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0107 CHINE WAY - Health
(107 Chine Way Marstons Mills A = 098 060 i C Town of Barnstable P# Deparfitnent of Regulatory Services Public Health Division Date 3 �A aa3q �e� Z00 Main Street,Hyannis MA 026.01 Date Scheduled 1c, Time Fee Pd. Soil Suitability Assess�m{ ent for Sew a Disposal Performed By: ���� S�—I J '� Y Witnessed By: LOCATION& GENERAL INFORMATION Location Address r o 7 C 1-r �� Owner's Name q �.xs 0-ck tey vi 1 Address /d-7 Ck'tle CVet vl �4 ✓ 05ko .-JCS Assessor's Map/Parcel: QC 6 (� 1 �n (�c10r Engineer's Name NEW neer CONSTRUCTION REPAIR �_ Telephone'# — Land Use' FS'i cke.�a4 GN Slopes{tyo) 2_� Surface Stones Distances from: Open.Water Body 7 ft -Possible Wet.Area 7 2�eJ ft' Drinking Water Well L�11 ft Drainage Way ��� ft Property line -�/^rt Other fC SKETCH:(Street name,dimensions of)ot,exact locations oftestholes&perc tests,locate wetlands(n proximity to holes) In 0lX L 9 t� u - l Parent material(geologic) v U + Depth to Bedrock. AJ Depth to Groundwater: Standing Water in Hole: I Weeping from Pit fence N'd^i n Fs[imated:Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: . Depth Observed standing in obs.hole:. ____ in. Depth to soil mottles: in. Depth to weeping from sideo obs.dote:. in. 'around.water Adjustment ft. Index Well# Reading.Date: . Index Well level— PERCOLATION TEST Date Thne Observation ^ Hole# r Time at0" Depth of Pere: 3 6 S t ,^ $a...cA Tltne at 6" Start Pre-soak Time.@ f t o 'lime(9"-6') End Pie-soak 2- Rate Min:/Inch Site Suitability-Assessment: Site'Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test into be conducted within 100' of wetland,you must first notify the P Barnstable Conservation.Division at least one(1)week prior to beginning. QASEPTI0PERCF0RM.DOC r DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface,(in.) (USDA), (Munsell), Mottling (Structure,Stones,Boulders.. n i ten . : ravel to'Y 2 s/ 7 2+- 13S 7f3, DEEP OBSERVATION HOLE LOG .Hole# Depth from Soil Horizon Soil Texture: Soil Color Soil, Other Surface(in.) (USDA) (Muniell) Mottling (Structure,Stones,Boulders. Consistency.% rave Lo YVZ_ y/Z y-Z 6 �q� 5�,,.1 _to Z6 —7 z C � DEEP OBSERVATION HOLE LOG Hole# Depth.from Soil.Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) } (Munsctt) Mottling (Structure,Stones,Boulders: nsiste c Gra k _..yam _._..__..__�,.,. ........ �. .. _...,.... .. .. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil other Surface(in.) (USDA)' (Munsell) Mottling (Structure,Stones:Boulders, onsi en ra I Flood Insurance Rate.Map: Above•500 year flood boundary No_ Yes _ Within 500 year boundary No ya • Within t00 year flood boundary No— Yes . Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? -- If not,what is the depth of naturally occurring pervious material.,_ _ . Certification I certify that on .. L qq (date)I have passed the soil evaluator examination approved by the Departmertt;af Environmental Protection an&that the above analysiswas performed y me consistent with the.required traImi expertise and experience described:in�10"CMR 15.017. (/ Date _ Signature Q;VSBPTICTERC FORM.DOC •3 m �r rq Ai Mi Er rl- . FICA L E �* cE) Certified Mail Fee -31 Extra Services&Fees(check box;add lee as ~pdate) MA 02601 2019 ❑Return Receipt(hardcopv) $ C3 Return O []CertifiedMaiipt l RestdctednlDeliyery $ '�'OSTAi,Pla IC k r3 ❑Adult Signature Required $ (0 ❑Adult Signature Restricted DeUvery$ 0� BUCKLEY, GLADYS M TR 107 CHINE WAY r%- k OSTERVILLE, MA 02655 Certified Mail service provides the following benefits: a A receipt(this portion of the Certified Mail label). for an electronic return receipt,see a retail ■A unique identifier for your mailpiece. associate for assistance.To receive a duplicate ■Electronic verification of delivery or attempted return receipt for no additional fee,present this 73 delivery./C` 4 1 y rIN USPS®-postmarked Certified Mail receipt to the.-, ■A record ofdelivery(including the reciplents` retail associate. Signature)that is retained by the Postal Service" Restricted delivery service,which provides —0 for aspecified period. • delivery to the addressee specified by name,or 1-4 f 2 to the addressee's authorized agent _ Important Reminders: W -Adultsignatureservice,whichrequiresthe ■.You may purchase Certified Mali service with iJi signee to be at least 21 years of age(not lFirst-Class Mail®,First-Class Package Service®, available at retail). a Priority Mail®service. h -Adult signature restricted delivery service,whlctL ■Certified Mail service is not available for requires the signee to be at least 21 years of age, international mail. and provides delivery to the addressee specified-? e Insurance coverage Is notavailable for purchasey by name,or to the addressee's authorized agent,a with Certfied.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 Fbverage automaficallJhaudedwith. accepted as,legal proof of mailing,it should bear aD certain Priorify'Mail items:','';; ". USPS postmark.If you would like a postmark on r7i a For an 8dditional fee,ai(d.with'A proper,. this Certified Mail receipt,please present your ,11 endorsement odthe mailpiece,youmay 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.. of delivery(including the recipient's Signature). of this label,affix it to the mailpiece,apply You can request a hardcopy return receipt or an -appropriate postage,and deposit the mailpiece. r_1 electronic version.For-a hardcopy return receipt, -I. complete PS Form 3811,Domesfic Return Receipt attach PS Form 3811 to your mailpiece; IMPORTANT:Save this receipt for your records. PS Form 3800,April 2015(Reverse)PSN 7530-02-000.9047 SECTION COMPLETE THIS. ON DELIVER Y ■ Complete items 1,2,and 3. A Sig ature ❑Agent ■ Print your name and address on the reverse X so that we can return the card to you. A ❑Addressee ■ Attdch this card to the back of the mailpiece, ceived byffPrinted Name) D to of `livery or on the front if space permits. 3 A.;..�na+��s,_z.. n_��_aec.,e ,address different from item 1? ❑Yes i delivery address below: ❑No � KLEY, GLADYS M TRH,_- 107 CHINE WAY OSTERVILLE, MA 0265& ° rrrr ���vino-ryNc j ❑Priodty.Mail Express® Il l'��I'I I'II I'I I(I II'I II'I I III I III'III II'I III ❑Adult Signature. ❑Registered Mail w❑Adult Signature Restricted Delivery ❑Registered Mail Restricted ` 9590 9402 4798 8344 8589 54 y Certified Mail® Delivery` f i7 Certified Mail Restricted Delivery":� Return Receipt for ❑Collect on Delivery ` Merchandise �^t on Delivery Restricted Devery ' Signature ConfirmationTm r,_. ,7 015 y 1730 00 01 .4 9 8 7 9 613 r{,!Mail ❑signature confirmation Flail Restricted Delivery Restricted Delivery over ) r,\:.� PS Form 3811,July 2015 PSN 7530-02-000-9053 Domestic Return Receipt' USPS TRACIUNG# First-Class Mail Postage&Fees Paid USPS Permit No.G-10 9590 9402""Wi8344 8589 54 United States •Sender:Please print your name,address,and ZIP+4®in this box* Postal Service L 1 Town_of Barnstable 0®R"'..'i, Health Division 200 Main Street Hyannis,MA 02601 I : .-.- i�i��iiitali, 1111....1111filIl iii'Ii,11 ill ill Iiiiiiiiii,11fil Town of Barnstable Barnstable P~ ti fd�-Am�icaCity °* Inspectional Services BARNS'TA9M q� 6 9: ,� Public Health Division prFO �s 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas A.McKean,CHO FAX 508-790-6304 CERTIFIED MAIL#7015 1730 0001 4987 9613 March 20, 2019 BUCKLEY, GLADYS M TR 107 CHINE WAY OSTERVILLE, MA 02655 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 MersTbNs mitts The septic system located at 107 Chine Way Osterville,MA as inspected on 03/18/2019 by Michael DiBuono, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • 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 T o cKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mail ing\Failed or Needs Further Evaluation Letters\107 Chine Way Ostervil le.doe sf+e Town of Barnstable • -.� w w • lhRN3CABIE, =h- Regulatory Services Department ----P ublic 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. 5/11/16 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 year 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 ltatic liquid level in the distribution box above outlet invert due to an overloaded or ogged SAS or 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 facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts v bib Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9, 107 Chine way ;, Property Address Gladys Buckley ' Owner Owner's Name information is required for every Osterville Ma 02655 3/18/19 gym. 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 v 13L� filling out forms Lj3 on the computer, use only the tab Michael DiBuono key to move your Name of Inspector cursor-do not DiBuono Sewer And Drain use the return Company Name key. 35 Content Lane Company Address Cotuit Ma 02635 Cityrrown State Zip Code B� 508-364-9587 S113522 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 disposal 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 3/19/19 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 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 107 Chine way Property Address Gladys Buckley Owner Owners Name information is required for every Osterville Ma 02655 3/18/19 page. Citylrown 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: ❑ 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: System contains a 1500 Gallon septic tank as well as a concrete distribution box and a concrete leach pit. 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 El N F1 ND (Explain below): t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 r , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments u 107 Chine way Property Address Gladys Buckley Owner Owner's Name information is required for every Osterville Ma 02655 3/18/19 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): ❑ 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): 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 107 Chine way Property Address Gladys Buckley Owner Owner's Name information is required for every Osterville Ma 02655 3/18/19 page. Cityrrown 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 m provided that no other failure criteria pp , p to a 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 ® ❑ 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 t5insp.doc•rev.7/26/2018,. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 107 Chine way Property Address Gladys Buckley Owner Owner's Name information is required for every Osterville Ma 02655 3/18/19 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ® ❑ 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 '/z 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 water supply 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 2000 gpd- 10,000 gpd. ® ❑ 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 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .. 107 Chine way v Property Address Gladys Buckley Owner Owner's Name information is required for every Osterville Ma 02655 3/18/19 page. Cityrrown 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 ❑ ® 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)] t5insp.cloc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 107 Chine way Property Address Gladys Buckley Owner Owner's Name information is required for every Osterville Ma 02655 3/18/19 page. Citylrown State Zip Code Date of Inspection D. System Information 1. 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 Description: Number of current residents: 2 Does residence have a garbage grinder? ® Yes ❑ No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: 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 years usage (gpd)): Detail: Sump pump? ❑ Yes ❑ No 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 F Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 107 Chine way V Property Address Gladys Buckley Owner Owner's Name isrequired for every very Osterville Ma 02655 3/18/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit resent? p ❑ 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: p 9 Source of information: Pumped in 2016 Was system pumped as part of the inspection? ❑ Yes ® 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v 107 Chine way Property Address Gladys Buckley Owner Owner's Name information is required for every Osterville Ma 02655 3/18/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: Original to home 1979 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 6.5feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 107 Chine way Property Address Gladys Buckley Owner Owner's Name information is required for every Osterville Ma 02655 3/18/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 6.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 Looks to be H 10 Rated If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: 10" Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 8 Distance from top of scum to top of outlet tee or baffle Over outlet tee Distance from bottom of scum to bottom of outlet tee or baffle 30" How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is full up to top of tank. Evidence of levels up and over septic tank t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 107 Chine way Property Address Gladys Buckley Owner Owner's Name information is required for every Osterville Ma 02655 3/18/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. 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 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): 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 Commonwealth of Massachusetts I� Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 107 Chine way Property Address Gladys Buckley Owner Owners Name information is Osterville required for every Ma 02655 3/18/19 page. CItyrrown 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 um in � p p g Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. 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.): 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 �a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 107 Chine way Property Address Gladys Buckley Owner Owner's Name information is required for every Osterville Ma 02655 3/18/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.'7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 107 Chine wa 19y Property Address Gladys Buckley Owner Owner's Name information is required for every Osterville Ma 02655 3/18/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Failed 12. 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 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 DisposarSyslem-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 107 Chine way Property Address Gladys Buckley Owner Owner's Name information is required for every Osterville Ma 02655 3/18/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts ` lip Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - N g p y of for Voluntary Assessments ' 107 Chine way Property Address Gladys Buckley Owner Owner's Name information is required for every Osterville Ma 02655 3/18/19 page. Cityrrown 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 I c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 107 Chine way Property Address Gladys Buckley Owner Owner's Name information is required for every Osterville Ma 02655 3/18/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 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: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: TBD at time of perc 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 Commonwealth of Massachusetts ,F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 107 Chine way Property Address Gladys Buckley Owner Owners Name information is required for every Osterville Ma 02655 3/18/19 page. Cityrrown 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 ❑ 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 COMMONWEALTH OF MASSACHUSETTS F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS �T$ DEPARTMENT OF ENVIRONMENTAL,PROTEG hN� 0 00 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSME T ,'�- SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION l Property Address: 16 17C Owner's Name: v, 7' Owner's Address: / 0:5�SSS_ Date of Inspection: /Q/9,f00: Name of Inspector: lease print) Company Name: Mailing Address: •U- Telephone Number:190 ya-e, 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 . s Furth valuation by the Local Approving Authority is Inspector's Signature: Date: /'d"&A 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 ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form .6/15/2000 page I Page 2 of l I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: o� Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. S stem Passes: I have not found any information which*indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years.old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water.level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval.of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL. INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner- Date of Inspection: /Q 11g10 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 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 environme.n _ 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 wai er supply. The system has a septic tank and SAS and the.SAS is within 50 feet of a private water.supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This.system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,proN ided that no other failure criteria are triggered.A copy of the-analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: bate of Inspection: t3 CiC� 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''/z day flow 7 Required pumping more than 4 times.in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped d Any portion of the SAS,cesspool or privy is below high ground water elevation. i�0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds .indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria �® are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. '�. • -ate. :. -^- F: .... . .. ... - .. ( . ," . . ... 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• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems.in addition to the criteria above) yes no _ .the system is within 400 feet of a surface drinking water supply Ythe v system is within 200 feet of a tributary to a surface drinking water supply y the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in.Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under.Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: /0/7 Owner: Date of Inspection: 0 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No V"'_ 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? i/'_ 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) /Z _ Was the facility or dwelling inspected for signs of sewage back up? V"' _ 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.SoiI Absorption System(SAS)on the site has been determined based on: Yes no/ �! Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15302(3)(b)] 5 Page 6 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: - _" Owner: Date of Inspection: 610 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): 2330 Number of current residents: Does residence have a garbage grinder`(yes or no):L "`� ;. ;v>.. ,• Is laundry on a separate sewage system(yes or no):/)17VZif yes separate inspection required] Laundry system inspected(yes or no);,, "'• Seasonal use:(yes or no): Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy:tca��{ �-�c.[�J� COMMERCIALANDUSTRIAL,,,,� Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records �/� � Source of information: ' - — � Was system pumped as part of the inspection(yes or no): D If yes, volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval t! Other(describe): App o imate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):12e - 6 . f Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �7 SYSTEM INFORMATION(continued) Property Address: ./ &4ze Owner: Date of Inspection: 0 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_(locate on site plan) Depth below grade: Material of construction:1LIfoncrete_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) i Dimensions: v '5- ?1'& , aC " Sludge depth: cy/e � Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 3 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle:—� How were dimensions determined: Qln-,°ems& ,0/VaZ6if ,1771L Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels related to outlet invert, evidence of.leakage,etc.): GREASE TRA cate•on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.):. 7 l_ Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 0 Owner: L Date of Inspection: d TIGHT or HOLDING TANK:must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction:__concrete metal fiberglass__polyethylene _other(explain):. Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX/ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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.): PUMP CHAMBE/R (� l�a on site plan) Pumps.in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): J 8 Page 9ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: J012 lud'v, Owner: V— T d Date of Inspection: 2 /q/00 SOIL ABSORPTION SYSTEM(SAS): L- (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: 1 leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, et �. CESSPOOc%cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRI�(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4 Owner: Date of Inspection:,Z,0 /R/ T'` 2 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 enter the building. t� it 10 Page 11 of 11 Y OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: owner: pL Date of Inspection: ®® SITE EXAM Slope Surface water Check cellar Shallow wells / Estimated depth to groundwater•! 7 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: / fro uad w Il r � - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _A Address of property � �� ���N� W �� . �CL`4 v'a � S TIA4. Owner's name ; ; o` Date of Inspection 0 915 W PART A ' CHECKLIST J U N 7 19�5 Check if the followinghave been done: �L07BARN MTN � �'�7d Q��aRNiT�E' ASS. Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. 3� As built plans have been obtained and examined. Note if they are not , available with N/A. V The facility or dwelling was inspected for signs of sewage back-up. y The site was inspected for signs of breakout. All system components, excluding the SAS, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS.' q C N �L c9�. � g SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS I f res-ident AX, numberlof bedrooms .Inumberr,of current residents e garYiagexgrnder, yes or no ruwf� :.#VA W* f d !�- =laundry connected To' system, yes or no seasonal use, yes or no ""'E BMW If nonresidential, calculated flow: . Water meter readings, if available: q� Idgay000 Gaffia,14 r Q 49 COO Last date of occu a p ncy GENERAL INFORMATION Pumping records and source of information: 1 . c p g Num A MQ_ System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: y e 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) Other (explain) Approximate age of all components. Date installed, if known S.ource of informati n• Oar 0 . t \�r4 tqj Sewage ;odorsjdetected when arriving at the site, yes or no r r ►. ! SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM \ PART B SYSTEM INFORMATION continued SEPTIC TANK.. (locate on site plan) a depth below grade: 7 �� material of construction: V concrete metal FRP other(explain) dimensions: r7 L . lor �► � .�� q„� �`�" puf��, y, 3 �, r� yam. srt"'o nZ sludge depth distance from top of sludge to bottom of.-Outlet tee or baffle scum thickness O distance from top of scum to top of outlet tee or baffle O distance from bottom of scum to bottom of outlet tee or baffle Comments: (recommendation for. pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, recommendation for repairs, etc. ) ' TaNly, DISTRIBUTION 'BOX: (locate on site plan) depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc. ) t PUMP CHAMBER: (locate on site plan) pumps in working order, yes or no Comments: " (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc. ) 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION PORK PART B SYSTEM INFO TION continued SOIL ABSORPTION SYSTEM (SAS) : (locate on site plan, if possible; excavation not required, but may be approximated by-non-intrusive methods) If not determined to be present, explain: Type. L,I-leachin9 pits and numbercc-Y1- { leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, 'dimensions overflow cesspool, number Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition o vegetati n, rpm,o\mmendations for mai�nwt�enan a 1�� epairs,etc ) CGSL QW �J ) 1 vC fa t� 1!S hape CESSPOOLS (locate on siapla )� number and configuration depth-top of liquid to inlet invert depth of solids layer 1 depth of scum layer dimensions of cesspool materials of construction indication of groundwater inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) PRIVY: (locate on site plan) 4' materials of construction dimensions depth of solids Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) i . 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE ETSPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' ao' t'f DEPTH TO GROUNDWATER depth to groundwater method of determination or approximation: 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined", explain why not) N Backup of sewage into facility? NDischarge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? 1�1 Required pumping 4 times 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 portion of the SAS, cesspool or privy: below the high groundwater elevation? within 50 feet of a surface water? , within 100 feet of a surface water supply or tributary to a surface water supply? within a Zone I of a public well? within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? s' within 50 feet of a private water supply well? less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well water analysi- for coliform bacteria, volatile organic compounds; ammonia nitrogen and nitrate nitrogen. I - 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector C��(' �����Ic S Company Name c'ess e o to Company Address ] rj tea-: �,.� S� '�F�c�S`����, ��` °L�•�5 . O pO _ L4-1-1 _ -,,, 00 3S Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and manitenance of on-site sewage disposal systems. C ei one: I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15. 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15.303. The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector' s Signature aO,��a� Date i Original to system owner Copies to: Buyer (if applicable) Approving authority P2 . au\ � �- o G A ci J l � q3 v LA,m e C /o OCATI,ON SEWAGE PERMIT N0: ol VILLAGE of s NA INSTALLER'S E i A� RESS L<< B U 1-0E R OR OWNER DATE PERM 71 IT ISSUED '/ ',, 11ANCE ISSUED /,2 —zf- - 7 DAT E COMP . VK /1-�D V ..�._. n' � v l� ,1 � ,� �� 4uz, `®7 LO AT ION SEWAGE PERMIT NO. r VILLAGE YS IN.STA LLER'S NA E & ADDRESS 12 BUILDER OR OWNER DATE PERMIT ISSUED zfzf DATE COMPLIANCE. . ISSUED i r'r' , -,----------�" ����Nk � , � �� � - ,� � �� �'� �� `� f �` � ���' s � !� .� �4��Q " A 114c.p V—(o c) No...... ----• � THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH _Y� 0 F............ Appliration for Eliiposal Mor o Tonotrnrtion Prrmit Application is hereby made for a P,er�mitXZ/l to Construct ( ) or Repair ( ) an Individual Sewage Disposal / System at�� � uG Z- r _ ...... •-------•..............••..._ .. _. . ..... L of ess or Lo ..__.... __ _-- .�..... .. .. .. ._ _ --- -------- - --------------�-_ ___•-_-_--........................ _..............- �J ow dr s W ... ..............&. . .. ........ YT.----- -_------_-_----4 --- ----------------------- -- -.... Installer Address Type Dwelling ng Size Lot.__.._. .. :..Sq. feet U T e ow�utld4 No. of Bedrooms____________________________________________Expansion Attic ( ) Gar age Grinder (��}i g 04 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures ...................................................... Design Flow.....................�`57.......__gallons per person per day. Total daily flow.......... _0..................gallons. WSeptic Tank-�Liquid capacityjti---gallons Length________________ Width................ Diameter................ Depth__.____-__-_---- x Disposal Trench—No..................... Width.................... Total Length-------__pp-........ Total leaching area....................sq. ft. 3 Seepage Pit No......../......... Diameter......Id...... Depth below inlet......1.............. 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__-___.-_-_-___-_------. f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-__-__---_--__--__-----. a ------------------ ------------------------ -------- O Description of Soil l c ---- ...�..-.. xy V -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 Article XI of the State Sanitary Code—The undersigned further rees not to pla the system in operation until a Certificate of Compliance has been issued by the bo healt Zigne .•-- .......-- •---••. •---....---•• --------•••---------•• ........ --•--�y-� --- Date Application Approved By--'•••--• ..... 2... = ----------• ... 77e .... Date Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------------------•----- ---------------•••-----•---•---•-•••-•••••-•--•--•-------•-••-•----••-••••-•-•-••----------.........._.....-••••-•--•---•-••••••-•-•-•-••----•-•--••-•-•••------•---•------••--•••---. :---------------•- Date i-7VPermit No......................................................... Issued..--$....................................----------- Date THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) i I m ^�� C DATA NO .._. Fu�.....�. ct . THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH -f ?�t .... ..............._.. ........OF...........l...-.............-.f.....--------------------------------------------------- Appliration for Uhipogal Wor '0 Tomitrurtiott Vuutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Y) / 1 t /// /�4)ej:� !,//J' V A it!� V'1 , I 6 1/ //\ _ ('/f/i /�-t f../�C,., f/ i r�. ('�9--Yl/��•, ............................................................ ---------•--......------------......--_...._------------ . -----•------_._._..._-----__.. Location•Address / or Lot.V.. �,. r�` Address / < j" r1 `'r, / r,� Fl/ /�.✓ Ci ... •-•-- - ........ Installer Address f /' Q Type of Buildif Size Lot....... ` ....Sq. feet U DwellingNo. of Bedrooms________________............................Ex ansion Attic rba Ga e Grinder / ) p� Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixturt .3 r________. _ W Design Flow_1_____________________________/,�-gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width---------------- Diameter................ Depth.-_-__--.--_---- x Disposal Trench—NI_____________________ Widthatd.............. Total Length------- Total leaching area....... 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_------;-__-_-__----_. f=I Test Pit No. 2................minutes per ' ch� Depth of Test Pit_F_�.__________ Depli to ground Vater__________ ___________ a0 _* --• -- ----- A----------- Descriptionof Soil-----------=-=--=-=------------•-----...-----•------•-•--------------------...------------------------------------------ ------------------------------------------- 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 Article XI 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 bo�arrd rof health`, gned �iC.G1.�t .- �t _'-------///L`. Application Approved By............ ..:. "'�``� ` '` D to--�-�-- Application Disapproved for the following reasons---------------•-----------------•-------------•-------•--------••••-----••---------------•--•----............. Date PermitNo. . .:.......................•-_. Issued_------•------------------------------------------------ i Date THE COMMONWEALTH OF MASSACHUSETTS BOARD HEA H , ............ (t•L^111.......O F...:. .-....... ..................... fir' �f"r a laf (tom4 iattrr THI O CER Y, Tra"t t e#I iva ual ag isposal System constructed ("AI) Or Repaired ( ) by.... f. . .A ............... -- r I at ... ---- �------- -- ---- - --- t -F l .�c vx0Ve has been installed.in accordance with the provisions of Arti o e tate Sanitary C c has ese in }} � application for.Disposal Works Construction &rmit No..... ..... -------------------- dated._.__!__ THE ISSUANCE OF THIS CERTIFICATE"SHALL NOT BE CONSTRUED AS A GUAR k TEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY DATE------------` � .. ----- - --- Inspector..... ...... --------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OJW HEAL T (� ............. ....OF__...... ._..................... `................ No......................... FEE........................ �tg1YI rat Tof V�rYtti Permission tr Y granted ----- ------------- k-;----------------- --------- --------------- tatc Constr ) o�% � ` z Ir>�ivi agDi s 9 stem,_ /s , J�' / � K/ - ---------- ------------------ ------------------------ s t ) , - .� as shown on the aPP..l.ication for Disposal Works Construction No --�__-------------.--______ ____________________ _______________________________________ _ _ __________________________ ___________________________ Board of Health' DATE.... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS - - <N —J Sl Li G,t-E FAM t lam'_-� �QppNt, / � O�G 495 P.G P P. A�L.♦f 1=�.ow � I l o � 3 +50 SEPTtc -r AW V * I-q,5V O �� 99Or',e,D, I ►3 ZSi Z � Xf ZS 0• �R�� 'C>15PCYSAL PIT U;ir I,00OGAI_W1-z'5TONE �> . ;I V..WALL Ae6A : 18 P 5•F Q BOTTOM AIZeA s -T t3 -5. F, (9 ToTA` a c,.P. TC.TA-L--VAILY FLOW-4°►5 Co . P• D. FAA' PI=Y.c� eAT�= 0. U -T 'ST II Z,-1 �1 `_ ,.• i oP Fero * Woo' 44C>LET t ry � � �r.,... .• •• !c �J�7Eolt_ �oi VKT tuu 4aC. qa. 1 ,- Z Its/ 80A. 9`'9 TS'AUV- i l aOo 95.8 t,w twv . C-,r kL .p Cf bey. �i f. y j LEAC14 , G WITt•1 .r y Ala t'I t IN T WI►SNr� CTOW& I I C�t2 T I F I D R-oT Pt—A N p2o Ft L.E- l..oIGaTlou L�rT�'t`✓l(..�.C� �:�-�`� IZ. Wo Sco► o_ $G4Lt= � 1l= Cnl.� D AT� Dcc.3,1�r7y l CEMT1FY T"AT TNT oufAV/I,:fIDt4 54bwy E.2E.O4.1 C0AAP`♦ ,5 W t TH T"F- �Lt 6►4� L� (3 A►JD S TBlsC�C V-eQo er-ME�.iTrj OF T � Sl1 4IE. '' ff Tbvuj" OF �A P, N S� I3t C>`�"'ST�`L F- L.L6 U.1 E��T DdTtr I � �(1' � `G •��C,�•.� B A XT E 2 t, u`(E 1�lC.. SZ.�1ST E LZEb L A1.1 D SU2VE`(Oe� T6414 QL&W (Ir (JOT BASED OLi AU IQ4TWME► 7 OSTEXVt,.- I i1�ta5rS. SUIZ+imo`! 4 TRIG OFFSET; -5"OULt> 'UOT isE U5EJ> APPL CAS -r To vETr-ZmiwE %.07 LIuE.;. F �ZCA4 I-P5&o. o VC-QLr' t Q- 107 CHINE WAY Osterville A = 098 — 060 TOWN OF BARNSTABLE LOCATION A) L "% SEWAGE# ,?O f A"' VILLAGE PUSSESSOR'S MA�P�&PARCEL INSTALLER'S NAME&PHONE NO. ;` SEPTIC TANK CAPACITY LEACHING FACILITY:(type) 2 S C �Jize) NO.OF BEDROOMS/ OWNER- a GC rlr e-KID PERMIT DATE: 20/f , 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 S 13�3,` 9 �. 1 167 c w7 No. 13 Fee A:�Lo THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE,.MASSACHUSETTS VYe 01ppliLAtton for Mispo8AY *pstrm ConstrUrtion Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot NO./O J ( ,�„e Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Oq GF e)CiC © 1�/i✓�`/( z Installer's Name,Address,and Tel.NoS�(� G y y�� Designer's Name,Address,and Tel.No. /C D 9 �,.e �a l A " e e/, 1-0 ii��r Ar 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 gpd Design flow provided 734 gpd Plan Date / Number of sheets Z Revision Date Title Size of Septic Tank Type of S.A.S. 2 57M, /1 G'v, Cji4,0 A415 Description of Soil >2 -Z�;!- Nature of.Repairs or Alterations(Answer when applicable) .�/-c G e.4 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of 'Compliance has been issued by this Board of Health Si ed 1`��� Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. ! Date Issued ram. ,4tT���w.:.� - ... .. ,,ly,,.�r-�... .h-,A.ri, M-.i«r^_.. Nt` ?w•� t, �`...-.,,� - . ..� IS, No. / 1 r / t Fee 14:5)e) THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: K. Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ' application for Disposal *#stern Construction Permit Application for a Permit to Construct( ) Repair( )• Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components .� �A*, Owner's Name,Address,and Tel.No. G. It y Location Address or Lot No../0') ('/� � W�,Y (�� yS�GL V 1:� . Assessor's Map/Parcel Og If 666 4Sly v. , Installer's Name,Address,and Tel.Nopt-g G y �1"9 Designer's Name,Address,and Tel.No. I)rpe 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.require d gpd Design flow provided gpd Plan Date y Number of sheets Z.Z Revision Date Title Size of Septic Tank Type of S.A.S. J ,-0 6-z,IlGn Description of Soil $ -Z Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: t The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health Signed '� .®�----- Date Application Approved by Date. Application Disapproved by 'Date for the following reasons r Permit No. / /r Date Issued --------- ---------'----------•-- - - - --- -- -- - - - - -- - -------- - - - THE COMMONWEALTH OF MASSACHUSETTS I1 BARNSTABLE,MASSACHUSETTS i Certificate of Compliance THIS IS TO CERTI/FV,that the On-site Sewage Disposal system Constructed{ ) Repaired(� Upgraded( ) Abandoned( )by `u u d r^o ��i�.t,) LJ (Jt.,✓�• �!�, .e at /D'I G ti i r h�. has been constructed in accordance with the provisions of Title 5?�d�thefor Disposal System Construction Permit No�`J?13 4 dated Installer l J, 9-ID.10 � 01 A Designer �r�l�i r�+ < el�i� � ek L #bedrooms Approved de�sign/ow^, ,..�� gpd The issuance of this permit,sh/all not/4 construed as a guarantee that the system v4ill function as designed. Date / /� Inspector = -��� --- ---' --- - - ---------------- -- -------- =-- ------------ r-�°.�`�-l ------- -- No 7 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS misposal *pSte -Construction Permit Permission is hereby granted Construct( ) Repair( �) Upgrade( ) Abandon( ) System located at /0 / " and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. �-�^-^ Provided:Construction mustibe//completed within three years of the date of this permit t. ..-- Date /! fG��( Approved bye _- , ,C A �� r 1 " I o Yn �t a -> s>t one r y1 eguIatc►ry S Tees £T » nnkr+sraaLs. T2rtliarc t� Sca} , Tri#e'rtrnDil'cctor ' 'y _ hf1S3 I, .1 ��° Pli=kTl]C health Di.1 Isi.atn rfi°"`avp 1'Iioina5 11fic-Kean; T?ircct:t►r 2pp Bain Str eet;Ilyanatts,�1E €J 661II (?Ffiu SUt S(i ,1(, : crstaTler S�D. si�nc r>C er'tifi tion:".F," m=' bate //� . Sew"age l'ermrt# /s�. r�ssessor's,a>Za f'arcei T)esrgrer '"` ,. e t-; is 3=- i- L c r't� Instatl€a r —r�" z1c$ tr.r� bF�s�-, Address 1 , 1�, Gr�u,s,;C .lc) t2�i �icTdue .3 _1,�,_ s' ,,,, ! , �� „r, �� .. --T '= On �`'�� . "-)� " 1.- _as s,5ued a perm} to Install a:" (date) {:atstallz ) .. %septic"SY15 art t G, ,O-,r�+� , �;-ka,"I ILe' - ! haacd on"rt dcsrl drat�.nb) (addres �fl +rt 2 t'd if -�L..,. ` c�l1tr f rry { ttc�i '(desrgq&) � - # i� �:, ,,, �.. '�' I certify that the scA" System rely rt., . tboti c ��as Installed sirb4t rn#rally accotdm (o " the design, � hrcil may ritc}ude mr> or. a}�protied cl7angessueh;as.}a#erl reioca;trr�n ol•=:t11 1.,. drstr.'ibu#ion box an,lot .septic tank. Strip out"(i;f rec}Wyed},*a's inspected and the,so"I were quid sRlt ,f,t,o , I certrfy that the septic aystcm referanccd ahtne,�t�aa r1.nstal}ed 7�rth Ira�or changes (�r c great. 'than Al . , ,teral relneatron of the SAS orany ti�etti,,i relocation' #a,iy t om�tlttcnt crf tl7e,5e}�ttc Sys#ern) but rn;accordlnc2 with State=c,:;I:oc" Reid latroiis Plan:re�rston.,,�111or. enrtrfied as l 1.tlt by'e1 .'. to to"f� la S-t ip ou;t;(if'retltii red} �, , irispec ted.arid a F., ,.orl, were"fbttnd sattsfac"tor�f y I certrfy that"the sysrcrn referenccel,abo� ..��as coiastr ucteci riI:c �vtt} the, tc>�n,1, , of the, , 1p Io Het r applicablz) `NSSgChvs PEtE��:r. `�'� N+cEt7E (Installer's Srgnaturc) �i�tt, : p 35508 '�Ff, � (Desigl7er s Sr �atttre); (.A1U�c Dzsigne erej IzLEA51� RETUI2?� TO T3Ak,&s A LE . 9 ,A IC"HEALTH 61, ItSi6m,::CERTII:�I.C&TE, { OF C;O IPLI NCE ',,III I�'O 1 B ISSUED LT�TYL B+QTII"THTS I!.ORitI""AMID .AS BLYIL,T C•�tD ARI✓ R1aC1IV>;D:B4 TIIE BA;R�ISTAT3I L PCTI3LI:C HI AL.TII_I?IS�ISIQi� .. �I11Al1K k.OU x F �, Sepfi Dastgnc�i c,,,,I '4on fofn Ruti 4 �4 l3 d+ �: Ehgtrteers note Tifs eorUtscation is Itrntte1.d to 2r`as b„lE ps *� i,-The o iron ct s. e, ,compcne!its as it=raised onar<to backf eng neerl<II d notzsupervtse construct on or the system T�e;tns alter= sumes resoq�,o,Ii y:cr aA m ierial"s,:4Lor z;ra isn,p caeHfilt,n to spe ,(icd grades�wih pxoppr ccmpac fo a f.d" air,.a,,,ser 'goae;s%as sGorm'on t!:e tizstgn plan,:; g � 99 --EXISTING CONTOUR N a x 100.98 EXISTING SPOT GRADE Yo Rd a� g 99,58 CATCH BASIN W EXISTING WATER SERVICE ?• � L7 ® 99,48 G ' ` EXISTING GAS SERVICE i a. 99.61 x ® TEST PIT 90 h CB 99,4499.07 � $ BENCHMARK LOCUS " I CATCH BASIN ' i ®99.54 4 . . LEGEND , oc \ 99.59 ���ccc PTO �� J�O Tran4�i11ity Ln + 9.90 { ,� LE 99. 9 N \ x 96.98 9845 100A2 {. Ux 94.50 7 [� 18 �\ � �' °� A,�• a� �a9� LOCUS -MAP NOT TO SCALE 98.65 I •98.72' ' + op � 98.85 \, 98,y?Ox 99,19 :.;:,: \� GENERAL NOTES: _ �/ 96.35 C,ARAGE �p \ 1.96� r 1 ALL CHANGES TO THIS PLAN MUST BE APPROVED BY. THE LOCAL 93.58 x L } 100.88 BOARD OF HEALTH AND THE DESIGN ENGINEER.+ 1 `� ' ' 99.02 / ��y, 2• ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS x 101.32 'c'\�•\ OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE 50 �1�,J\ LOCAL RULES AND REGULATIONS. 1 I ��/ o2,os 100.62 99,24 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR 92.2 � LOT . 13 O 93.1y _ TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE 7 J 19s,9a 28,225 ±S•F: DESIGN ENGINEER. o QQ \ 96. PATIO EXISTING 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING 90,23 1•27 HOUSE (#107) '9885 :��\ FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN EXISANG SEPAC TANK i x I ® TOF=100.if +99,io 99.09 \ ENGINEER BEFORE CONSTRUCTION .CONTINUES. TOP OF TANK, EL.=91.78t 97.6 Cellor FL.=92.7t INV.(OUT)=90.45t(VERIFY) II I 9�ao G �� 5. ALL ELEVATIONS BASED ON AN ASSIGNED DATUM. EXISTING LEACH PIT \\ \ 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF - (PER AS-BUILT) I x THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF TO BE PUMPED, FILLED I sa.1 9s.es ---�0- 99.85- HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. WITH SAND &ABANDONED I \ !y 106s2 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. 91.4 95,74 x9�a3/ W 9a.6 •xe �� 8. THERE ARE NO WELLS WITHIN. 100' OF THE PROPOSED S.A.S. 98 46; 96. 1 w per✓ 9: ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE yap x y\93.79 98.aa DIRECTED BY THE APPROVING AUTHORITIES.. x 94.55 �\ 92.3d 8752 JX 90,07 14. :4 Qp, 10. IT SHALL.BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY v. J THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING CB �� Z::.r• • CONSTRUCTION. h 93.90 t \ 98.67 Q. x 96.58 �\� 981 p� 11. 'WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS I 9aoz. IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S.`-AND 16 j - REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). S 00r \\ ;:` �aAp 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL'BE S 99.07 �:'• ��� q� INSPECTED .BY DESIGN ENGINEER PRIOR TO BACKFILL. PROPOSED S.A.S. �2• I } + {.. y� 2-500 GALLON CHAMBERS 2Q 4g l o PETER T. 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND x NOT CONSIDERED TO BE A PROPERTY LINE SURVEY. SURROUNDED W 4' STONE �'' E 96.82 MCENTEE N CIVIL NO. 35109 PARCEL ID: 098-060 Cb 97,6 !' +GG� F�� BENCHMARK 9' Sl � ORANGE DOT ON 97.98 PROPOSED SEPTIC SYSTEM UPGRADE PLAN + ' TOP OF 9743ET. WALL ,° 107 CHINE WAY, MARSTONS MILLS, MA Prepared for: DiBuono Sewer & Drain, 35 Content Ln, Cotuit, MA 02636 f OWNER OF RECORD Engineering by: SCALE DRAWN JOB. NO. 107 CHINE WAY 'REALTY TRUST 97.26 BUCKLEY, GLADYS M TR Engineering Works, Inc. 1"=20' P.T.M. 158-19 107 CHINE WAY 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO. - OSTERVI.LLE, MA 02655 (508) 477-5313 4/11/19 P.T.M. 1 of 2 hµ I NOTE: TO PREVENT BREAKOUT, FINAL GRADE SHALL NOT BE AT, OR BELOW, EL.=89.5 SEPTIC TANK PROPOSED D-BOX FOR A DISTANCE OF 15' FROM THE EDGE OF THE PROPOSED S.A.S. INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & WATERTIGHT PROPOSED S.A.S. X/STING OUTLET AND SET TO 6" OF FINISH GRADE COVER SET TO 6" OF GRADE4 INSTALL RISER & COVER OVER ONE CHAMBER AND HOUSE (#107) T.O.F.=100.1f SET TO 3" OF F.G. TO SERVE AS INSPECTION PORT TOF=100.1t/ F.G. EL.=98.Of F.G. EL.=97.6t F.G. EL.=92.3t F.G. ELto9 1.5 BACK OF HOUSE to 91.St MAINTAIN 27 SLOPE OVER S.A.S. 'ro s� 7EE LEVEL FOR 2' 3,g�oo ® S=1%0(MIN.) q (MIN.) 2" LAYER OF 1/8" TO 1/2" GARAs49.-4"SCH40 PVC 40 PVC 6" DOUBLE WASHED STONE (OR APPROVED FILTER FABRIC)1a^ s EFF. a®aa®gaEXISTING 48" LIQUID PTH aaaaa�a -3/4" TO 1-1/2" DOUBLELEVEL 4' 4.8' 4' WASHED STONEADDINV.=89.30 PROPOSEDINV.=89.13 g�• GAS �� EFFECTIVE WIDTH = 12.8' INV.=90.45 D-BOX EXISTING SEPTIC TANK INV.=89.00 34.5' 2-500 GALLON LEACHING CHAMBERS SURROUNDED WITH STONE AS SHOWN PA TIO H-10 RATED TOP CONC. ELEV.=89.7t SEPTIC LAYOUT BREAKOUT ELEV.=89.50 NOTES: INV. ELEV.=89.00 a�aoa 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPES & oaaaaaaaaoa INVERTS EXITING HOUSE, PRIOR TO INSTALLATION. BOTTOM ELEV.=87.00 2) SEPTIC TANK & D-BOX SHALL BE SET LEVEL AND 4' 2 x 8.5' = 17.0' 4' TRUE TO GRADE ON A MECHANICALLY COMPACTED 4' OF NATURALLY OCCURRING EFFECTIVE LENGTH = 25.0' SIX INCH CRUSHED STONE BASE, AS SPECIFIED PERVIOUS MATERIAL =E3 IN 310 CMR 15.221(2). 5' (MIN.) ABOVE G.W. - 3) INSTALL INLET & OUTLET TEES AS REQUIRED. NO G.W., EL=80.4 4 LEACHING SYSTEM 'SECTION 1- ® q33"4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE Of `t' WU AS• MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. SEPTIC SYSTEM PROFILE zU N.T.S. SOIL LOG 102" DATE: APRIL 3, 2019 (REF#15,954) 4" KNOCKOUT SOIL EVALUATOR: PETER McENTEE PE(SE#1542) WITNESS: DAVID STANTON R.S. HEALTH AGENT 20" DIA. COVER DESIGN ' CRITERIA ELEV. TP-- 1. .DEPTH ELEV. TP-2 DEPTH 92.1 q 0" 92.0 q 0" 4" KNOCKOUT / 4" KNOCKOUT 58" • - NUMBER OF BEDROOMS: 3 BEDROOMS LOAMY SAND LOAMY SAND SOIL TEXTURAL CLASS: CLASS 1 91 $ 10YR 4/2 ( 10YR 4/2 DESIGN PERCOLATION RATE: <2 MIN/IN LOAMY SAND LOAMY SAND 4" KNOCKOUT DAILY FLOW: 330 G.P.D.. 10YR 5/6 10YR 5/6 DESIGN FLOW: 330 G.P.D. 90'1 C1 24 89'8 C1 2s" GARBAGE GRINDER: NO-not allowed with design PERC 500 GALLON CAPACITY, H-10 LOADING LEACHING AREA REQUIRED: (330) = 445.9 S.F. 2.5Y SAND /D 3s"/54' 2.5Y SAND CHAMBERS .74 N.T.S. EXISTING SEPTIC TANK: 1500 GALLON CAPACITY 85.7 78" 81 6.0 PROPOSED D-BOX: 1 INLET, 3 OUTLETS, H-10 RATED C2 C2 72 USE 2-500 GALLON LEACHING CHAMBERS IN SERIES PROPOSED SEPTIC SYSTEM UPGRADE PLAN SURROUNDED BY DOUBLE WASHED STONE ON ALL SIDES MED. SAND MED. SAND 107 CHINE WAY, MARSTONS MILLS, MA 2.5Y 7/3 # 2.5Y 7/3 SIDEWALL AREA: 2(12.8' + 25.0') X 2 = 151.2 S.F. Prepared for: DiBuono Sewer & Drain, 35 Content Ln, Cotuit, MA 02636 BOTTOM AREA: 12.8' x 25.0' = 320.0 S.F. 80.4 138" 80.5 138" Engineering by: SCALE DRAWN JOB..NO. TOTAL AREA:.............................................................. 471.2 S.F. PERC RATE <2 MIN/IN. "C" HORIZONS Engineering Works, Inc. 1"=20' P.T.M. 158-19 DESIGN FLOW PROVIDED: 0.74 GPD/SF(471.2 SF) = 348.7 GPD NO GROUNDWATER ENCOUNTERED 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO. (508) 477-5313 4/11/19 P.T.M. 2 Of 2