express(b lIl IIIIII I'll III I I I i I I II II Illll I II I it III I II III ❑Adult Signature ❑Registered Mail ❑Adult Signature Restricted Delivery ❑Registered Mail Restricted) O Certified Mail@ Delivery 9590 9403 0922 5223 8288 44 ❑Certified Mail Restricted Delivery ❑Return Receipt for ❑Collect on Delivery Merchandise 2._.Article Number(Transfer from_Service label) ❑Collect on Delivery Restricted Delivery ❑Signature ConfirmationTm 0 Insured Mail ❑Signature Confirmation 015 15 2 0y 0x0 01 t 2 2'7 3'' 2 6 7`1 m� ❑Insured Mail Restricted Delivery Restricted Delivery. lover$500► PS Form 3811,July 2015 PSN 753.0-02-000-9053 Domestic Return Receipt USPS TRACKING# First-Class Mail Postage&Fees Paid USPS Permit No.G-10 9590 9403 0922 5223 8288 44 United States 'Sender:Please print your name,address,.and ZIP+4®in•this box* Postal Service l Town of Barnstable ` Public Health Division 200 Main Street Hyannis, MA 02601 I I ins-�S :s.� i�i t •i li ii ii� = i°3i'3 ii= ii l.; :f' i•3=t's 1 ai iis� � 't i �it ii3; i �� '�� � itlliii�i81 1 Of1HE Town of Barnstable Barnstable Regulatory Services Department ABOUnWOM saxtvsr�Bt�, ; , Public Health Division �A 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard Scali, Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7015 1520 0001 2273 2671 February18, 2016 Elizabeth Walsh 20 Brigantine Avenue Osterville, MA 02655 . ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 20 Britantine Avenue,Marstons Mills,MA was last inspected on 1/14/2016 by David B. Mason, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. You are ordered to repair or replace the septic system within one (1)year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH • c can, S., CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\20 Brigantine,MM Feb 2016 Town of Barnstable HARN3fAHLE, • - 9 8 Regulatory Services Department prED MA't� . Public Health Division 200 Main Street,Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A McKean,CHO Feb 6,-2007 - Rev. 7/6/15 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑Discharge or ponding of effluent to the surface of the ground ❑Pumping more than 4 times during the last yea-r not due to clogged or obstructed pipe. ❑Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE 1 YEAR DEADLINE CRITERIA Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS ox cesspool ❑Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑Any portion of the cesspool within a Zone 1 to a public well ❑Any.portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑Any"conditionally passed systems" (broken cover,relocation of a pipe,relocation of a driveway due to H-10 components; etc) ❑.Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code §360-9.1) OTHER Repair deadline: WSEPTIMDEADLINES TO REPAIR FAILED SYSTEMS.doc Parcel Qetail Page 1 of 3 71 . �ry.a.,,J�. ...,.+h.. d -a . I/i+�l6z> Logged In As: Pa rCe I Detail Wednesday,February 3 2016 Parcel Lookup • Parcel Info Parcel ID 121-139 m._...� - �_m- - ~I Developer I FI Lot Location 20 BRIGANTINE AVENUE �µI Pri Frontage F125 .... I Sec Road , Sec Frontage e ....�..,_�.._.�.�.».._.�...� ..�.�.�.I village MARSTONS MILLS I Fire District C-O-MM Town sewer exists at this address NO r T I Road Index Asbullt Septic Scan: Interactive , 1211391 MapF ,'`� T ^^fin Owner Info owner•WALSH, ELIZABETH _ _ y I Co-owner streets 20 BRIGANTINE AVENUE ( Streetz city OSTERVILLE " I State'MA Zip 02655- country i Land Info Acres 0.78 I use Single Fam MDL-01� ( Zoning ;R Nghbd;0105 Topography'LeVel I Road ;Paved� I Utilities Public Water,Gas,Septic I Location 1i Construction Info Building 1 of 1 Year' I Roof jG Ext able/Hi (Wood Shingle Built Struct p I wall g Y .I Living Roof ACCentral>. .�-- Area 1132 I cover Asph/F GIs/Crop I Type Style,Ranch wall;Drywall � �I Bed f2 Bedrooms _I 1a - Rooms ,� -_ ____ .b; tfal I Int Car Bt " Bath Model Siden Floor p I Rooms1 Full-1 Half �_ Heath___ . ._ Totals .. Pia ., 2 Grade,AVerage ( Type,Hot Water I Rooms " Heat Found- Stories,1 Story - I Fuel Gas Iation Poured Conc. Gross'28 - _ — _. .I Area • Permit History _ Issue Date Purpose Permit# Amount Insp Date comments B/21/2012 New Roof 201205112 $4,500 6/30/2013 12:00:00 AM REROOF OVR 1 LAYER http://issgl2/intranet/propdata/ParcelDetail.aspx?I0=7615 2/3/2016 Commonwealth of Massachusetts W Title 5 Official Inspection Form COQ� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 20 Brigantine Avenue Property Address Elizabeth Walsh ►+ Owner Owner's Name �.. information is MM MA 02655 January A required for every ffe ry 14, 201�, page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered irony way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not David B. Mason use the return Name of Inspector key. David B. Mason Company Name 4 Glacier Path Company Address East Sandwich MA 02537 City/Town State Zip Code 508-367-1617 S1287 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspector's Signatur ' 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 C Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 20 Brigantine Avenue Property Address Elizabeth Walsh Owner Owner's Name information is Osterville MA 02655 January 14, 2015 required for every ry page. Cityrrown State- Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 20 Brigantine Avenue Property Address Elizabeth Walsh Owner Owner's Name information is Osteryille MA 02655 January 14 2015 required for every ry , page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).. The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ 'Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain.below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR ` 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/1.3, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 20 Brigantine Avenue Property Address Elizabeth Walsh Owner Owner's Name information i e Osteryllle MA 02655 January 14, 2015 required for every y page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines,that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well"*. Method used,to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 20 Brigantine Avenue Property Address Elizabeth Walsh Owner Owner's Name information is Osterville MA 02655 January 14, 2015 required for every ry page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped.- El ® 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form II c Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Brigantine Avenge Property Address Elizabeth Walsh Owner Owner's Name information is Osteryille MA 02655 January 14, 2015 required for every rY page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® 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): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 20 Brigantine Avenue Property Address Elizabeth Walsh Owner Owner's Name information is Osterville MA 02655 January 14, 2015 required for every rY page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Yes 9 ( Y 9 (gp ))� Detail 2014; 25,000 gallons and 2015; 49,000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: currentDate 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 I - Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 20 Brigantine Avenue Property Address Elizabeth Walsh Owner Owner's Name information is Osteryille MA 02655 January 14, 2015 required for every ry 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: Board of Health Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Truck gauges Reason for pumping: Maintenance Pumping Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy f ❑ 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•3113 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 ;M 20 Brigantine Avenue Property Address Elizabeth Walsh Owner Owner's Name information is Osterville MA 02655 January 14, 2015 required for every ry 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: Installed March 10, 1995 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 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.): Aging materials. Septic Tank (locate on site plan): Depth below grade: 1 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 Typical Sludge depth: 6" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 20 Brigantine Avenue Property Address Elizabeth Walsh Owner Owner's Name information is Osterville MA 02655 January 14, 2015 required for every ry page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cant.) Distance from top of sludge to bottom of outlet tee or baffle 40" Scum thickness 6" Distance from top of scum to top of outlet tee or baffle 1" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Scour 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.): Effluent level with,outlet invert. Maintenance pumping required. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date l5ins•3/13 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 20 Brigantine Avenue Property Address Elizabeth Walsh Owner Owner's Name information is y Cisterville MA 02655 January 14 2015 required for 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 HoKbg Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below g-ade: 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•3/13 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 20 Brigantine Avenue Property Address Elizabeth Walsh Owner Owner's Name information is Osterville MA 02655 January 14, 2015 required for every ry 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 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 backed up above outlet invert. Evidence of carry-over. Distribution box is collapsed due to decay of the box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Leaching field without inspection port. Inspected with camera. t5ins•3/13 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 wM 20 Brigantine Avenue Property Address Elizabeth Walsh Owner Owner's Name information is OSterville required for every MA 02655 January 14, 2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3-Infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Use of camera indicated that effluent is standing in the chambers above the effective leaching area. The observations represent the conditions observed at the time of inspection only. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 y Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 20 Brigantine Avenue Property Address Elizabeth Walsh Owner Owner's Name information is Osterville MA 02655 January 14, 2015 required for every rY page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 f Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 20 Brigantine Avenue Property Address Elizabeth Walsh Owner Owner's Name information is ry ,Osterville MA 02655 January 14 2015 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 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 20 Brigantine Avenue Property Address Elizabeth Walsh Owner Owner's Name information is Osterville MA 02655 January 14, 2015 required for every y 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: 12 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: Groundwater Contour Map ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Groundwater Contour Map I Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 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 wM 20 Brigantine Avenue Property Address Elizabeth Walsh Owner Owner's Name information is Osterville MA 02655 January 14, 2015 required for every y 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Assessing As-Built Cards Page 1 of 2 r. TOWN OF BARNSTABLE jAnoN_L0 Joe SEWAGE# ` VILLAGE_ ASSESSOR'S MAP& LOT INSTALLER'S NAME& PHONE NO., �c'� . c•S'c Y i S �' SEPTIC TANK CAPACITY/ d c; •�. i LEACHING FACILITY:(type) w >t .._ (size) NO.OF BEDROOMS__3_PRIVATE WELL OR PUBLIC WATER, BUILDER OR OWNER DATE PERMIT ISSUED: 3-1 Ca •- DATE COMPLIANCE ISSUED: J /C VARIANCE GRANTED. Yes No X-' tom.. f ' 0 http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=121139&seq=1 1/30/2016 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 20 Brigatine Ave, Property Address Elizabeth Walsh i Owner Owner's Name information is every Oste, le MA 02655 Janau required for eve � ry 18, 2012 page. City wn� State Zip Code Date of Inspection In ection results must be submitted on this form. Inspection forms may not be altered in any wa . Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, � q� use only the tab 1. Inspector key to move your cursor-do not David B. Mason use the return key. Name of Inspector , David B. Mason � Company Name 4 Glacier Path Company Address East Sandwich MA 02537 Cityrrown State Zip Code 508-367-1617 S1287 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Janaury 18, 2012 Inspector's Signature Date The system inspectors*hall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)withi 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. t5ins-11110 Title 5 Official Inspection Form:Subsurface ewa a Dis osal System+Pa P 9 P Y ge1of17 r� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 20 Brigatine Ave, Property Address Elizabeth Walsh Owner Owner's Name information is Osterville MA 02655 Janau 18, 2012 required for every ry page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This inspection information represents the condition of the system on January 18, 2012 at Noon and only that date and time nor does the inspection guarentee the future operation of the system. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Brigatine Ave, Property Address Elizabeth Walsh Owner Owner's Name information is ry Osterville MA 02655 Janau 18 2012 required for every , page. Citylrown 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Brigatine Ave, Property Address Elizabeth Walsh Owner Owner's Name information is ry Osterville MA 02655 Janau 18 2012 required for every , page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *'This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Brigatine Ave, Property Address Elizabeth Walsh Owner Owner's Name information is ry Osterville MA 02655 Janau 18 2012 required for every , page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® 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-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 20 Brigatine Ave, Property Address Elizabeth Walsh Owner Owner's Name information is Osterville MA 02655 Janau 18, 2012 required for every ry 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 20 Brigatine Ave, Property Address Elizabeth Walsh Owner Owner's Name information is ry Osterville MA 02655 Janau 18 2012 required for every , page. CityTTown State Zip Code Date of Inspection D. System Information. ' Description: Number of current residents: 1 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 years usage(gpd)): Detail: 2011; 25,000 gallons and 2010; 23,000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: Current 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Brigatine Ave, Property Address Elizabeth Walsh Owner Owner's Name information is Osteryille MA 02655 Janau 18, 2012 required for every ry 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: Board of Health 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M ,•�'° 20 Brigatine Ave, Property Address Elizabeth Walsh Owner Owner's Name information is Osterville MA 02655 Janau 18, 2012 required for every 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: 1995 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: NA feet Comments(on condition of joints, venting, evidence of leakage, etc.): Those components visible appear in good condition Septic Tank(locate on site plan): Depth below grade: 1 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: Typical 1000 gallon tank Sludge depth: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ,•'` 20 Brigatine Ave, Property Address Elizabeth Walsh Owner Owner's Name information is ry Osterville MA 02655 Janau 18 2012 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 36" Scum thickness 5" Distance from top of scum to top of outlet tee or baffle 2" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Scour 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.): Effluent level with outlet invert. Tank has precast tees which appear in working condition. No evidence of leakage at the time of inspection. Septic tank is in need of maintenance pumping. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Brigatine Ave, Property Address Elizabeth Walsh Owner Owner's Name information is Osteryille MA 02655 Janau 18 2012 required for every ry , 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 El 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 20 Brigatine Ave, Property Address Elizabeth Walsh Owner Owner's Name information is ry Osterville MA 02655 Janau 18 2012 required for every , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Even with outlet pipes 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.): Dbox covered found cracked. Requires riser and new cover. Dbox is approx 18inches below grade. 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: Existing leach pit and newer leaching; infiltrators installed in 1995. No inspection port required at that time. Probed area and appeared dry. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 20 Brigatine Ave, Property Address Elizabeth Walsh Owner Owner's Name information is ry Osterville MA 02655 Janau 18 2012 required for every , page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ® leaching chambers number: 3 infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No signs of hydraulic failure. Probed area and appears dry. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 7-7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 20 Brigatine Ave, Property Address Elizabeth Walsh Owner Owner's Name information is Osterville MA 02655 Janau 18, 2012 required for every ry page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 20 Brigatine Ave, Property Address Elizabeth Walsh Owner Owner's Name information is Osteryille MA 02655 Janau 18 2012 required for every ry , page. Cityrrown 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 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 20 Brigatine Ave, Property Address Elizabeth Walsh Owner Owner's Name information is ry Osterville MA 02655 Janau 18 2012 required for every , page. Cityrrown State Zip Code. Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 30 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: Ground water contour map ® Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: gourndwater contour map and septic designs in the area Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 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 ,M 20 Brigatine Ave, Property Address Elizabeth Walsh Owner Owner's Name information is Osterville MA 02655 Janau 18, 2012 required for every ry 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 I � ,, r� t ��. p"y I i � i � .:� _ �l , c • � ,� � . ..r; _ �:�' ti ��: ,,� :__..__ Q, d s .�� 2 � t CAT Ion l iU I ,� rro. ILLAGE P DDRESS , L/PLICANT FEE p n-refundabl �Q/yIn2 HONE NO_ NGINEER TELEP ONE NO. ATE SCHEDULED n �-- t (API 2nt5;s signature) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SOIL LOG UB=DIVISION NAME - DATE__ /� �.. XPANSION AREA: YES!�, NO _ �l/. ( ,�oSS �'l1�11� ENGINEER OWN WATER , CPRIVATE WELL �ol� BOARD OF HEAL' EXCAVATOR KETCH: (Street name, etc. ,dimensions of lot, exact location of test holes and percolation tests, locate wetlands in proximity to test holes) NOTES: �UTZ qSr PERCOLATION RATE: TEST HOLE NO: ELEVATION: TEST HOLE NO: ELEVATION: 2• - �5��3�5 1 - 2 3 3 4 4 - 6 7Z7 6 7 7 9 9 10 10 11 .11 12 y 12 13 13 14 14 15 -15 16 16 SUITABLE FOR .SUB-SURFACE SEWAGE-: LEACHING ,.FIELD LEACHING _P_TTS LEACHING TRENCHES UNSUITABLE FOR SUB-SURFACE SESJAGE . REASONS TE : ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICATION ,_jR IG I%1AL : CO'-1PLETED TN ENTTRETY BY P F AND RFTUR`iFD TO BOARD OF HEALTH '! l o f T( T LOC TIOb SEWAGE PERMIT UO. VILLAGE a/ — /37 � o INSTALLER'S NAME A ADDRESS 0UIL0ER OR owpER C iv/v/ S ]�r9� Cvti y u a ,OAo DATE PERIRIT ISSUED 9 /U _ DATE COCIPLIARICE ISSUED /oZ o23 t k r� r 30 3 H,)uS- No... .1. Fss.......................... _ . THE COMMONWEALTH OF MASSACHUSETTS r j BOAR® OF HEALTH Wd1........I.................OF...... Appliration for Disposal Works Tonstrnrtinn 1hratit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................ ............. r ! Locati p Address oy Lo ......... r%0--d............ ^�oY_.. .. ..v.... n , Oyvner Address Installer Address PQ d Type of Building Size Lot..-...®R ----Sq. feet U Dwelling—No. of Bedrooms- �-------------- Expansion Attic ( ) Garbage Grinder ( ) a --- p, Other—Type of Building ................. No. of persons....... ----------------- Showers ( ) — Cafeteria ( ) a' Other fixtures ............................ . W Design Flow.......S.S............................gallons per person per day. Total daily flow...............13 ................gallons. Septic Tank—Liquid'capacity fP....gallons Length-... ......... WidthN..4._..--. Diameter................ Depth......4..... W Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area......................sq. ft. Seepage Pit No..................... Diameter.--...--.---.--..... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) -. a Percolation Test Results Performed by....A.6.-AVAiv.....� .......... Date.....b _.,2_ ............ a Test Pit No. 1...A......minutes per inch Depth of Test Pit....l.?........ Depth to ground water----�✓ f'. .-." (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.........--.........--.. a -------------- ----------------------------------------- ------------------------------• --•-..........-------•-----•----•---•-.....------....-----•----- O Description of Soil...S.V.b... .....row.r.Ie..........r'-J_k P / ire' ....... ------------------------------ x W UNature of Repairs or Alterations—Answer when applicable............................................................................................... -------------•--------------------------------...........•---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT-TE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i sued by the oa d of health. Signe ----- ----••------..----- ..... S - ..... .............. J Da Application Approved BY x1----------. Date Application Disapproved for the following reasons----------------•-------•---...------------------------------...----------------...----------------.....----..... ....................•----•-•-•---...-----•--•---...-----------......---------------..._•----------•------ Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS f BOARD OF HEALTH Appliratiun for Disposal Works Tuntrnrtion Varaft Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: �o T..... ........r.c� — f � ,,� � iL /ices�..................................................................... .........._...___...__...................... ......................................... Locatign-Address i o LotiNo. ............ •• --•.. .... ............•---•••-•....................._.... �.. //fr, li Owner Address Installer Address Type of Building Size Lot...... Sq. feet Dwelling—No. of Bedrooms... ...•...............................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—T e of Building/g- No. of persons....... ................. Showers ( ) — Cafeteria ( ) dOther fixtures ------------------------•-----------------------•-•---•••••••-•-•••••••---•••••••••••---•.............-••--•-••••---.........-••-••......---•-----•-- W Design Flow....... ...•..........................gallons per person per day. Total daily Pow............... .....................gallons. WSeptic Tank—Liquid capacity?K, ...gallons Length--_`--......... Width!a.- ....... Diameter................ Depthl..... _.. x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area•.-.-•••_..-----_-_-sq. ft. Seepage Pit No--_----------------- Diameter.--................. Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '~ Percolation Test Results Performed by..../-!r^i. ±/?r ...........1..(.....-1 fl c�.............. Date..... 2, �_�.....__..... 9 Test Pit No. 1...e5?!:........minutes per inch Depth of Test Pit.... :%.._...... Depth to ground water----N� _ ._.. (s., Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ••-•-•••••--•...-•--••-•••--......•••••...••••••....•••• ••-•....••-•••--------------•-•-••-•--•-•......................................................... O Description of Soil--,S�..... •-=- fin.{,r F .. cr 6', ,r. ....... U -••••••••-••-••••••••......•-•••-•---•--•----••-••-....-•••••......-•----•--•-....••-----••---••-•••-••--•-•--•-•-••••-••-••-•-•-•-••••----•----•---•••••.....-•..................••••-•--....-•-•••••. W VNature of Repairs or Alterations—Answer when applicable............................................................................................... ------- ------------------------ --------------------------------------------------------------------------- -•----------------------------------------------------- ••••••••-......••••-------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T?TLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i sued by the board of health. Signed.__ } �--------•- -fl.:Gc.1------••-------••----•--. .. /f f /...._.... ' Date Application Approved By---...... .....: ./✓•! _ z-S-/_K.�---......... /Date Application Disapproved for the following reasons------------------------------------=•----------......---------•-----•-----------•-----•-•-•••••--•.....----•-• ........••-•--•-•••-----•-•---•-•••---••.......-----••••••••........•-•---••--••......--•---....•-••-----••••-••-••---•-••••••••••-•••-••--•••-•••-•-••---•••-•••••-•••-•.............•••-••---••--•--- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r ........................OF..., sr. ...(2..................................... Turrtifiratr of Tootplinurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (,l ) or Repaired ( ) t s� � . /,� Installer at.....r`.-7.._....-...5 " ---•--..= s .T.:��'i" :/ �CJ�---•---- ` ,•!r'r==: `!l P �rJ ............ has been installed in accordance with the provisions of TIT LE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.-(�..�r%.�................ dated-.-............................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....................................... ----•------ Inspector.......--. --•--------=, ............................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH , �✓ P /, .. =.. . No.gJ.1 /.. FEE-�cam......•--..... Disposal orkp ion r ion rrntit Permission is hereby grante� .43-o......... r ----------------------------------------------------------------------- - to Construct (iO or Repair (; ) an Individual Sewage,,,Disposal System / c, ,.r is J /t/ L ! �� - -------------------- Street as shown on the application for Disposal Works Construction Permit No...................:. Dated.......................................... fir. '---:=f- Board of=Health DATE •• 8 .�/✓.••------.-.•----------------------- �. FORM 1255i HOBBS & WARREN, INC., PUBLISHERS I TOWN OF BARNSTABLE LO("ATION ..� 3� I�' N /�;! SEWAGE # 0 " i VILLAGE � � M M ASSESSOR'S MAP LOT,,2 Y1,1 INSTALLER'S NAME & PHONE NO.> J{V b . �s�-��'<* t , SEPTIC TANK CAPACITY d 6 e LEACHING FACILITY:(type) .3 TA (size) -- NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER /�i/�' �> i r '�(� :off✓ DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED• VARIANCE GRANTED: Yes No W 3 ; Y F Y y w � F ASSESSORS MAP N0: C�/ PARCEL NO, / 3 0 0 0 SNo....�.7-- �l-a-. Fx$............._............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Applirativit for Divi-pw3al Works Tonitrurtion Daum Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: 20 Brigantine Ave Osterville ..--•--.........•.............................•----------....----------------------.........--•-•• ....................................................•........................................... Location-Address or Lot No. ................Gge•_B i ge 1 ow....................... ._.. Owner Address a W.E......Rob_inson-•SePtic-„Service•_____________ P,.-0...... ox....1,089.... enterville...MA.................. Installer Address d Type of Building Size Lot.... ......... .........Sq. feet U Dwelling—No. of Bedrooms-------------3-----------------------------Expansion Attic ( ) Garbage Grinder0-4 ( ) Other—Type of Building ---------------------------- No. of persons..----------------.-.--.---- Showers ( ) — Cafeteria ( ) a Other fixtures •----------------------------- - - W Design Flow--------------------------------------------gallons per person per day. Total daily flow....---..................-----..------....--gallons. WSeptic Tank—Liquid capacity------------gallons Length---------------- Width----.-.----.---- Diameter_............. Depth---..-----...... x Disposal Trench—No. .................... Width---.......--.---.... Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No..................... Diameter...............--.-- Depth below inlet..--................ Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by--------------------------------------------------------------------------- Date---------------=....................... Test Pit No. 1----------------minutes per inch Depth of Test Pit.----............... Depth to ground water..--....--.--........... Test Pit No. 2................minutes per inch Depth of Test Pit.-.----.-.---------. Depth to ground water....................--.. R: ------------------------------------------•----------•--------------------------------------------_._...--•-•---------------•--•--...---..._........•-- 0 Description of Soil.........sand-•-----------•------------------•----------------------•------------------- U •---•--•------------------------•-•--.......-----------------------------•---------------------------------------•-------------•--•----•-------•-------•---------------•--•----..........---•---------• W ------•---------------------------------------------------------•------------------------------------------------------------------------------------•----------------------------•-•--•--.-...•-•------ U Nature of Repairs or Alterations—Answer when applicable.--.-install---3,--stonepa---. d .....inf iltxatOrs ...min......3....... tone, .off---exi-sting---d--boX• ,•••-i-netal-l----speed---le-ve-l-er---kn---d—box•------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed ----------------------------------------------------------------------------------------------------------- --------------------------------------- Date Application Approved By ........... .. ------------------------------------------ .---- le Application Disapproved for the following reafon - ----- -------- --------------------------------------------------------------------------------------------------- ..............:...........................................................................................................................................................--.................................... ----------......Dace.................. Permit No. ..........15------.... -� .,7C.----------- Issued ........................D--a re ----------------------------------------- 3. q J No.--1-�'� J. S� RmB 3 0.0 0............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 9, TOWN OF BARNSTABLE , Appliration for Di-ripnittl Works Tomitrnrt"inn Frruiit t Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individud'Sewage Disposal System at: 20 Brigantine Ave Osterville •..........................................••-•----•-------••--------------------------.......---- ...................._............................................................................. Location-Address or Lot No. George Bigelow ......................_.......--................................................................. -•-•-••------------•--•---••---••---•--•-•••----••••-------•••----................---------------- Owner Address a W._E.•••Rob inson--Septic Service P.O. box 1089...Centerville---IJ[A Installer Address UType of Building Size Lot-___•-•_____________________Sq. feet t, Dwelling— No. of Bedrooms...............3 ............................. Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons-------__--_____.-___---.--_ Showers ( ) — Cafeteria ( ) dOther fixtures ------------------------------------------------------------------------------------•--.............................................................. Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacitv............gallons Length---------------- Width----------- --: Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length---_____--...__-____ Total leaching area....................sq. ft. Seepage Pit No-----------_-------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) . aPercolation Test Results Performed by------------------------------------------------------------------------- Date------------------------------•-•••--- : a Test Pit No. 1................minutes per Inch Depth of Test Pit_................. Depth to ground water..................... (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ••--••-•--•--•---------------•----.....-•-•---••-------•-....----•------•----------•---......------.......................................................... 0 Description of Soil......... x W UNature of Repairs or Alierations—Answer when applicable.-_--Insta l---3- tOnepaoke-d---inf ltratQrs emi-st-,-*nc;--- ?--box , nsta—11----Speed----Leve Leveler .a—... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed -------------------------------------------- ----------------- ---------------------------------------- Due Application Approved B �� ��•���� PP PP Y ------ ---------------------------------------------------------------- .---..1��...—��'_"�--- l 15ace Application Disapproved for the following reasons: ------------------------------------------------------------------------------------------------------------- ------ -------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------- Permit No. ........ ''...-....J�..'�,t,.- Issued . -------- Date --—————,— ——— —.---- ..—_—-------.--------_.----.—. — —. -.— —.—.-------.—.----.— ----- r THE COMMONWEALTH OF MASSACHUSETTS s BOARD OF HEALTH TOWN OF BARNSTABLE (111-ex#iftcate of (1:111ontyliance } THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( X ) V: E Robinson._..Septie---- erv.i.c ----------------- -------`---- ------------------------------_-------------------............--------------------------- - Installer at --------2.0....Brigantine....Ave --Os.tervi-l.l.e----- ------- ----------------------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ....... ..��—_3., .fir-._. dated _-------------------- -------------- --- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTICIN SATISFACTORY.,— DATE 11.1 -- -- --- ---------- Inspector,,.:..__ �— Bigelow ------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH qq TOWN OF BARNSTABLE 3oao FEE......................... Mipotittl World Tnntrurtinn rrmit Permission is hereby granted--•-- ", -- ervi:c(........................................................ to Construct ( ) or Repair (X ) an Individual Sewage Disposal System 20 Br.i antine Ave___Ostervllle......-............at No. -••. --••---..--••-------------- Street � as shown on the application for Disposal Works Construction Permit No.,_._ s�__' - - Dated----- _::r .._ ...... rs -------------------------------------•-- f H ...._. C� ... oard of DATE----------------�_.`.�©__�/...., ............................... FORM 36508 HOBBS&WARREN.INC..PUBLISHERS• '�, i COVERS TO BE WATERTIGHT AND SEPTIC SYSTEM PROFILE TOP OF FOUNDATION BROUGHT TO WITHIN 6"OF FINAL GRADE Flaherty Environmental Services (not to scale) EL. 56.0' EL. 54.0' INSP. PORT W I 3" OF GRADE CLEAN SAND P.O. BOX 81 2" of If to " DOUBLE WASHED EL. 54.0' Yarmouth Port, MA 02675 4" CAST IRON or EQUIVALENT PEASTONr-OR GEOTEXTILEFILTER FABRIC 508.362: 1657 MIN. PITCH 1/4" PER FOOT `�pp a"SCHEDULE 40 PVC PIPE 4" SCHEDULE 40 PVC PIPE VENT IF REQUIRED (L� FLOW LINE jflist2'tobe/avel) ° 10' 1% —► S' 1% °' EL. 52.0't L.EXISTING 14 ®®C= 0 Q•: ° 'O �® o o _ 00010oo0o00 o p p O O 0°0°0°o°c EL. EXISTING —► 10 00 0 0 0 .'®� � o 0 0 0 L.51.3' o 0o 0 0 0 0 0 0 0 c REQUIRED: 5' SOIL REMOVAL f•' EL. 51,03' oo°o° OoO0000000o O O`O ® C7 0°O°o°0°C EL.51.2 0 0 0 0 0 0 �� "' °o°o°o°oc 2.0� LATERALLY AND BENEATH GAS BAFFLE EL. 51,0' Ooo0 0OOoo°oo0000 ��® �Qa�O ® o0000000�' PROPOSED SAS TO ELEV. 47,7'f 0000000000 000000 •d' •° O O O O •',•;_ o 0 0 0 0 0 0 °• d }", '"Oo°o°o°o° EL.49.0' (D-BOX) SOIL ABSORPTION SYSTEM :.'g.•`•.'`•ai�., / 6"CRUSHED STONE OR 1000 GALLON SEPTIC TANK MECHANICALLY COMPACTED (2) 500 GALLON CHAMBERS 6.5' (DATUM: ASSUMED) I WITH 4' STONE AROUND IN A 3" tom" DOUBLE WASHED STONE 12.83'W X 25=01 X 2'D CONFIGURATION �,• EL. 42.5' J BOTTOM OF TEST HOLE EL. 42.5' LOCATION MAP 52 Q D' 26143' USGS ADJUSTMENT: N/A GROUNDWATER ELEV: N/A N TH 0m GARAGE o DECK Rt.28 / b EXISTING L❑T 2 LOCUS 3 BR �. DWELLING EXIST, S.T. (APPROX.) 0.78 ACRES± Q EXIST, SAS c m ° NTS °� 5' REMOVAL AREA n 52 22' F f•'} ��ySN OFIy,�ss BENCHMARK: ia•?, o,':j' y ^� i R. TOP OF FNON f,'• 2 EL, 56.0' TH-1 0 21 p O �0/STERN TH-2 sq �T 1PN _ 54 54 52' 1 DA TE:61612016 REVISED; - SITE AND SEWAGE PLAN FOR B & B EXCAVATION, INC./ ELIZABETH WALSH �� 20 BRIGANTINE AVENUE SCALE : 1 = 3� OSTERVILLE, MA REF.'LCP 38071 A SH-1 PAGE 1 OF2 - .... .. ... ............. ............................................. ................................... ... ...- ................................ ..................................... .. ... .................................................................................................................................................................................................................................................................................................................................................................................................. GENERAL NOTES DESIGN CAL CULA TIONS S YS TEM DETAIL Flaherty Environmental Services P. O . Box 81 1. ALL PRECAST COMPONENTS TO BE H-1 0 Yarmouth Port, MA 02675 RATED UNLESS OTHERWISE SPECIFIED. NUMBER OFACTUAL BEDROOMS 3 508.362. 1657 ALL COMPONENTS WITH ANY ANTICIPATED VEHICULAR TRAFFIC TO BE GARBAGE DISPOSAL UNIT NO H-20 RATED. 2. THE DESIGN OF THIS SYSTEM DOES NOT TOTAL ESTIMATED FLOW ALLOW FOR THE USE OF GARBAGE (I 10 GAL/BRIDA Y X 3 BR) 330 GAL./DAY GRINDER. 3. MUNICIPAL WATER IS AVAILABLE. REQUIRED SEPTIC TANK CAPACITY 660 GAL. 4. ALL CONSTRUCTION TO CONFORM WITH SIZE OF SEPTIC TANK 1000 GAL. (EXISTING) 310 CMR 15.000 AND ALL OTHER APPLICABLE LOCAL, STATE AND FEDERAL SOIL CLASSIFICATION I 0 0 12,83' CODES AND REGULATIONS. DESIGN PERCOLATION RATE 2 MIN./INCH5. INSTALLER/CONTRACTOR TO REVIEW& VERIFY ALL ELEVATIONS AND DETAILS AND REPORT ANY DISCREPANCIES TO EFFLUENT LOADING RATE 0.74 GAL.IDA YIF T2 DESIGNER PRIOR TO CONSTRUCTION OR LEACHINGARE4 ASSUME ALL RESPONSIBILITY (2)x(25.0'+ 12.83)(2) = 151 SF 25' 6. INSTALLER/CONTRACTOR IS 25.0'x 12.83' =320 SF RESPONSIBLE FOR MAINTAINING SAFE 471 SFx 0.74 =348 GPD WORK AREA, VERIFYING ALL UTILITIES AND NOTIFYING "DIG SAFE" USE(2)500 GALLON CHAMBERS WITH 4'STONE (1-888-344-7233) 72 HOURS PRIOR TO AS DIAGRAMMED INA25.0'XI2.83'X2'CONFIGURATION CONSTRUCTION. Z ANY CHANGES TO OR DEVIATIONS FROM RESERVE LEACHING CAPACITY NIA THIS PLAN MUST BE APPROVED IN WRITING BY FLAHERTY ENVIRONMENTAL SERVICES AND LOCAL BOARD OF HEALTH. 8. FINISH COVER OVER COMPONENTS IS NOT TO EXCEED 3'PER 310 CMR 15.000 (NTS) UNLESS SHOWN PER PLAN. 9. ALL ABANDONED SEPTIC SYSTEM COMPONENTS TO BE PUMPED DRY AND SOIL EVALUATION FILLED WITH CLEAN SAND OR REMOVED TESTHOLE#1 PW 15068 TESTHOLE#2 P#15068 OF AND REPLACED WITH CLEAN SAND. Evaluator. DavidD Flaherty Jr,RS,REHS Evaluator David D.Flaherty Jr.,RS,REHS 1 OALL COMPONENTS TO BE PROVIDED SE#2755 SE#2755 BOH Witness: David Stanton,RS BOH Witness* David Stanton,RS WITH WA TER TIGHT ACCESS PORTS Date.- June 6,2016 Date: June 6,2016 0 WITHIN 6"OF FINISH GRADE. 11.ALL SEPTIC TANKS, DISTRIBUTION 7 certify that on November 12,2002,1havepassed TH-1 ELEV.53.0' TH-1 ELEV.53.0' the examination approved by the Department of BOXES AND PIPING TO BE INSTALLED Environmental Protection and that the above analysis O/STERGO WA TER TIGHT. 0'-8- AIE LS I0YR212 0.-9. AIE LS 10 YR 212 has been performed by me consistent with the R\ 12.NO KNOWN WETLANDS OR WELLS required training,exped1se,and experience described WITHIN 100 FEET OF PROPOSED 8'-33- B LS I0YR516 9'-34- B LS 10YR 516 in 3 10 CMR 15.018(2). LEACHING. 13.THIS IS NOT CERTIFIED PLOT PLAN 33"-64" C1 A 5Y 614 I 34"-62" C1 SL 5Y614 AND UNDER NO CIRCUMSTANCES IS THIS PLAN TO BE USED FOR ZONING OR 64%126" C2 MS 2.5Y614 I 62--120" C2 MS 2.5Y614 SITE AND SEWAGE PLAN . BUILDING PURPOSES. FOR F7/ 14.LOT IS SHOWN AS ASSESSOR'S MAP 121 El 46.3'perc LOT 139, 8 & B EXCAVATION, INC./ ELIZABETH WALSH, 15.LOCUS PROPERTY IS LOCATED WITHIN G.W ELEV.NIA G.W ELEV NIA AN AQUIFER PROTECTION DISTRICT 20 BRIGANTINE AVENUE (ZONE II). — OSTERVILLE, MA BOTTOM TH-1 ELEV 42.5' BOTTOM TH-1 ELEV. 43.0', PAGE 20F2 .......................... .......................-............................................. ........... .......... ............................................................................................................ ......................................- ...................-...................................... .......................... ........................................................... .................... .......................... ........... ... ........................................................................................................................................................................... ..................... 4, ( t L- s ,J me-Atk .3 SEA. a �' 1.•. f5A.I.Sev "fix ....�. *pt*rc-t-t V. t LJ ItS tit i►,J r co'� - ,. . � Vs• 1L�'S'S oTtr••1 ?t5�. 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