HomeMy WebLinkAbout0025 CHESAPEAKE BAY AVENUE - Health L
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100�1No.
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467
COMMON'WEALTfl OF MASSACHUS ETT
Board of Health, .lJPRnS A 6 L-E MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct("epairO Upgrade(--rAbandonO - 3r omplete System ❑Individual Components
Location 3 UUTE ` as Owner's Name . A, D
Map/Parcel# 98 t Address
Lot# Telephone#
Installer's Name �lh �' Designer's Name t Ci� �-� � C� �-e
Address &-(; Address Or
Telephone# °` 'Lz I Telephone# O b
Type of Building 5i F !. bw e l i 1* Lot Size 60 8517 sq.ft.
Dwelling-No.of Bedrooms Garbage grinder ( )
Other-Type of Building No.of persons Showers ( ),Cafeteria ( )
Other Fixtures
Design Flow (main.required')I gpd Calculated design flow Design flow provided gpd
Plan: Date [ �5// /7,'f Number of sheets Revision Dilate h ' ,p ���,�
Title L)f l tl�l'�2 �C r'Ge 0 S�� IOW 106 Qbep hal �.M6ll RUMN V ft-
Description of Soil(s) _
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not t ace the in operation until a Certificate of Compliance as been issued by the Board of Health.
Signed ate
� Q
Inspections AG G
_ FA�}TTO�VN�F BA INSTABLE
LOCATION 3 O Z.5 K �� /.I SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT ``0
��iJ s M 1 LL
INSTALLER'S NAME&PHONE NO. /�/i f7l >1�('i i� �� 5�A0
SEPTIC TANK CAPACITY �� Q
LEACHING FACILITY: (type) C'� �a (size)
NO.OF BEDROOMS
BUILDER OR O /�
PERMITDATE: COMPLIANCE DATE: (./
Separation Distance Between the: '
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
13
/4 ,/ 3® i
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17F.
/ � 9 97
� .r + ..✓_k\r_..... -.'�..� b �.-}r+.r^..� ,v"`\•..;_ .h^ a,.,�•('."..^^.�7'!.'"""^'�^.s�T^.-a..---...+.r �I+ra`Kr"'tJ`rtr.,,J�'.! .�.r' "" .. .�i ..-c:�'`� :s ��i=Y.._.
No. ` 14 ' FEE O�
%ice' ', us• : , � � '� + t
C®MM® r=�LTIJ OF MASSACHUSET44'
Board.of Health 1Z ns- qq 1--G- MA. g
APPLICATION FOP, DISP®.AL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct(1RepairO Upgrade(4''Abandon O 0 Complete System 0 Individual Components y;
Location og �U( ' Owner's Name , A, b ev Qp oA P
Map/Parcel# � / Address ��
r
s Lot# f Telephone# '
Installer's Name iZ/ I lh/ Designer's Name
Address �� - � Address l_ - ,�, pr C
Telephone# lt? Telephone#
Type of Building 5)on le F l'I V �w e I I 1• C f Lot Size 60 85 / sq.ft.
Dwelling-No.of Bedrooms Garbage grinder ( )
Other:-Type of Building fr t No.of persons Showers ( ),Cafeteria(
F' t' i
Other Fixtures 4 Q
Design Flow (min.required) gpd Calculatedesign flow Design flow provided 8 gpd
Plan: Date r,�/,,�JS/b y r Number of sheets Revision Date {� .{�'�� �\
Title-Y.Mr eie .Q_k_, Ge I szjxS � �CJS�P rho�C�rej�A oG# 30 d fM_t�C 1�11Lbejno• �
Description of Soil(s) :�_QA �-�'"1 / 4,
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
ti
DESCRIPTION OF REPAIRS OR ALTERATIONS ¢
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
+� further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed ��``'� i � Date
Inspections
No. 7�r '�`..���K" ,,((�� ��(l�ll �T V'V' ¶�,� � jt' M �,('���T TT a FEE
'l OM ®1V� if•f1�� ® S� 'l 11 U S� S,
Board of Health, > l�-'MA.
CERTIFICATE-OF.COMPLIANCE
Description of Work: ❑Individual Compbnent(s) ❑Complete System '
The and signed hereby e certify tha th Sewage Disposal System; Constructed ( ),Repaired (�(),-Upgraded ( ),Abandoned ( )
by: 5 !ln/+CA u f s Z t. d,-
at 4� V. a j
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. �•y u`�- 30 , dated I Q--1 qi-y`� . Approved Design 11�ow v (gpd) 3-&dfD(> � s
Installer S ,l d/ t� 1�/ti 'VI
Designer: Inspector: ��--� qv. Date: ,�0 Ll- 0%
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.XOAI_`�e
FEE �..
COMMONWEALTH OF MASSACHUSUTS
Board of Health, T , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an indhridual sewage disposal system
1'
at as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date Board of Health
_ y'TOWN OF BARNSTABLE
LOCATION /� ®� " ` � SEWAGE # "
VILLAGE z/'r7 5 iP� ASSESSOR'S MAP & LOT -0 1
INSTALLER'S NAME&PHONE NO. �✓/.C��/�i?7 , 7� � /�� �r��
SEPTIC TANK CAPACITY
a LEACHING FACILITY: (ty (size) `
NO.OF BEDROOMS
Al
BUILDER OR O
PERMIT;DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
I
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®E /� f/
Town of Barnstable
fFlE •'Regulatory Services` -
Thomas F. Geiler,Director
* HARNSTABU, •
. Public Health Division
rFo. ,�a Thomas McKean,Director .
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax:.508-790-6304
Installer & Designer Certification Forth
Date:
Designer: ��%�'� �'�� Installer:
Address: Address: 22� k41100
P—r
On ��f �,�//1 ;,/"U "was issued a permit to install a
(date) T (installer)
septic system at ton based on a design drawn by .
(address)
dated a4RLkrX
(designer)
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.
Zertify 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.
(Installer's ignatupef RA
< m
S gFGIS i cR�� QJ�
S��N o 5J
esi er's Signature) (Affix DE amp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOT191 THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE P LIC HEALTH DIVISION.
THANK YOU.
Q:Health/Septic/Designer Certification Form
1 } V
, + 1
'BORTOLOTTI CONSTRUCTION INC.
�BIIHBVRYAC_L BEt(J1f3L 0119 RY
SAL eYSTEH ZNBPECTTON. PLO
QeEe oL�tnspaction14Y Vt-,5-E96
•
PART a:
�- x _;�cgzcxLsT.
Check f the :`f61.owing have been _done: :
t.
Dttmpnq information �+`as :requested _of..the owner, occupant , and Etc>., ;
Health.
2tona .ofstem components `have been pumped for at least two
and the �4rs� m has been rcceiv.inq normal flow rates during that
piriod. e vo,°lumas of :.watar . ha�e, not�been introduced into the
s stem retl y y or as; part of ;this impaction.
11s built plans have been obtained .and `examined Note if they ar
avai'Iab ` �iU
e ta`Ci �� 'or dwelling yas inspected for signs of sewage
The s.1te «�P 3
incp`act ad for Sign& of .
breakout .
A11 systems G�braponents , .excluding the SAS , have been located ter,
Sit
The. aaptie .tank ai'anh.oles , were:: :uncovared, opened, and the inter r
the septic tank .vas anspected' Lor condition of baffles or tees ,
material of con=tiuction, .'dimensions, depth of liquid , depth o
sludq.i, depth of scum
_�,G T slze and .location of :.the ,.SAS :on the site has been determined
on existing antormation, or,;.approximated by non-intrusive method .
_�h Zacility:.ovi�er ,(a.nd` occupants, if different from owner ,
provido -with intorm.ation on. the .proper maintenance of sSDs .
SUBSURFACE .SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEX SNFORHATION
FLAW CONDITIONS
If 'resident.ial
. ;number .of bedrooms
number .Of Current residents .
garbage grinder, yes or no'
laundry connected . to system,. yes .or no
'seasonal_°use,-. yes,=or `no
St nonresidential`, : cal'culated flow;
W•�ter;.meter readings, if available: `
Last, date of occupancy
GENERAL :.INFORMATION
Pumping records and source ,of information:
�Zt
System pumped `as .;part.:_ of inspection, yes or no
if yes, volume pumped
Reason fo`r pun►pinq:
Type = system;
Septic tank/distribution box soil abs
orption sor tion system
S:i ng�s ^�A:sr;;oy p Y
Overflow cesspool
Privy
Shared. system. (yes or no) (if yes, attach previous inspection
records, if any)
Other:_ '(explain) .
Approximate' age of all components. Date installed, if known . Source of
inform,' ion:
Sewage. odors detected when arrivingat the s ' _
site, yes or no
. r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART. B
SYSTEM INFORMATION continued
SEPTIC. Vf NKs, ,9 Gr 7
(lodate'.,on 'Site p an) '
depth below grade:
material 'Ofrconstru.ct.ion: l/concrete metal FRP other (explain)
dimensions: ..'$ J Gx ��✓Xf�r --
sludge depth
' distance _from top.. of_. sludge to bottom of outlet tee or baffle
scum`:thickness
S'r ;distance; trom.top of scum to top, of outlet tee or baffle
:.: distance'.lrom `bottom of scum .to bottom of outlet tee or baffle
Comments
(recommendation. for,:.pump ing, condition. of inlet and outlet tees or baffles ,
depth of :liqutd bevel` in'.relation< to outlet invert, structural integrity ,
lakae : coamen fo repaevidence "o irs, etc.
Q` -W %44,7P
`DISTRIBUTION BOX:_
(locatw:On'`a to plan)
depth of: liquid level above outlet invert
:Comments -;
(note if 'level and distribution is` equal, evidence of solids carryover ,
eyidenee :of leakag into� Or. out cif `box, recommendation for repairs , etc . )
b-= 3er - Gtve/ y���r�''
PUMP: CHAMBER s:,LL1,L
(locate :on site;,plan)
.. pumps.,.in :working order, yes.-or no
Comments.:
(note condition of pump chamber, condition of pumps and appurtenances ,
recommen ations,. for maintenance or repairs, etc. )
SUBSURYACE SEWAOE DISPOSAL SYSTE?S INSPECTION FORM
PART'.B
SYSTEX INFORMATION continued
SOIL.:.ABSORPTION SYSTEM:..:(SAS) :
(locate;:on; site , pl:an, possible; excavation not required , but may be
approxintiatad °by. non-intrusive methods).
If .not do'termined .to be ,presant, explain:
Type
leaching; pits ;and ;.number l le00 Qa/ 4eaeh
leaching chaers and :.number
leaching galleries and ;number
leachinq_ trenchas, number, length
leaching: fields; numbe r, dimensions
overtlow:. cesspool, number
comments:
(note .condition ;ot . So 11 signs of hydraulic failure, level of ponding ,
,condition o v getataon, recommendations for maintenance or repairs , etc . )
CESSPOOLS (locate on . site plan) :W0
number and confi.guration
depth .top ot; liquid ao inlet invert
.:depth o!:` solids: layer. _--
depth oi; scum layer
dimensions :of cesspool'
Ai of:::constru6tion
ind`icat on of':g.rouridwater ,
inflow' (cesspool must :be pumped as
part of inspection):: ''
Comments:::::
(note eondit on: of soil, 'Signs. of hydraulic failure, level of ponding ,
condition of'-vegetation, recommendations for maintenance or repairs , etc . )
(locate .:on a te ,*plan)
xmaterias ot:Construction
dimensions ---
'depth ot. solids -
Coaunents:.
(note conditfon. of 9o112; signs of hydraulic failure, level of ponding,
.condition 0f ;vegetation; recommendations for maintenance or repairs , etc . .)
8 Q B 8 Q RPJ►CE SEWAGE DZSppSAL SYSTEM INSPECTION PORN
PART. B' '
SYSTEX INPORKATION continued
SKETCH OF:SEWAGE DISPOSAL SYSTEM:
include ..,ties .-to at least two .permanent references landmarks or benchmarks
locate all we.Ils within 100 '
1
RCn, r
�9
0
DEPTH .TO.'GROUNDWATER
55- 'depth to .groundwater
aethod of determination or: approximation:
:a
,t
SUBSURFACE,.BEW71GZ....DISP0SAL SYSTEM INSPECTION FORM
PART C.
FAILURW CRITERIA
Indicate .yes, no; or' not determined (Y, N, or ND) ��Describe basis of
tt iration ,in al.l instances:. , If not determined" , explain why not)
Backupol. sewaq fnto facility?
Discharge .or ponding of effluent to the surface of the ground or
surface.;.'waters?
Stat%^ Ai yid e�rel ;n the distr butior, box above outlet invert?
t}�'
Liquid depth. in _cesspool <6" below invert or available volume< 1/2 c+<+ ,
flow?
Required pumping 4 time or more in the last year?
number-'of'., times' pumped
Septic :tank; .is metal? cracked? structurally unsound? substantial
infiltration?: substantial exfiltration? tank failure imminent?
Is .any,-port ion ' 0f the SAS,; .ce.sspool or privy:
below,` the high groundwater .elevation?
within 5.0 feet 'of a surface water?
within: Y
'100 feet: of a surface water supply or tributary to a surface
water supply?
within'�'a :2one I of a public well?
, ,within 5,o. feet of a bordering vegetated wetland or salt marsh
(cesspools .and privies only, the SAS) ?
within'-.50 ' feet of. a rivate w
p ater supply well .
. less:'.than 100 feet` but greater than. 50 feet from a private water
supply well :'aith=no ::acceptable water. quality analysis? If the well
has baen;>analyz.ed to be: acceptable, attach copy of well water analys
forr `ooliform'bacter.ia,. volatile organic compounds , ammonia nitrogen
and ;nitrate: nitrogen.
SUBSURFACE SZWAOE DISPOSAL. SYSTEM INSPECTION PORN
PART D..
CERTIFICATION
Name of • -hspector
Company ,'Name ( /0 (SM Velu cso(lo Y-), :Z cC
Company Address `76v 5- Via- by�o
I :cert fy " .hat :I ��ave per inspected the sewage disposal system at.
this`:.addr4sa ';and .that .the ;.information reported is true, accurate and
complete as of the 'time- of ' inspection. The inspection was performed and
any: recomwbadatfons `regarding. upgrade, maintenance and repair are
consistsnt vith :my..traininq ;and experience in the proper function and
manitenancesof. on site- sewage .di posal systems.
.Chec one*
I-:have not,`.;found .any information "which indicates that the system fails
to_A:Qquately protect.,public h"ealth or the environment as defined n
310 CMR- 15 .303.." Any.. failure 6 i.te.ria not evaluated are as stated ir.
the P7IILORE ;CRZTERZ7► :section :of this . form.
I hire -determ .Tied that the system fails to protect public health or,.i
the environment as= defined in 310 'CMR 15 . 303 . The basis for this
determ nat'ion' is provided. in '-the FAILURE : CRITERIA section of this
f orm
Inspector' s;: Signature
Date
Ori:ginal .to ;system owner/
Copies . to:
Buyer (if. applic.able)
Approving, authority
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
MLE® IN MAP
INSPECTION PARCEL ,,
LOT
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
C `
Property Address: 3085 Falmouth Road
ervi a M A rc h—W 5 I
Owner's Name: Jilian Jones
Owner's Address:
Date of Inspection: 5/25/2004
Name of Inspector: (please print) Patrick T. Sullivan r-
Company Name: Ready Rooter c) M
Mailing Address: P.O.Box 371
Sandwich,MA 02563
Telephone Number: (508)888-6055
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address-and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The System:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Authority
Fails
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 is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
c� +� no
****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.
Page 2 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 3085 Falmouth Road
Osterville
Owner: Jilian Jones
Date of Inspection: 5/25/2004
Inspection Summary: Check A,B,C,D or E/ALWAYS co ete all of Section D
C. System Passes:
I have not found any information_which in ' tes that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any fail criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described i/rea
ditional Pass" on need to be replaced or
repaired.The system,upon completion of the replacempair,as appro ed by the Board of Health,will pass.
Answer yes,no or not determined (Y,N,ND)in thee folio 'ng statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old* p c tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltratio 'lure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tanked by the Board of Health.
*A metal septic tank will pass inspection if it is structnd,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is ava
ND explain:
Observation of sewage backup or brealout or high static water level in the distribution box due to broken or
obstructed pipe(s)/bokettl or uneven distribution box. System will pass inspection if(with
approval of Board
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The systemore than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if e Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 3085 Falmouth Road
Osterville
Owner: Jilian Jones
Date of Inspection: 5/25/2004
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require furthe;valuathe by the Board of thin order to determine if the system
is failing to protect public health,safety or thnt.
1. System will pass unless Board of Hine accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a mann rotect public health,safety and the environment:
Cesspool or privy is within 50 fe water
Cesspool or privy is within 50 fering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,
/safgJ and environment:
_The system has a septic tank and soil absorption system S))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 S is within a Zone 1 of a public water supply.
The system has a septic tank and SAS an the SAS is within 50 feet of a private water supply well.
_The system has a septic tank and S and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**. Method sed to determine distance
**This system passes if the wel ater analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic cons ands indicates that the well is free from pollution from that facility and
the presence of ammonia nitro n and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. copy of the analysis must be attached to this form.
3. Other:
Page 4 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 3085 Falmouth Road
Osterville
Owner: Jilian Jones
Date of Inspection: 5/25/2004
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
_,.�ischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool L,,,__
Static liquid level in the dislFibWen-box above aatW invert due to and overloaded or clogged SAS or
cesspool
— j/A Liquid depth in cesspool is less than 6"below invert or available volume is less than%s day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is 50 feet of a private water supply well.
_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
z (Yes/No)The system fails. I have determined that one or more of the above 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 fac' ty with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the folio 'ng:
(The following criteria apply to large systems in additi to the criteria above)
yes no
the system is within 400 feet of a surfa drinking water supply
_ —the system is within 200 feet of a butary to a surface drinking water supply
_the system is located in a ni gen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water ly well
If you have answered"yes"to question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the ge system has failed. The owner or operator of any large system considered a
significant threat under S on E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system own should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 3085 Falmouth Road
Osterville
Owner: Jilian Jones
Date of Inspection: 5/25/2004
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?
_ _ZHave 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 than owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
_Z ____ Existing information.For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 3085 Falmouth Road
Osterville
Owner: Jilian Jones
Date of Inspection: 5/25/2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): _
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 3 ;l ,
Number of current residents: -
Does residence have a garbage grinder(yes or no): Yc�
Is laundry on a separate sewage system(yes or no): 6, [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use: (yes or no): 2, � DQ b
�
Water meter readings,if available(last 2 years usage(gpd)): a c3p� Q0 6e;-.�P
Sump Pump(yes or no):
Last date of occupancy: r.v�•r�w�
COMMERCIALANDUSTRIAL
Type of establishment: _
Design flow(based on 310 CMR 15.203)l
Basis of design flow(seats/persons/sq , tc.):
Grease trap present(yes or no):
Industrial waste holding tank p nt(yes or no):
Non-sanitary waste disc harg o the Title 5 system(yes or no):_
Water meter readings,if a lable:
Last date of oocupancy/
OTHER(de ):
GENERAL INFORMATION
Pumping Records
Source of information: r F- c��,,,,,,,��-cam B n,w�t s--
Was system pumped as part of the inspection(yes or no):±cam
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank, ttiewbox,soil absorption system
Single cesspool
T Overflow cesspool
_ivy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
T Other(describe):
Approximate age of all components,date installed(if known)and source of information:
�7ti s����✓�. �.ti��r`C �c�� `l�,A,1-� chi SJIa
Were sewage odors detected when arriving at the site(yes or no):A,k:D
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 3085 Falmouth Road
Osterville
Owner: Jilian Jones
Date of Inspection; 5/25/2004
BUILDING SEWER(locate on site plan)
Depth below grade: 1 9 "
Materials of construction: cast iron Z40 PVC other(explain):
Distance from private water supply well or suction line: IeA
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: (locate on site plan)
Depth below grade: 1 O'•
Material of construction: ✓ncrete—metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: C.�&, �c.
Sludge depth: 17 1'
Distance from the top of sludge to bottom of outlet tee or baffle:
Scum thickness: 10 "
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: 7
How were dimensions determined: '
Comments(on pumping recommendations,inlet and outlet tee or baffle concfition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
GREASE TRAP:_(locate on site plan)
Depth below grade:
Material of construction:__,_concrete_metal_fiber s_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outle/teeaffl:e:
Distance from bottom of scum to bottomr baffle:
Date of last pumping:
Comments(on pumping recommenda ' ns,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence leakage,etc.):
f
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 3085 Falmouth Road
Osterville
Owner: Jilian Jones
Date of Inspection: 5/25/2004
TIGHT or HOLDING TANK: (tank must be puipped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction:_concrete me fiberglass_polyethylene_other(explain):
Dimensions:
Capacity: at s
Design Flow: ons/day
Alarm present(yes or no):
Alarm level: Al in working order(yes or no):
Date of last pumping:
Comments(conditio f alarm and float switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(I on site plan)
Depth of liquid level above outlet invert:
Comments(not if box is level and distribution to ets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: (locate on site plan
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pum hamber,condition of pumps and appurtenances,etc.):
Page 8 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 3085 Falmouth Road
Oste"ille
Owner: Jilian Jones
Date of Inspection: 5/25/2004 ,
TIGHT or HOLDING TANK: (tank must be puipped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction:_concrete_me fiberglass_polyethylene_other(explain):
Dimensions:
Capacity: gal s
Design Flow: Ions/day
Alarm present(yes or no):
Alarm level: AI in working order(yes or no):
Date of last pumping:
Comments(conditio f alarm and float switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(I on site plan)
Depth of liquid level above outlet invert:
Comments(not if box is level and distribution to ets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: (locate on site plan
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pin hamber,condition of pumps and appurtenances,etc.):
• Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 3085 Falmouth Road
Osterville
Owner: Jilian Jones
Date of Inspection: 5/25/2004
SOII.ABSORPTION SYSTEM(SAS):_(locate on site plan,excavation not required)
If SAS not located explain why:
Type
_ �ching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
t `.�[�I t X 1_�✓�� VaY :�.y�.t� Wes/• �i�'V.i.e� �S� ,r U�Ti��i Z.V i1lA/�1
CESSPOOLS: (cesspool must be pumped as part 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 s or no):
Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY:. (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,si of hydraulic failure,level of ponding,condition of vegetation,etc.):
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 3085 Falmouth Road
Osterville
Owner: Jilian Jones
Date of Inspection: 5/25/2004
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
no
-kj)a - LAo { 3
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 3085 Falmouth Road
Osterville
Owner: Jilian Jones
Date of Inspection: 5/25/2004
SITE EXAM
Slope
Surface water
Check cellar✓"
Shallow wells
Estimated depth to ground water>LcD feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record—If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
_LGChecked with the local Board of Health-explain: U:� 1, L ;, �. .a.�.
Checked with local excavators,installers-(attach documentation)
_Accessed USGS database-explain: . e, z,< �,�
You m Adescribe how you a lished the high ground water elevation: j
.
V-2.7
,~~'�� � � ��m
THE COMMONWEALTH orMxssAc*ussrrs
BO�� 0� U�
BOARD. " "
''���{�=�.-��F',��
Appliration for
Application is hereby made for u Permit to Construct ( X or Repair ( \ an Individual Sewage Disposal
System at:
4.4 Owner .... �&J
Installer ��a�,Address -��
Type ofBoil �� g �� Size
Dwelling:—I�u of 8edr000`o----'~�!.............................Expansion ( ) Garbage Grinder ( )
Other—Type of Building ............................ No of persons.......P------ Showers ( ) -- Cafeteria ( )
~� Other -----_.-'--.----____._____..._________________
Design Flow'---_-����'----'----gUl000per - ---
6c�dc Iaok--��u�� looa I.coct6�.�L��-- \��dt6��.{(�. D�mc��r------.. Dentb/"Y,'/°..
Disposal Trench--No .................... Width ....... Total Length.. Total leaching oz�--------------------
sq. 8
� Other Distribution box u osp, g ta n k
Percolation Test Results b� A, v f P-Date....YX
c�
0 � `�
-'---'---'---'--'--~-°---1~~��~^~k`~~~.................................................................................................................
� --.----------.-__----_.--_-------__------'--___-'-.--'_-.-_'-_----------'--------
[] Nature of Repairs orAdtorutions--Aoswcrwheounnicable.-.-----.----_-.--.-_-'-----.-.-----------
--__--_----.-_--_..-__'_----_----'-----__---_'-'--'--.---'------.--.--._-__----'-_--- �
The undersigned agrees to install the afore6cxcrB6ed Individual Sewage Disposal Byatao in accordance*with
the provisions of TL ITill-� 5 of the State Sanitary Code The undersigned further agrees not to place the system in
No...... n-� Fxs.... .....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appliratiun for Disposal Works Tom3 uriiun Vrrutit
Application is hereby made for a Permit to Construct ( V) or Repair ( ) an Individual Sewage Disposal
System at:
y
Location-Address x // corLo
i_: :...!'. ...} ...... I ( `(1..... ( Cy --4 0 6------L�,,!..h1LL,Z.x Z ,r!yo
caner { \ ddress
al t ......... 4� ------- ----------•----------------•- ....... _ ---------------- ------------.....
Installer Address
U Type of Building Size Lot...-=3.................
Sq-feef
�-, Dwelling—No. of Bedrooms___.......-:=2.............................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons-------(.1................. Showers ( ) — Cafeteria ( )
Other fixtures -------------------------
W Design Flow...............t)Cam
..................... per person per day. Total daily flow......... .....................gallons.
WSeptic Tank r—Liquid capacity!;h»gallons Length-`�z...... Width.4.1J.0.'. Diameter_____________ _ Depth_`>
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No....._._-_ --------- Diameter.Ah.C?_._.. Depth below inlet_1,�,'-D....... Total leaching areal-_�I( ._?...sq. ft.
Z Other Distribution box ( ) Dosing tank
r
aPercolation Test Resultsv Performed ------ �t....... �`S.:.0 4:1.. !1_ C!'Date.._. f�s.._. .........................�
Test Pit No. I................minutes per inch Depth of Test Pit.�!n.r,.__......._ Depth to ground water____ :' __-_____.
fs. Test Pit No. 2.......7..-....minutes per inch Depth of Test Pit__'.Ek... Depth to ground water____: ............
.-••---. --•-----------------------------------------------••---•-
D Description of Soil .._:--��t�a'.._�__�.n� -- �1 (JSb.c ... 1 �: (t_. , t
—� I .......... ..._... I r
V �
W .......................................................................................e...............................................................................................................
U Nature of Repairs or Alterations—Answer when applicable_............................................................................................
...............................-........................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the�...b..o��•ar•d of h th i
Signed rw .c=?�F.
Date
ApplicationApproved By.............................................................................................•--
Date
Application Disapproved for the following reasons:...................................................?............................................................
..........................................................1..............................................................................................................................................
I Date
Permit No........�.- 7 Issued
Date
i
THE COMMONWEALTH OF MASSACHUSETTS
BOARD -OF HE .LTH
C�rrtifiratr of untplianrr
THIS VIS TO-CERTIFY That the Individual Sewage Disposal System constructed ( or Repaired1by ................................................•--
nstaller -
// .
at-•--•----- _.�-466IL �(/ ----.r,t ..............................
has been installed in accordance with the provisions of T-f T171 of 'Re State Sanitary Code rs de�cribeA in the
application for Disposal Works Construction Permit No..__._..._>__ ________ ____________ dated...... -��_77 // { �'
t7`T ;
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON TRUE® AS A GU RANTEE TAAT THE
SYSTEM WILL FUNCTION ATISFACTORY.
i
DATE....--••-•---•----......._Lt_" Inspector ......
�,...... ..................... ------------------------------•-----------
THE COMMONWEALTH OF MASSACHUSETTS
OARD OF HEALTH
..........rc .. ..............
tJ'•• •- XFEE_._.
;Disposal orks Ton #r ion rrntit
Permission is ereby granted. +�/K��G - .. a----------------------------- -----------------------------------------
to Constru or Repair ( � an In 'victual Sewag posal mm
atNo.. .... .1-.....__ C ..S-f --6 -----•.. ..... ......
Street Q
as shown on the application for Disposal Works Construction Permit No.../ _ ated--- .._ .. _.-f}-••_.
. -------_---
rd of Health
DATE....................... ~..
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
i
S YS TEM PROFILE
NOT TO SCALE
TOP F"DN. FINISH GRADE FINISH GRADE OVER
ioi , o
EL. ioa,o a..p: e: FINISH GRA DE-0VE-R `
:.o... DIST. BOX 9B,o
.�.°•.°•: SEPTIC TANK FINISH. GRADE OVER
p
\ LEACHING PIT
12" MAX. /
`d 0
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a SHED PEAS TONE PRECA S T CONC. OR
d.. . o e. q •6. .:0.:.b.
BRICK & MORTAR
,•. 'o•: ': 3„ e OUTLET PIPE LEVEL TO 12" BEL OW GRADE
FOR 2 FT. MIN. ..a..o..° ., :-..
0
• ��'Q: .e a .o y O :Q •o
'o C. I. OR PVC TEES 9 EEZ
741
:o:�•'A. .a u4 0 0• ' , per-;c7 0• '
1000 GALLON
b.: DISTRIBUTION BOX o °�
EL . ° ' I
°Q::po Qu INSTALL ON LEVEL BASE 3/• TO ?-1/2" a 6 o
PRECAST CONCRETE a WA.SHED o PRE•CA S T p I
o..o•.b o.:o'.•:
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o• g; r•�
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I> .� •°! .
H-je0 REINF.
SEPTIC TANK
INSTALLON LEVEL BASE
NOTE.' EXCA VA TE TO ELEV. �'��. o D�',T ' •' '• '• ° • �a•'
• •n• n o-• O• 'a• ' • p:p' D' O• '
LOWER TO REMOVE ALL IMPERVIOUS I c 'n
MA TERIAL BENEA TH THE L EA CHING AREA �, 2 -, � 2 '-0 „
REPLACE EXCA VA TED MATERIAL WI H
6 '_0 ,,
CL EAN, CL A Y FREE SAND 10 .-0 „
EFFECTI VE DIAMETER
—' LEACHING PIT
GENERAL NO TES
ASSUMED INS TALL ON LEVEL BASE
?. A L L EL EVA TIONS SHOWN ARE BA SED ON
2. ; AL L PIPES IN THE S YS TEM MUS T BE CA S T IRON [,
fop G `ass�r' R_H9G0. ,o< _ OR SCHEDULE 40 PVC. y
3. THE BOARD OF HEAL TH MUST BE NOTIFIED
O SER VA TION PI T
WHEN CPv.,r TRUC T- ON IS COMPLETE. PRIOR
O A TION RA TE:
/o° -._.,o d TO BA CKFIL L ING
PERC ' ro i
MIN./IN.:
4. AlV.Y CHANGES IN THIS PLAtJ M;J,�T BE APPROVED 4, $
r/ BY THE BOARD OF HEALTH AND CAPE & ISLANDS
WITNESSED B Y*
SURVEYING CO., INC. G DUNNING
5. MATERIALS AND INSTALLATION SHALL BE IN BARNS.
Lo COMPL IANCE WI TH THE STA TE SA NI TARY - VA 40 HE-AL TH DESIGN DA TA
PRECAST CONCRETE CODE - TITLE V - AND LOCAL APPLICABLE DA TE.• _ _ _ _ _ _
L EACHINe PIT f i z 5...., P,t z
/�1� ' a� RULES AND REGULATIONS 3
6. NORTH ARROW IS FROM RECORD PLANS AND 0 „ 9 9.7 NUMBER OF BEDROOMa'S NO
/ r s
IS NOT TO BE USED FOR SOLAR PURPOSES TOPSOIL 6 GARBAGE DISPOSAL
� ��GAL .k 7. FL 000 HAZARD ZONE C SUBSOIL DAILY FL ON
ER
B. WA TER SUPPLYWN 36" SEPTIC TA NK REO 'D. u U GA L .
SEPTIC TANK PRO VIDEO GAL .
xr LEACHING REOUIPED 0—GPD.
MEDIUM
I / - SAND
l BO�� M AREA
000 sAccoN SI �✓ALL AR�AS= 1B8 S. 471
yl �� ✓ PRECAST CONCRETE S. F. X. GII,,$ F. s GPD
r s SEPTIC TANK /s
4 y�
' 0' o�2'�b � '° LEGEND ` o1�_s. F. �s
S. F. X G/S. F. GPD
►� �q zz �� ' No LEACHING PROVIDED — OGPD
/ \ 66" GROUNDWATERa s 9
PROPOSED EL EVA TION NO
EXISTING CONTOUR SINGLE FA MIL Y RESIDENCE G
OBSERVA TION PIT
❑ DISTRIBUTION BOX
PROPOSED SEWAGE DISPOSAL S YS TEM
y O LEACHING PIT PREPARED FOR
7 0 o SEPTIC TANK F .T��Y� ': BARNS TABL E HOLDING
3y PC 1 7 ROUTE 28
s tR?I RESERVE , xe\A" BARNS. OS TERVILLE - MASS.
DAV±D
PIPE INVERT EL EVA TION I sAt,."cC a
;1 2ti085
. /�� DA TF:' Fed. �' 9 i ��
r�srFR�° CAPE 6 ISLANDS SURVEYING, INC.
PLOT PLAN SCALE AS NOTED
►► ��- ro P. 0. BOX 334
�-9 SCALE.' 1 a _.3 O 98 7 9
z 9�' MAP SEC PCL L 0T j l-,_qE _'' `` PLAN NO. so /o e 9 TEA TICKET, MASS
'7
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