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HomeMy WebLinkAbout0076 EBENEZER ROAD - Health 76 Ebenezer Road Marstons Mills A=_123-053 / - - J ,� No. O 9-?fo Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -,TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplication for Disposal *pstem Coustrurtiou 3permit Application for a Permit to Construct( ) Repair(:Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 76 Eh_-rj 6_ur R Owner's Name,Address,and Tel.No. /1Ac�.rsto�� M ills Assessor's Map/Parcel /d�°j —S3 Jp�► j� Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. U,_ 1 5 s�v Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building IeSidnQf c-) No.of Persons—' Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) �:3 3(7 gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank X►S� ►r�TV Type of S.A.S. /0 5-GO !i,2A04 CA GM has Description of Soil Nature of Repairs or Alterations(Answer when applicable) 42 di -/ Sc�o ��11� c1nc ht�cs i �' s 1-nave i a /�.ejxg C' A(e j 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. Signe - Date 7 Application Approved by Date Application Disapproved by Date for the following reasons Permit No. 2-0;-0 �—�� Date Issued a✓�' Fee �i� "` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:__6�z PUBLIC HEALTH DIVISION Yes ,=WOWNIOF BARNSTABLE MASSACHUSETTS application for Mispasal 6pstem Construction Permit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components _ r Location Address or Lot No. 'i G bC,je-Cvr goOwner's Name,Address,and Tel.No. ' -Assessor's'Map/Parcel S Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. r v/d A.4,50N Type of Building: Dwelling `No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building 1t­,5,. reoh'cJ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) '3{� A— gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title j Size of Septic Tank FX t sy� Type of S.A.S. //•/o sC 0 'ie111w 1!/1" Als V'Description of Soil Nature of Repairs or Alterations(Answer when applicable) lnlCfc,l! It we") �li��l� t1f/nr� �ts�' r.�►I� 4 bo n(.A10 r,) (Vu"A 60(J u.) w S ofoe i Cc .�/ec, V Date last inspected: Agreement: ,,.. The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal g g g ,Y 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. Signe— �"" ,+� Date 1 Application Approved by �...+�: ,�'�". Date Application Disapproved by Date for the following reasons Permit No. 2.4)xo Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance; { THIS IS TO.CERTIFY,that the On-site Sewage Disposal system Constructed Re aired + Upgraded _g P Y ( ` ) P ( ) ( ) Abandoned( )by 1,7(C.1v)� (i at -7e, P1--h qV P 7 P/ ,[ /1/!/. S has been constructed in accordance ordance f with the provisions of Title 5 and the for Disposal System Construction Permit No. 4ated Installer A : xrxAw 1-ric Designer vir� O(�G Gn 3 #bedrooms '� Approved design flow Q gpd The issuance of this permit shall not be construed as a guarantee that the system,will function as,designed. Date ' "A0^V Inspector j`...,.. No., a�Cl r C3 sy - Fee 1. THE COMMONWEALTH OF MASSACHUSETTS h, PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal opstem Construction permit Permission is hereby granted to Construct( ) ✓�ReDpair(�/l Upgr�adde( ) Abandon( ) System located at �f rbe1l-Z'e-r- 9�t,/ /6/t`(.�/ /lir�� and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. (13 Date Approved by w,y 4�fi o iY:�+r !: 'ill:: '�•Lmi�„ ,. a• ` �',. +, �� �r_:-!G�_�,■ o- o �. ul -i !, �_.' - I - ' �• y�. ,.., a Ij. . .-.'s •.� sii� _ _ ,..i ., L ':' 4.. _ c a'i!...+ 7`li t:� t, . W A i i d i s � Im F� ■- rr �:ii - ,I , y . _t:F1r R.I!•M :rr Ir r n • I rd P 1PW L 'i ft'l .Y�' Y m �+, -J x. [� / �. - ,4 fl, O [ 1 i ,.. I� �4 L OI FBI �� �A ��'•I� �� ,i � �, i� r� l��.!' I!�" r �.�kiL�iT cis .' AXIM Aj f JI � �� � � ... 9 1 TOWN OF BARNSTABLE LOCATION &naer R SEWAGE # VILLAGE O Iry l k ASSESSOR'S MAP & LOT INSTALLER'S NAME.&PHONE NO. SEPTIC TANK CAPACITY mil) r LEACHING FACILITY: (type) O� (S x(0 I (size) 16Vd � NO.OF BEDROOMS BUILDER OR OWNER Ai ke l( PERMITDATE: COMPLLICE 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�acility) ---�• /' Feet Furnished by 7/I $nGlG y 4ly 31 p � 31 3 � y � y TOWN OF BARNSTABLE LOCATION '76 SEWAGE# c�©oZO a`7 VILLAGE , } M /u��ASSESSOR'S MAP&PARCEL A S INSTALLER'S NAME&PHONE NO. D-A SOcovoo SEPTIC TANK CAPACITY 4ZE x►b+i^'S LEACHING FACILITY:(type) j✓-/0 SWC CAAWS (size) /2 ,0 X?C NO.OF BEDROOMS 3 OWNER JGTn� ati PERMIT DATE: rt COMPLIANCE DATE:5 _ 3Oa.O Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility G Yf�oee,"C Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY , C�c V A 35- � N/ -Z - Nv . 3G ' 3 - ifs I TOWN OF BARNSTABLE LOCATION 7 G E B,! ZCe- R EWAGE# d1O.Zb - 02.7 P S t VILLAGE 4�Ao(y,}oa-,t AoCt s ASSESSOR'S MAP&PARCEL / INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) Y y0 coc>j Chan 5 (size) /2.0 X'2 C- NO.OF BEDROOMS 3 OWNER 76V\%j s ab PERMIT DATE: .411 COMPLIANCE DATE: y_l-AO:.C) Separation Distance Between the: wO^'e dc Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility G jOe- 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 P .M(,,,,x,1 '�4 c << A 3C ' 3 qS 52 4• '37 i Commonwealth of Massachusetts W Title 5 Official Inspection Form "s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76 Ebenezer Road - Property Address , Thomas Spencer t Owner Owner's Name ^' information is til tet� e required for every Os Qr5 tins M i Its Ma. 62655 03/16/2017 page. City/Town State Zip Code Date of Inspection � I Inspection results must be submitted on this form. Inspection forms may not be altered in any - way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms S��►' (P on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael T Bisienere use the return Name of Inspector key. Cape Septic Inspections Company Name 624 Old Barnstable Road Company Address rem Mashpee Ma. 02649 City/Town State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority �, ����03/17/2017 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. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts w L W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G'M 76 Ebenezer Road Property Address Thomas Spencer Owner Owner's Name information is required for every Osterville Ma. 02655 03/16/2017 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This 3 bedroom home has a 1000 gallon H-10 septic tank a H-10 D-Box feeding a precast leaching pit.At the time of the inspection the liquid level was one plus foot below the inlet pipe to the leaching pit.The septic tank was pumped after the inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 76 Ebenezer Road Property Address Thomas Spencer Owner Owner's Name information is Osterville Ma. 02655 03/16/2017 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9° 76 Ebenezer Road Property Address Thomas Spencer Owner Owner's Name information is required for every Osterville Ma. 02655 03/16/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well ** Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76 Ebenezer Road Property Address Thomas Spencer Owner Owner's Name information is required for every Osterville Ma. 02655 03/16/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurfa ce Sewage Disposal System Form Not for Voluntary Assessments 9 p Y rY °M 76 Ebenezer Road Property Address Thomas Spencer Owner Owner's Name information is required for every Osterville Ma. 02655 03/16/2017 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): >330 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 76 Ebenezer Road Property Address Thomas Spencer Owner Owner's Name information is required for every Osterville Ma. 02655 03/16/2017 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No No n-sanitary waste discharged to the Title 5 system. ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °°M ,•' 76 Ebenezer Road Property Address Thomas Spencer Owner Owner's Name information is required for every Osterville Ma. 02655 03/16/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts H - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 76 Ebenezer Road Property Address Thomas Spencer Owner Owner's Name information is required for every Osterville Ma. 02655 03/16/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 19"feet Material of construction: ❑ cast iron ®40 PVC ❑ other'(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 12"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Standard H-10 1000 gallon Sludge depth: 3" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage'Disposal System Form - Not for Voluntary Assessments 76 Ebenezer Road Property Address Thomas Spencer Owner Owner's Name information is required for every Osterville Ma. 02655 03/16/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 3" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 35" Distance from bottom of scum to bottom of outlet tee or baffle 5" How were dimensions determined? Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The septic tank was pumped as part of the inspection. I would recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home.The Barnstable Health Dept. has a list of local septic pumping Co. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 76 Ebenezer Road Property Address Thomas Spencer Owner Owner's Name information is required for every Osterville Ma. 02655 03/16/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 76 Ebenezer Road Property Address Thomas Spencer Owner Owner's Name information is required for every Osterville Ma. 02655 03/16/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" 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.): At the time of the inspection there was no visible evidence of leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 76 Ebenezer Road. Property Address Thomas Spencer Owner Owner's Name information is Osterville Ma. 02655 03/16/2017 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: One ❑ 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.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 76 Ebenezer Road Property Address Thomas Spencer Owner Owner's Name information is required for every Osterville Ma. 02655 03/16/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 76 Ebenezer Road Property Address Thomas Spencer Owner Owner's Name information is required for every Osterville Ma. 02655 03/16/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 TOWN.OF BnAR]NSTABLE LOCATION SEWAGE k VILLAGE ASSESSOR'S MAP&LOT INSTALLER'S NAME.&PHONE NO. SEPTIC TANK CAPAC1Ty LEACHING FACILITY:(type) (size) / A NO.OF BEDROOMS kd� _ J, I BUILDER OR OWNER A�1 PERMITDATE: COMP CE 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 acility) ——�-^ Feet Furnished by :Z,/1 S�JGLl/Yt Dr, v2 A � yy 31 i a y 66 3� a 3 Sa ya y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 76 Ebenezer Road Property Address Thomas Spencer Owner Owner's Name information is required for every Osterville Ma. 02655 03/16/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 15 plus feet 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: I augered a hole to fifteen feet to show five plus feet of seperation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76 Ebenezer Road Property Address Thomas Spencer Owner Owner's Name information is required for every Osterville Ma. 02655 03/16/2017 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file js Feei .DTT°M A' S 5 Pigs Fee r t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76 Ebenezer Rd. Property Address Bill Sprague j Owner Owner's Name information is esterytWe Ma. 02655 4/5/13 required for every _ page. City/Town State Zip Code Date of Inspection I4 " Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: n 1 key to move your cursor-do not Ricky Wright use the return Name of Inspector key. B & B Excavation,lnc. � Company Name 14 Teaberry Lane Company Address Forestdale MA 02644 City/Town State Zip Code 508-477-0653 S14595 Telephone Number License Number B. Certification , I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passe ❑ Falls ❑ Needs Further Evaluation by the Local Approving Authority 4/5/13 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. ****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 I the same or different conditions of use. t5ins•11/10 Title 5 Official Inspe n Farm:Subsurface Sewage Disposal System•Page 1 of 17 I Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 76 Ebenezer Rd. Property Address Bill Sprague Owner Owner's Name information is required for every Osterville Ma. 02655 4/5/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76 Ebenezer Rd. Property Address Bill Sprague Owner Owner's Name information is required for every Osterville Ma. 02655 4/5/13 page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76 Ebenezer Rd. Property Address Bill Sprague Owner Owner's Name information is required for every Osterville Ma. 02655 4/5/13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 76 Ebenezer Rd. Property Address Bill Sprague Owner Owner's Name information is required for every Osterville Ma. 02655 4/5/13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts . _ F Title 5 Official Inspection Form w Subsurface Sewage Disposal System Form - Not for Voluntary Assessments o^ 76 Ebenezer Rd. M Property Address Bill Sprague Owner Owner's Name .. information is required for every Osteryille Ma. 02655 4/5/13 requir page:" City/Town! State Zip Code Date oflnspection C. Checklist Check if the following.have been done:.You must indicate 'yes" or"no".as to each of the following: Yes ... No Pumping information was provided by the owner, occupant, or Board of Health ❑ Z Were:any of:the:systern 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 theaystem: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 El ® ::approximation of distance is:unacceptable) [310 CMR 15.302(5)] D. System Information Residential.Flow Conditions: Number of bedrooms(design).:: 3 .... Number of bedrooms (actual); 3 DESIGN flow based.on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): . 330 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-.Page 6 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76 Ebenezer Rd. M Property Address Bill Sprague Owner Owner's Name information is required for every Osterville Ma. 02655 4/5/13 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d n/a 9 ( Y g (gP ))� Detail Sump pump? ❑ Yes ® No Last date of occupancy: 3 weeks ago Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 76 Ebenezer Rd. Property Address Bill Sprague Owner Owner's Name information is Osterville Ma. 02655 4/5/13 required for every � page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 76 Ebenezer Rd. Property Address Bill Sprague Owner Owner's Name information is required for every Osterville Ma. 02655 4/5/13 page. City(fown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 25 years est. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >20feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in working order no sign of leakage or blockage. Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ® No Dimensions: 1000 gal Sludge depth: no sludge t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts ti r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 76 Ebenezer Rd. Property Address Bill Sprague Owner Owner's Name information is required for every Osterville Ma. 02655 4/5/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle no sludge Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appears to be structurally sound. No sign of back-up.Installed new outlet tee. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts - Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 76 Ebenezer Rd. Property Address Bill Sprague Owner Owner's Name information is required for every Osterville Ma. 02655 4/5/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76 Ebenezer Rd. Property Address Bill Sprague Owner Owner's Name information is required for every Osterville Ma. 02655 4/5/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakace into or out of box, etc.): At time of inspection d-box appears to be in working order,some sign of carryover due to lack of outlet tee on tank. Pump Chamber(fixate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 I ' Commonwealth of Massachusetts L W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 76 Ebenezer Rd. Property Address Bill Sprague Owner Owner's Name information is required for every Osterville Ma. 02655 4/5/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At time of inspection leaching appears to be in working condition.Some sign of carryover due to lack of tee on tank, water level was 3' below invert at time of inspection.Stain line 1' below invert. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 76 Ebenezer Rd. Property Address Bill Sprague Owner Owner's Name information is required for every Osterville Ma. 02655 4/5/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76 Ebenezer Rd. Property Address Bill Sprague Owner Owner's.Name information is required for every Osterville Ma. 02655 4/5/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.,Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below El drawing attached separately s is13 ji _o B � , Ay- t5ins•11/10 Title 5 Official Inspection.Form:Subsurface Sewage Disposal System•Page 15 of 17 I ' Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 76 Ebenezer Rd. Property Address Bill Sprague Owner Owner's Name information is required for every Osterville Ma. 02655 4/5/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >144" 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: records on file 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: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 76 Ebenezer Rd. Property Address Bill Sprague Owner Owner's Name information is required for every Osterville Ma. 02655 4/5/13 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 V COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTEC_TLQN- RECEIVED OCT 0 2 2003 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 76 Ebenezer Road MAP Osterville, MA 02655 PARCEL 5 3 Owner's Name: Brian Kelly .�.� Owner's Address: LOT Date of Inspection: September 12, 2003 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fai s Inspector's Signature: Date: September 15, 2003 The system inspector shall su it 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 1 Page 2 of 11. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 76 Ebenezer Road Ostend le. AM Owner: Brian Kelly Date of Inspection: September 12, 2003 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. if"not determined", please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 4 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 76 Ebenezer Road Osterville, MA Owner: Brian Kelly Date of Inspection: September 12, 2003 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/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 well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either Y :"""` es or no to each of the following: g (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 76 Ebenezer Road Osten,ille, MA Owner: Brian Kelly Date of Inspection: September 12, 2003 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner, occupant, or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection ? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓ Were all system components, excluding the SAS, located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge and depth of scum ? ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ Existing information. For example, a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 76 Ebenezer Road Osterville, MA Owner: Brian Kelly Date of Inspection: September 12, 2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 1 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system (yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 02-22,000 01 -21,000 Qals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMIVIERCIAL/INDUSTRIAL 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: None on file Was system pumped as part of the inspection(yes or no): No If yes, volume pumped: sallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank, distribution box, soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components, date installed(if known)and source of information: Unknown Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 76 Ebenezer Road Osterville, MA Owner: Brian Kelly Date of Inspection: September 12, 2003 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: 10" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: I" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): 7 f Page 8 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 76 Ebenezer Road Osterville, MA Owner: Brian Kelly Date of Inspection: September 12, 2003 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box,etc.): The D-box was level. No solids were present. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 I Page 9 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 76 Ebenezer Road Osten ille, MA Owner: Brian Kelly Date of Inspection: September 12, 2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 - 6'x 6'(1000,gal.) leaching chambers, number: leaching galleries, number: leaching trenches,number, length: leaching fields,number, dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): The pit had 6"of water on the bottom. The scum line was approximately]'up from the bottom. There did not appear to be any signs of failure. The cover was 2'belowgrade. The bottom to grade was 8'. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth -top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 76 Ebenezer Road Osterville, MA Owner: Brian Kelly Date of Inspection: September 12, 2003 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. 04 y v 31 a 'Y�b 3 a -3 Sa ya y 10 f Page 1 1 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 76 Ebenezer Road Osterville, MA Owner: Brian Kelly Date of Inspection: September 12, 2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25 +/- feet Please indicate (check) all methocs used to determine the high ground water elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database:-explain: You must describe how you established the high ground water elevation: Using the Barnstable topographic.map and the Cape Cod Commission water contours map,the maps were showing approximately 25'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system,will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 Conunonwealth of Massachusetis Executive Office of Enviromiental Affairs Dept. of Environmental Protection Jolt, Grad One winter Street,Boston,Ma. 02108 D.F.P. Title V Septic Inspector P.O. Box 2119 Teaticket, MA 02536 (508) 564-6813 WILLIAM F.WELD Governor ARGEO PAUL CELLUCCI Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO M,) (9 PART A CERTIFICATION � Property Address: 76 Ebenezer Rd.Osterville CJJ Address of Owner: Date of Inspection: 315198 (If different) Name of Inspector: John Graci Ron Fomier:10 Rodney Rd. ast Bruna J 08�k JO I am a DEP approved system inspector pursuant to Section 15.340 of Title°k(310 CMR 15.000) OG bey' Company Name,Address and Telephone Number: .w t Z� CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the infortation reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: x Passes This Inspection is based on criteria defined In Title V code 310 CMR 16.303.fury findings are of how the system is _ Conditionally Passes performing at the time of the inspection.My inspection does Needs Furt r Evaluation By the Local Approving Authority notImply any warranty or guarantee of the longevity ofthe septic system and any of Its components useful life. Fails Inspector's Signature: Date: 311o198 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C,or D: Aj SYSTEM PASSES: x I have not found any information which indicates that the system violates any_of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: Bj SYSTEM CONDITIONALLY PASSES: _One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of CoMpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04127)97) One Winter Street • Boston,Massachusetts 021108 a FAX(617)556-1049 0 Telephone(617)292-5500 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 76 Ebenezer Rd.Osterville Owner: Ron Fomler:10 Rodney Rd.East Brunswick NJ 08816 Date of Inspection:315198 _ Sewaae backup or.hreakoutor hiah.static water level observed.in.the distribution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)--are replaced obstruction is removed distribution box is leveled or replaced —The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: _ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No _ Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged cesspool. SAS is in hydraulic failure. (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC TION FORM PART A CERTIFICATION (continued) Property Address: 78 Ebenezer Rd.Osterville Owner: Ron Fomier:10 Rodney Rd.East Brunswick NJ 08816 Date of Inspection:315/98 D]SYSTEM FAILS(continued) 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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(napped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 70 Ebenezer Rd.Osterville Owner: Ron Fomier:10 Rodney Rd.East Brunswick NJ 08816 Date of Inspection:315198 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: _x_ — Pumping information was requested of the owner, occupant,and Board of Health. x — None of the system components have been pumped for at least two weeks and the 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. x As built plans have been obtained and examined. Note if they are not available with N/A. x — The facility or dwelling was inspected for signs of sewage back-Lip. x — The system does not receive non-sanitary or industrial waste flow. _X_ — The site was inspected for signs of breakout. x — All system components, excluding the Soil Absorption System,have been located on the site. x 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. x — The size and location of the Soil Absorption System on the site has been determined based on . The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is — — unacceptable)(15.302(3)(b)) (revlsed 0427/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 76 Ebenezer Rd.Osterville Owner: Ron Fourier:10 Rodney Rd.East Brunswick NJ 08816 Date of Inspection:315198 FLOW CONDITIONS RESIDENTIAL: d./bedroom for S.A.S. Design flow: 330 g•p Number of bedrooms: 3 Number of current residents: 0 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings,if available:(last two(2)year usage(gpd). nfa Sump Pump(yes or no): No Last date of occupancy: August COMMERCIAL/INDUSTRIAL: Type of establishment: n1a Design.flow:0 gallons/day Grease trap present: (yes or no) No Industrial Waste Holding Tank present: (yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings, if available: nia Last date of occupancy: n1a OTHER:(Describe) Ma Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: nla System pumped as part of inspection: (yes or no)No If yes,volume pumped:0 gallons Reason for pumping: nla TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records, if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components,date installed(if known)and source information: 1991 Sewage odors detected when arriving at the site: (yes or no) No (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 76 Ebenezer Rd.osterville Owner: Ron Fomier:10 Rodney Rd.East Brunswick NJ 08816 Date of Inspection:315198 SEPTIC TANK: x (locate on site plan) Depth below grade: t' Material of construction:x concreate metal FRP Polyethylene—other(explain) If tank is metal, list age nia . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: 1_e15^H57"w57" Sludge depth:2" Distance from top of sludge to bottom of outlet tee or baffle: 25" ^ Scum thickness:3" Distance from top of scum to top of outlet tee or baffle:S" Distance form bottom of scum to bottom of outlet tee or baffle: 15" How dimensions were determined: measured 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, etc.) Septic tank and all components are structurally sound and runctloning properly.Recommend pumping every two years. GREASE TRAP:_ (locate on site plan) Depth below grade: n1a Material of construction: concrete metal FRP Polyethylene_other(explain) Dimensions: rda Scum thickness:rda Distance from top of scum to top of outlet tee or baffle:rda Distance from bottom of scum to bottom of outlet tee or baffle: nla Date of last pumpingn't- 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, etc.) nla BUILDING SEWER: (Locate on site plan) Depth below grade: vv- Material of construction:_cast iron_40 PVC_other(explain) Distance from private water supply well or suction line?own Diameter: 4" 1�deimments: (conditions of joints,venting,evidence of leakage, etc.) (revised 04127/97) I _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 70 Ebenezer Rd.osterville Owner: Ron Fourier:10 Rodney Rd.East Brunswick NJ 08816 Date of Inspection:315198 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: nra Material of construction:_concrete_metal_FRP_Polyethylene_other(explain) Dimensions: wo Capacity: nla gallons Design flow: n1a gallons/day Alarm level:_nla Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Ma DISTRIBUTION BOX: x (locate on site plan) Depth of liquid level above outlet invert: liquid level vvith bottom of pipe Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.) D$ox Is structurally sound. PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)l!o Alarms in working order(yes or no)_yes Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) nla (revised O4127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 76 Ebenezer Rd.osterville Owner: Ron Fomler.10 Rodney Rd.East Brunswick NJ 08816 Date of Inspection:315198 SOIL ABSORPTION SYSTEM (SAS):x (locate on site plan,if possible;excavation not required, but may be approximated by non-intrusive methods) If not determined to be present,explain: nla Type: leaching pits,number: one:1Aoo gallon leach plt leaching chambers, number:We leaching galleries, number: nla leaching trenches, number,length: nfa leaching fields,number, dimensions:nla overflow cesspool,number:n1a Alternate system: n1a Name of Technology:_rd Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Leach ph and all components are structurally sound and functioning properly.Leach plt Is now empty.Leach ptt was never more than half full. CESSPOOLS:_ (locate on site plan) Number and configuration: Na Depth-top of liquid to inlet invert: nla Depth of solids layer: We Depth of scum layer: We Dimensions of cesspool: n1a Materials of construction: nla Indication of groundwater: rda inflow(cesspool must be pumped as part of inspection) n1a Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) nla PRIVY:_ (locate on site plan) Materials of construction: n1a Dimensions: n1a Depth of solids: rya Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n1a (revised OW7197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) a 76 Ebenezer Rd.Osterville Ron Fornier:10 Rodney Rd.East Brunswick NJ 08816 315198 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) i filet 10714 ti A� 4o f3B 35 Pape f of 20 (revised 04R7197) I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 78 Ebenezer Rd.Ostervllle Ron Fornler:10 Rodney Rd.East Brunswick NJ 08916 315198 Depth of groundwater 12. Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers x Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS maps and charts. (revised04127197) page 10 at 10 00 THE COMMONWEALTH OF MASSACHUSETTS �—/ BO�eR® �F HEALTH�.. ✓)........OF.......%. .... '!. J ..----_-------_--_----- Appfiration for Utspoiml Workii Tnntrnrtiun rrmfit Application is hereby made for a Permit to Construct (k) or Repair ( ) an Individual Sewage Disposal System at -.y ........-,......... .e.i........ . `.---- . -------- .... ----- .............•---- ----- ----------------------- -- n-Ad es oj�i /) grabc�t"��� �� l� . ` Location .J_�. G./.. Zr f �l. ................. ' caner Address w �- ..D121C ) ... G . ' S�,ramE� a .1------- ----------- ---------------------------------- es-s---.-------------.--------------------.----. Installer Address ��� / Type of Building Size Lot____•.._..____./__ --.Sq. feet V Dwelling—No. of Bedrooms_______________ _____________ __ Expansion Attic ( ) Garbage Grinder ( ) -------- '14 Other—Type of Building �_1 No. of persons............................ Showers — Cafeteria Q, Other fixtures -------------------------------- - W Design Flow............... ..........gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity/ .gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area_.-ei-e- .... ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box (-k) Dosing tank ( ) Percolation Test Results Performed by.__..._____ _ �t`'�' _.. ��.°................ Date_... ._�� �......_.. a Test Pit No. I..�'SJ T Mnutes per inch Depth of Test Pit.../_2..._..... Depth to ground water../.xi&��,..-_. Test Pit No. 2....2.........minutes per inch Depth of Test Pit.................... Depth to ground water........................ ................------------ ----... ----•-•-----. ............ O Description of Soil------ ......--... %�!_V....... r,<,f.__.....• �-l---� � f.�1 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 i: L p 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 board of health. Signed _1.. . ..................... Date Application Approved By.............. . — . • --•-......................... ------ Date Application Disapproved for the following reasons:................................................................................................................. ...........-•--••-•------------•--•----•------••------••--•--------•--••------•--._..._...•--------------...•-••--•••--••-•-•-••----. Date PermitNo......................................................... Issued....................................................... Date � s r— N �.:�'� -- FEs..... ............... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OFHEALTH )._-... - .. ..-.......OF..... . n': c................................„ Appliraffou for Uhip t ial 10orkg Tomitxurtinn Urrmit Application is hereby made for a Permit to Construct °( ) or Repair ( ) an Individual Sewage Disposal System at: d *• ----------------- Location A fsr A �� ------. .. ----...�...y-•--.--rp f•-•--- orww�7p ......... --j•a.................... t Own Address .... Installer ,/ Address f Q Type of Building Size Lot..................... _____Sq. feet U Dwelling—No. of Bedrooms______________ Expansion Attic ( ) Garbage Grinder ( ) �+ •-•---------- PL4Other—T e of Building ^*�C No. of persons____________________________ Showers — Cafeteria Pa Other fixtures -------------------------------- ✓'Q o W Design Flow_________________ ______ _______________gallons per person per day. Total daily flow............................................gallons. u W Septic Tank—Liqid capacity dUQ.gallons Length................ Width---------------- Diameter................ Depth................ Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area.z! __�`�_�_______sq. ft. Seepage Pit No..................... Diameter____________________ Depth below inlet.................._. Total leaching area..................sq. ft. Z Other Distribution box Dosing tank ( 11 �1,,� �, `" Percolation Test R sults Performed by.____.___ 4_'____.__-___:".___.__.�____...1.7� ' __. Date_________________________________...... aj Test Pit i�lo. �J�_.' minutes per inch Depth of Test Pit_f� .......... Depth to ground water 4� feti�_..._. Test Pit No. 2................minutes per inch Depth of Test Pit____________________ Depth to ground water........_______________- ..T44- ----------------- Descriptionof Soil..... ---------------------- ---_--------------------------------------------- - - 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 TITLE,p 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_board of health` Signed----------': ✓.,/� ,' r'�/..._._.. f d'.�, j •-----,4_L Date Application Approved By....... �: -° ' ____________________________ . ✓° "r!�._.._._ Application Disapproved for the following reasons________________�___.__________________________-______.___-.___._-_..______._________-__..ate__......____-- ........................................................ •-•••--•-------•••-••--------------------•-••--•---•--•--•--••••---•-•----•-----••-----•--•-----------•---------•-------------•-•-•--•--------- Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD QF HEALTH ..{........OF........... !�•/°ir r•1"✓.i.'j h ............................... �le�ifixtt� ,af (1�u�t�rli�n�� � THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed.,,(') or Repaired ( ) --------------••--•••------..-•--•- by...._._..... t Install -- "' �" " A/ has been installed in accordance with the provisions of ,5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit _______________ dated----.-------.................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SA ISF CTORY. DATE,........................................ .............. Inspector............. ----------~ 1 THE COMMONWEALTH OF MASSACHUSETTS BQARF HEAL�T.H;+ ' ,�� �7f 7 ,..... d'"""..'r`r......................OF..-../1s .._..rt... :.......................................... T�O._._r,.. - FEE........................ -----•--_------•- Disposal Workv Ton nrtiolt anti# Permission is hereby granted__.__.______ _'__._: :!�/�r+� ! _______________________________ to Construct ( ) or Repair I d vldua wage ikosal System— at No...................•...t.-r - �-----..<;& • .� . , �`' a Gyp Street as shown on the application for Disposal `Forks Constructio ...Permit No_____________________ Dated _____ . __________-____-_____._____-__- Boardbe Health DATE----------------------- •• ---/------- -------------------------------- FORM 1255 1255 HOBBS & WARREN. INC., PUBLISHERS Jg D S �h--� z . .3 � N N v LVI k tV c k09HRT LEGEND t ki CERTIFIED PLOT PLAN EXISTING SPOT ELEVATION 0jt0 EXISTING CONTOUR --- 0 ——— ►+o.ea2o ��r o 'FINISHED SPOT ELEVATION tREQraTe ��► FINISHED CON.TOU'R IN APPROVED BOARD OR HEALTH 'SAAA ,tASLjl,ldAS8• DATE AGENT. SCALE=. � ,�� o � DATE `S"/g/�/ DREDGE E'NG/NEERIAry CQ IN CLIENT I CERTIFY THAT . THE PROPOSED EGISTERE REGISTERED J08 N0. �� d BUILDING SHOWN ON THIS PLAN CIVIL LAND CONFORMS TO THE ZONING LAWS DR.BY, A ,,q,/"�. 41NE R 'SURVEYO'R OF BARNSTABLE, MASS. ' 712 MAIN ST. CH- By, :,. MYANNfS, MASS. $HEET..L..OF DATE REO. LAND SURVEYOR /1107"F /F E/TNER THE SEPTIC TA V k OR 20 FT. M/N. �!EAC/I/n!G P/T ARE MORE 7',HAIV /Z"ffELON/ /O M/N GRADE, Ai 24•O/AM ETER CONCRETE COVER b. SNALL BE aROtIGNT TO 4MAGE.64'y EXT'4zA .¢"f�VC PI PE CONCRETE j-/,ERvy CAST IRON CO�/ER S/�.4LL C3E USE.O /D O. o COVERS MiN. PITCH IF/N pR/VEN/AY �B OPR FT 2•J• MiN. CONCR•�'TE Al :=a: G .4oE COVER CLEAN SAND &ACACF L/QU/D LEVEL Z"LAYER CAST 1... - q e OF 1 IRON P/PE (i/1L. ° • • • • • • • • / p oAc'¢ MIN.P/TGN L�/ST m • • • • • • , Q WASHED STONE SEPTIC TANK a • •e BMX • • e • • • • • • a • 1L;; 'r Qp • • •EFfEC777✓C 1 : ♦ ♦ 3�4"— I �2" e 1 • • p �-N • • • • e WAShlED STONE 0 o: ti a v 1 • • • • • • • f o , ,�:;e; s •ao e / 1 • a • • • • • ' o p pRECAS T SEEPAGE o e o • • • • • • • • • a o P/7 ,OR E VI V. 1 AWPA'7r EL E✓AT/DNS • INVERT AT OU/LO/NG 96` FT. 6 D/AM. INLET SEPTIC TANK FT. D/AM. C�SFE TADULA TION� DU�LET SEPTIC TANK INLET DISTR/EUT/oN BOX �s'�' FT. SECTION O.= GRouND wA7ER TABLE O�lT[ETD/STR/Bl/T/ON BOX . INLET LEACH/IVG PIT C FT. SEWAGE /S'POSA L SYSTEM 7AS411-AT/DN LEACH//Nlr: P/T DIMENSION A FT. DESISN CRITERIA SCALE - O D/�►1EN5/CN 8�-FT NUMBER OF BEDROO/y„S 3 GARQ.aGEDISPOSALlJIY/T SOIL LOG S'D/L TEST TOTAL E.STlMA7'ED F1_0*V 3-3 C G.4L..IDA-' . SO/L TEST ,if/ SO/L TES7-#2 i1lUMBER aF 4E.4cMtNG P/rS_ I�—� f^FLEY. ,DATE of SO/L TEST L--TRI 'Z S^ SdOE LEACH/NG PER PIT SQ. PT. G 1 RESULTS H//T/VESSED BY �" h aoTTO/H 4E4CH/NCr PER AP1772 SQ. FT. PE'RZOLAWON RATE At/ /o s 1 MI/Vr/'NGM y7AI_ LEACH/NG AR,--A ESQ. FT. J°1FX'COLAT/GN RATE 2 M/N.IINGN RESERVEGEAC/'/INGAREA G SQ. FT. ot 30ROBERT i a 90 •.- ' �at,rntcas t = ' EL DREDGE ENG/N"P/NG CO,//VC. 7/Z, MA//Y 3T. tq c�rsr� �© NO GROGJNc7 1-V,47&R ENCOUNTF2ED HYAAIIV/J, MASS. rF.,. suvv `� �_! GIRO UND N.ATER AT EL C(/. _ . -.._:. ..,:.��« JOB ND. �/0-1 s��T-oF . tm,."9Ra•i�:•"t�7.�-,.-v�^`•t:,w:= 7R9�RIY_e.'M'PQ.',.�vti-_' .r.�-�-t"c�T .�r.v::'L4�b.'_.. . -. .. ...K..u:"V+..•'395:"•+. .:t-.r.••:e__.. __ �_ -_ - �y.+.y./('LA". aw.:-,.•a.•rm.'f-arae,vu- _,�,....y.�r�w..;. :+,�.•.�yt!- instaitatlon shalt ecnt ly witb;hey ' n i - . j p :ate k: tnni._rrial Goctr Tirir wn of .0 'J.10 of tie-Ith Keg+,:?:ions. �( //'f� L- y/^/t�.{� ��,)Q•• �)` •�',�,,� UQ•�'�'��r � N ,�/.�{ /�.! / J 1�l�1,-i�/' w� f ^ I VYi'►V ' 1,/Y 1 n r• e b t S 1 sept,c s�;si..rr ..rs ,.• o{ws ci or: ..r_!an s.,a., nos. ue inst3ls'Pd until a tice--ed town insta;ler R -- l��,i/ ` �.% � / � � / 1_- � `�? ' 1 � •.='�'�eS 3pt:rvUai an -��rt uf3+r7tl,.f�;,ermit+rent the applira��2 =,7Y1:'. to instaliarioa,tlii,rr:Tr;;±e- .Ball-aril the Iccaticn o .,vents. seta;ef :inz5 y�,. s =��•-�� existing, sepii;rot'1!rCili`tiia�:;i;�r i!:in5taltaior:. 1 8y: A'l ravity ewer piping s is ae into:schedir{e0 PVC at 1�i3" ?r`o<c, h: first Z feet ou`cf ":e distribution box shalt b-�ii ltxvt-;. All ;:king connections to be v,U?o ' t i.i;sF•ptic design plan, ' _e rt ? -%?d for property ling d?tei ryrlt=3 it-n c,r for any other / s: : p65e othN: tin the p;csl:•osed system instatlation. ri . .. „•..k.:w..:r.-.,..�•,.:.••.._�_.,,4.,,,,.�.�.a..,id...o.. ,!' � :tle r c:om¢o,:ent: !c mers ?.We V s e.if:tcatro n . (� �p� ✓ < (� %� kip,sisal!be r ohibite+i 3dC'r'YWC V COM^ Xurtents unle.,-, ."1po vnts arc H2O loaded. :'2c+eXi$t!n react ---.r crib 'r}CiS 5 .:c': t}f :'t-,P i fi r g -t p t , d and fille�) wtth n:a,.eral pe. 1 ftie V :f al!�njopment or.7ceo-,, _ t a8chinq .: cesSpcul(s) and cvrtat'nirtai-.d soils within;he q J tzo, =h l! he : m-wE-d a M =aced with r.reat+sa:td iw_ 'itie V sp i(irtit ons. ee,nDunents 3v. •,atef setvice line. Sewpf-is ie! ro....ils a watee. lime OV bt- sleeved tafrh an ai,;,, i 4hedule'�0 PVC with;nd--.a.rt;ier,. The water servl < `�' t lri1:-Or t`11+ h the s;eeve. be'ng a 6ska' ,1 i /' ;F ✓' ,l t � '+►U[� 2�1b the line i F ga;aage gander ex:: . � �e, It is to be remo�rt�d if ti•te ser:..:• '..stem is nai I r '_ ignC d to ac(omme = i;nder. installer is rrypcns�,_ x_cava*.ion arot;r : a :he , o0er-t•r and - ; .. . struct.ir Cur .iiairsn pr, _s_ '�r se t t ,, tectic�,the strtacrt. ,i;?• :f .ti tas t ,c . o; 1, '%r`ly reorese';', -1v a :,eptir system art be irtstalio'_.t ur, tri nice,,np Title %a piciperty owner +,_;' revietu des:g„criteria to approve ti,�i total numtrw of bedrooms an.J gr,flaw. lttstallatic,• oT the SEf+tic =ttm,as proposed a^^ receipt c'. pav:nent for the des»;i { , t((( %f ' l�-• C� :'.a;l be deemed appro4a{Cf:' d si,ri nit=°ria by the_ prope-iiy owne-o a.i nt of. vaWity of'tiis plan si all expire with the expirnon of the town instellaucir! perm?t issuec. f i t �Z ��d� �+/ t}18r1 1> .•.lTrs t7lldi!' +la: ShallexClirp'irt tllc!!> CSr.xplllt� c! i_.. Pt'i'rICBTP of(Qnl,r>`li4nf. \ V / � �� i. . �'�'� l `t Iv`lS-Iaa , ! wed Wr til._ !) `.VSrI it C-*, :ri5 pluii. %J L { _ .. + l `- �.� / i570KJt_ LO��L..> OF\ - qJs CIS ICU 4- U1 Te"' /z, �� �(ZxJ-47 - L-4r � DRVIJ g MASON r� . i �\ r ,� No.1066 ( � /✓ � it; A� � 19� t �i�� t fir__ -.3 �- --si OF AD - o , i J 3 Ste._ �b�� o4� --�C 5'f HV tC &k4 i 3740 0 s I AND , A(?F, F. A14 r i ,i_ti V . 'n.uY{,ia,....wra�'s,sw'N71t�sfai'+wn...^-Ri`r+l�1Sa•:.is i7.iew+nsnwgr...vr.- - -- . Tl. f4A V ll�rl L�4 v al 31 -ur:<.-a`a-: •f i.•-T.N••�+�..�Y• ��••. a(.•.6lJt!>'✓.i+"vr•Lbf.:a..:"::.P'_ �_ P^11E•.j�'�'•r-•TaMW7•MWY ... •T !.• 7,FiAfi.-•��.!.YY.;•-y _ e'•4i..i?LMC�f...aY.-..r-4_ t"a. .t - - .. .. AOiIW�Y/IiY/�Y�Si�I�•l�f✓..r. - w .. , l .tn.:F.r•• ... 71/tV'Xi•CN+I�SSMfilw 7 :4+ .. .iGf0.T..'+rt�"