HomeMy WebLinkAbout0325 OST.-W.BARN. RD - Health 3..25 OsV-W. soh
Marstons Mills - - - - - -- - - -
A= 121-144-002 \
TOWN OF BARNSTABLE
LOCATION 32S (�Sf— W gg✓h5t �`� SEWAGE #
VILLAGE ����' �� P ASSESSOR'S MAP & LOT
'�
E, INSTALLER'S NAME&PHONE NO. f• P= Dr'Sco"'
--,- SEPTIC TANK CAPACITY
LEACHING FACMITY: (type) P t t (size) ���� •�
NO.OF BEDROOMS
BUILDER OR OWNER 20k n fLyc'n
PERMIT DATE: t Z I 4rq COMPLIANCE DATE:Q 1246 9
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 L L)O {
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist lOb f
within 300 feet of leaching facility) Feet
Furnished by
€:� --- _ -
LOCATIONS
A B C
1 '22 ft 19 f f
2 IS ft 40 ft
3 29 ft 45 ft
A
EXISTING
SEPTIC a DWELLING
TANK' o
B # 325
4 a 2 W
❑ D-BOX Z
J
W-I
� F
LEACH a
PIT
3
NOT TO SCALE
OSTERVILLE WEST BARNSABLE ROAD- .
/ TOWN OF BARN:Aj3 DDDtttiiiLOCATION LvT �d DS;. �c�cNs` WAGE #
VILLAGE �Ci� ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY -,;AX
LEACHING FACILITY:(type) lea6� �/7 (size)
NO. OF BEDROOMS PRIVATE WELL OR BLIC WATE
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COLIPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
-•,
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No.. FEB
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
Appliratiuu for R-4puual Works Tuuutrurtiuu rumit
Application is hereby made for a Permit to Construct ('C) or Repair ( ) an.Individual Sewage Disposal
System at:
4 S I Le-v.r t e e
.. ............__ ........ ...... ----•-_-----
Location-Address /' or Lot No
.............. 31 z 1 �±t.7 ...... '/----- ..........--------- '�---_ (.�?._. . ....... ..............................
W Z3 SC 56
^j Address
,-� •..........................••---...------...---.�..�-----------................------------...---.... .._..-•-•-------•-------------•-----....--••-----------•------�-----•----•--•------ ..--
Installer Address S
Type of Building Size Lot_a__�_�.3_ ....... q. feet
Dwelling—No. of Bedrooms............................................Expansion Attic (re/) Garbage Grinder (N)
pa, Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures __________________________________
W Design Flow.............6__5.____.___.___.~_._____._gallons per person per day. Total daily flow-----------�_M...................gallons.
1:4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter____________________ Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'—' Percolation Test Results Performed by..___.3!a x?�'� . Date . ��
W /
Test. Pit No. L._�_ .__._minutesperinch Depth of Test Pit....!A'5----- Depth to ground water_-___N1.R_._____.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water----------......_.......
---- - ------ -------
O Description of Soil___.__� ^'s � - Sri^.�� Grimm'
x
U ---•-----••••-•-••••-•---------•-----••-----•---•----•---•-----•••---__--•_-----••--------------------------•--••-•-_---------•••---_•------•-•---_••---••-------------_---•_---........ ..............
W
x ••-•---------------•------•-•------•••••-••••-•••-----_•••-•--------••--•---------••-•----•_-•---------•--•-_-•-----------------•-_--•--••---------••-----_•-----__-----•-•--••---_----•._...-•------•_-
U Nature of Repairs or Alterations—Answer when applicable.
Agreement:
The undersigned agrees to install the aforedescribed In idual Sewage Disposal System in accordance with
t'1T/'1'-•-�
the provisions of 'TIE 5 of the State Sanitary Code—The dersigned further agrees not to place the system in
operation until a Certificate of Compliance has be s e by t board of h
0 - o l
Signed-•----•----•=-------:... /=-•==•--C----------.............-................ ------IIIIIT-------(t.....-1-.......
D to
Application Approved By.............. ........d O. a y'--ey--•---
Date
Application Disapproved for the following reasons:.................................................-..............................................................
---....-•-•---•------------------------•-.._..__..-•----------------•------•------------.._._....._.._.....--•---•-_-_-_--------------•-•---•---••-_•------------•---•-••_------_•---••-•••---------_..._
Q Date
PermitNo.------ ----------------------- Issued.......................................................
No..........'............... Fss...........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
ApVliratilan for Disposal Works Tonstrnrtiun rrrnti#
Application is hereby made for a Permit to Construct ("` ) or Repair ( } an Individual Sewage Disposal
System at:
"t. a F < S a-t-ie v.s c ��
................ -•.....................••--------•............�...-------------------- --
L cation-Ad ss or Lot 10
Owner Address
W . ....
Installer Address
Type of Building Size Lot------•_____________________Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic (e, Garbage Grinder ( }
Other—T e of Building No. of persons............................ Showers — Cafeteria
al Other fixtures -------------•------------------------•---•--••••••...
W Design Flow..............5.5........................ per person per day. Total daily flow................. .....................gallons.
Septic Tank—Liquid capacity............gallons Length---------------- Width................ Diameter................ Depth................
J Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
r Seepage Pit No..................... Diameter-------------_...... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) J
'-' Percolation Test Results Performed b ...__�' '�_ :`}.........9...._/V............ / '
a Y --------------- Date:.----------------------�-!------------ �
a Test Pit No. 1___ _ .....minutes per inch Depth of Test Pit.... Q_. ----- Depth to ground water----- ..........
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--._-___-_-___---._.__.
a
......--•-••.. ::
----------/
Description of Soil------ ---------•------------------------------------------------------••-
x
U --••-•••-•••••--------•••••••••--•--•-•--•-•-•.........................•-•-•-•-,•••••=-�•••-----•••-••----•------•-•----•••-••--••---••-••-•------••.......
w
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
----------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed In - idual Sewage Disposal System in accordance with
f•1T r1�•�•
the provisions of iT'jE" 5 of the State Sanitary Code—The dersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ssuedhy t e board of III h.
f Signed-•....S 14 t ' ..
A licat=on Approved B �' _ e.
Date
Application Disapproved for the following reasons---------------------------------------------------------------------------------------------------------------_
-------------------------------------------------------------------------------------------------•------•---._.....•---........---•-•----•--•------•-••••••••--••••••----•••-•••-•---•--••-••-••-..-•---
� � Date------ II
Permit No...... X::.-ti•-y}....................... Issued.......................................................
D t.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....,. ..................OF........ ��'fa,t
...........................................................
Tntifirttte of Tuntplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (X) or Repaired ( )
..........................................................----•-----------------------------------------------------------------------------•----•--•----------.--
Inst ller, �.
------------------------•------------------------•----------------------......-------••--•---
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
c�•c^
applicaticn for Disposal Works Construction Permit No.___. ../_.._... j_�f_.. .... dated________________________________________________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..... ... �?.... �G,�...............•--.....--------- Inspecto .. �
........ ......... •.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH.
�� . ` .
q,y ��!? !................OF.....................................................................................
No........._..,- FEE........................
Disposal Works 0. nns#rnr#ion Prrmit
Permission is hereby granted...... '.J_:___...-..1>>t _�5 e,'.t)t_(_. _c6 '°'
. ----------------.....
--........-------•----..........---..
................... ..._
to Construct (6() or Repair ( ) an Individual Sewage Disposal System
atNo.....Co-------------Vb................................................................. ....
Street
as shown on the application for Disposal Works Construction Permit Dated
•.•................................ Board of Health
DATE................ --- --------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
r
R3CECLEI V E
ECOJECH 4 2004
NOV 2
Environmental
www.eco-tech.us TOWN OF BARNSTABLE
HEALTH DEPT.
THIS FORM IS A FACSIMILE OF THE STANDARD SEPTIC INSPECTION FORM ISSUED BY THE MASSACHUSETTS DEPARTMENT
OF ENVIRONMENTAL PROTECTION(revised 6/15/2000)
TITLE 5
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 325 Osterville-West Barnstable Road IAPF 60
Osterville
Owner's Name: John&Mary Alice RyanARCE�
Owner's Address: 325 Osterville-West Barnstable Road LOT
Osterville,MA 02655
Date of Inspection: November 16, 2004
Name of Inspector: (Please Print) David D. Coughanowr,R.S.
Company Name: Eco-Tech Environmental
Mailing Address: 43 Triangle Circle
Osterville,MA 02563
Telephone Number: (508)364-0894
CERTIFICATION STATEMENT:
I certify that I have personally inspected the sewage disposal system at tlus address and that the information reported
blow is true,accurate and complete as of the tune 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:
X Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature ems— fLS Date: D U 7, �O
+
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority
NOTES AND COMMENTS
Irspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger
any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed
on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. .
""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.
Tile 5 Inspection Form 6/15/2000 page 1
r
a
Page 2 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 325 Osterville-West Barnstable Road
Osterville
Owner: John&Mary Alice Ryan
Date of Inspection: November 16, 2004
INSPECTION SUMMARY: Check A,B,C,D or E/ALWAYS complete all of section D:
A] System Passes:
Yes I have not found any infonnation which indicates that any of the failure criteria described in 310 CUR
5.303 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,or ND). in the_for the following statements. If"not determined" please
l exP ain.
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.
1\71)explain:
Observation of sewage backup or breakout or high static water level in the distribution box is due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with
approval of 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 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
ND explain
2
Page 3 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 325 Osterville-West Barnstable Road
Osterville
Owner: John&Mary Alice Ryan
Date of Inspection: November 16, 2004
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 and environment.
1 System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2) System will fail unless the Board of Health(and public water supplier,if any) determines that the
system is functioning in a manner that protects the public health,safety,and 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 by 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 amrnonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form
3) OTHER
3
Page 4 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 325 Osterville-West Barnstable Road
Osterville
Owner: John&Mary Alice Ryan
Date of Inspection: November 16, 2004
D) System Failure Criteria applicable to all systems:
I
You must indicate either"yes" or"no" to each of the following for all inspections:
I have determined that one or more of the following failure conditions exist as described 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
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped
X Any portion of the SAS,cesspool or privy is below high groundwater elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well
X Any portion of a cesspool or privy is within 50 feet of a private water supply well
X 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 by 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 Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
d
You must indicate either"yes" or"no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well.
If you have answered"yes" to any question in Section E the system is considered a significant threat,or answered
"yes" in section D above the large system has failed. The owner or operator of any large system considered a
significant threat under section E or failed under section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 325 Osterville-West Barnstable Road
Oste:rville
Owner: John&Mary Alice Ryan
Date of Inspection: November 16, 2004
Check if the following have been done: You must indicate either"Yes" or"No"as to each of the following:
Yes No
Y _ Pumping information was provided by the owner,occupant or Board of Health.
N Were any of the system components pumped out in the last two weeks?
Y _ Has the sysb.-m received normal flows in the previous two week period?
N Have large volumes of water been introduced to the system recently or as part of this inspection?
Y _ Were as built plans of the system obtained and examined?(If they were not available as N/A)
Y _ Was the facility or dwelling inspected for signs of sewage back-up?
Y _ Was the site inspected for signs of breakout?
including
Y Were all system components,exclu the SAS. located on site?
Y _ Were the septic tank manholes uncovered, opened,and the interior of the septic tank inspected for
the condition of the baffles or tees,material of construction, dimensions,depth of liquid, depth of sludge and depth of
scum.?
Y _ Was the facility owner(and occupants, if different from owner)provided with information on the proper
maintenance of subsurface disposal systems?
For information on The proper maintenance of subsurface disposal systems please go to:
WWW.ECO-TECH.US
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Y Existing information. For example,Plan at the Board of Health.
Y 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: 325�Osterville-West Barnstable Road
Osterville
Owner: John&Mary Alice Ran
Date of Inspection: November 16, 2004
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):330gpd
Number of current residents 2
Does the 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): n/a
Seasonal use(yes or no): no
Water meter readings, if available(last two year's usage(gpd): 159 gpd
Sump Pump(yes or no): no
Last date of occupancy: current
C OMMERCIALAND US TRIAL:
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: System last pumped in March, 2003 (Owner)
Was system pumped as part of the inspection: (yes or no) No
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM:
X 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/Alternate 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:
Age: 14+years Certificate of Compliance issued 12/22/89(BOH permit#89453)
Were sewage odors detected when arriving at the site: (yes or no) no
6
i
Page 7 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 325 Osterville-West Barnstable Road
Osterville
Owner: John&Mary Alice Ryan
Date of Inspection: November 16, 2004
BUILDING SEWER_(Locate on site plan)
Depth below grade: 2 ft
Material of construction:_cast iron X 40 PVC_other(explain)
Distance from private water supply well or suction line 20+
Comments: (on condition of joints,venting, evidence of leakage, etc.)
Sewer is vented through roof and appears structurally sound with no evidence of leakage or backup into dwelling
SEPTIC TANK: Yes (locate on site plan)
Depth below grade: 8 inches
Material of construction: X concrete_metal_fiberglass_polyethylene
other(explain)
If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(yes or no):_(attach a copy of
certificate)
Dimensions: 8.5 ft x 5 ft x 5 ft(1000 gallon)
Sludge depth: 4 in
Distance from top of sludge to bottom of outlet tee or baffle: 30 in
Scum thickness: 2 in
Distance from top of scum to top of outlet tee or baffle: 9 in
Distance from bottom of scum to bottom of outlet tee or baffle: 13 in
How dimensions were determined: Probe to top of tank
Comments:.(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
Pumping not required at this time but maintenance pumping is recommended within and every 2 years Liquid level at
outlet invert. Tank and tees appear structurally sound and functioning as intended No evidence of leakage in or out
GREASE TRAP: none (locate on site plan)
Depth below grade:
Material of construction: _concrete_metal_fiberglass_polyethylene
other(explain)
Dimensions:
Soum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:_
Date of last pumping:
Comments: (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address. 325 Osterville-West Barnstable Road
Osterville
Owner: John&Mary Alice Ryan
Date of Inspection: November 16, 2004
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 inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: none (if present must be opened) (locate on site plan)
Depth of liquid level above outlet invert: at outlet invert
Comments:(note if box is level and distribution to outlets is equal,any evidence of solids carryover,any evidence of
leakage into or out of box, etc.)
D-box appears structurally sound with no evidence of leakage in or out.Effluent level at outlet invert.
Few solids in sump.
PUMP CHAMBER: none (locate on site plan)
Pumps in working order: (yes or no)
Alarms in working order: (yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 325 Osterville-West Barnstable Road
Osterville
Owner: John&Mary Alice Ryan
Date of Inspection: November 16, 2004
SOIL ABSORPTION SYSTEM(SAS): Yes (locate on site plan;excavation not required)
L SAS not located, explain why:
Type:
X leaching pits,number 1
_leaching chambers,number
_leaching galleries, number
_leaching trenches, number,length
_leaching fields,number,dimensions
_overflow cesspool,number
—innovative/alternate system Type/name of Technology
Comments: (note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.)
Soils above leaching pit appeared unsaturated. No evidence of surface ponding,breakout, lush vegetation or
other evidence of hydraulic failure was observed. Leach pit contained 2.5 feet of effluent.
CESSPOOLS: none (cesspool must be pumped at time 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
1
. Page 10 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 325 Osterville-West Barnstable Road
Osterville
Owner: John&Mary Alice Ran
Date of Inspection: November 16, 2004
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100'(Locate where public water supply enters the building)
LOCATIONS
A B C
1 22 ft 19 ft
2 18 ft 40 ft
3 29 ft 45 ft
A
EXISTING
SEPTIC DWELLING
TANK o
# 325
B C
2 Z
❑ D-BOX
�Iw
3
LEACH
O PIT
3
NOT TO SCALE
OSTERVILLE - WEST BARNSABLE ROAD
10
r
Page 11 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 325 Osterville-West Barnstable Road
Osterville
Owner: John&Mary Alice Ryan
Date of Inspection: November 16, 2004
SITE EXAM
Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to groundwater: 35 feet
Please indicate(check)all methods used to determine 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)
X Checked with local Board of health-explain: GIS Dept records
Checked local excavators,installers-attach documentation)
Accessed USGS database
You ou must describe how you established the high ground water elevation.
Town of Barnstable GIS Department records indicate that the property os 35 feet above the groundwater table
11
Commonwealth of Massachusetts ! ;. E ,
Executive Office of Environmental Affairs
Department of
Environmental ProtectioIVA. .
William F.Weld �_ Trudy Coxe"
Arw Paul Celluooi Da~vld S.8tru sh
u.Governor Comm►Miornr
V
n SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
O S �/, lJ!/I.S . /av� PART A
CERTIFICATION
Property Address: { Address of Owner.
Date of Inspection: — h/— y� (If different)
Name of:Inspector. W.E. Robinson SR
Company Name,Address and Telephone Number. ( 5 0 8)7 7 5-8 7 7 6 h fd n /v�A
W.E. Robinson Septic Service
P.O. Box 1089 Centerville MA
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 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:
_✓ passes
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: fu i L r Date: 4 — r)—o/ 4
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A,B, C,or D:
i
A) )ElY$S�E1VI PASSES:
�� I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B 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.
Iadica 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, cracked structurally unsound, shows substantial infiltration or exfiltratio_ pt' y n,.or teak 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 11/03/95) 1
One Winter Street a Boston,Massachusetts 02109 a FAX(617)556.1049 • Telephone(617)292-5600
40 Printed on Recyded Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Party Address: vo2 5 0 f lr/, i3/���Sfi�G/� A V
Owner. 4J rn. A'p—9 Q/7
Date of.Inspection:
BJ SYS CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health):
broken pipe(*)are replaced `
obstruction is removed.
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will paw
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
C1 FUR EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
ditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
lic health,safety and the environment.
1) STEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
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) S STEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
S AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply 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 is less than 100 feet but 50 feet or more fiom a private water
supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free
fi+om pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
3) O
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Addres Qc5�jJ ,Ji9errs r9G/2 ,a O Q.S /�/l
s: sr—
Owner. VM
Date of Inspection:
D) SYSTEM FAILS:
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
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet 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).
Number 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 I 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
ooliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E)LARG SYSTEM FAILS:
Th following criteria apply to large systems in addition to the criteria above:
The serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
and safety and the environment because one or more of the following conditions exist:
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)
The owner or operator of any such system shall bring the system and facility into fall compliance with the groundwater treatment program
require to of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information..
(revised 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
i
Property Address: 3c::,2
Owner: (,t J%6'( "P/d h
Date of Inspection: /, �y
(� V /— / �p
Check if the following have been done:
_Jumping information was requested of the owner,occupant, and Board of Health.
_"None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
Z
t plans have been obtained and examined. Note if they are not available with N/A.
or dwelling was inspected for signs of sewage back-up.
�ze system does not receive non-sanitary or industrial waste flow
YThe site was inspected for signs of breakout.
system components,excluding the Soil Absorption System, have been located on the site.
septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of bates or
tees,material of construction,dimensions, depth of liquid,depth of sludge,depth of scum.
size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
1- ' facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub.
Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 2c'2
Owner. i(�/Yl J 1 9�n
Date of Inspection: p�i
FLOW CONDITIONS
RESIDENTIAL:-
Design tlow: llons
Number of bedrooms:_
Number of current residents:.3
Garbage grinder(yes or no): l- _
Laundry connected to system or no):
Seasonal use(yes or no): j-% 1
Water meter readings,if available: / d a/S
leT9 / d d tz/�
Last date of occupancy: l_
COIAMERCIAL/INDUSTRIAL:
Type o lishment:
Design fl w:gallona/day
Grease present: (yes or no)_
Industrial aste Holding Tank present: (yes or no)_
Non waste discharged to the Title 5 system: (yes or no)_
Water r readings, if available:
Lest da of occupancy:
O (Describe)
Last da of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)_
If yes,volume pumped: pllons
Reason for pumping:
TYPE�41F SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records,if any)
Other(explain)
APPROXIMATE AGE of all components, date installed(if known)and source of information: (I T ri S
Sewage odors detected when arriving at the site: (yes or no)Ai O
(revised 11/03/95) b
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C ,
SYSTEM INFORMATION(continued)
Property Address: 3,,?,�— os7Z'
Owner. (�cJ t-n A
Date:of Inspection:
SEPTIC TANK: s/
(locate on site plan)
► ti
Depth below grader
Material of construction:_1/eeacrete_metal_FRP_other(e:plain)
Dimensions `4 & J
Sludge depth: 4/, '
Distance from top of sludge to bottom of outlet tee or baffle: "3
e.
Scum thickness: 3 r '
Distance from top of scum to top of outlet tee or baflle:L"$ Y
Distance from bottom of scum to bottom of outlet tee or baffle:_!d
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.) s ►'k- /e c i-
o o t;I -& ,
GRE TRAP:_
(locate on 'te plan)
Depth bolo grade:
Material of nstru Lion:_concrete_metal_FR.P—other(explain)
ns:
Scum
Distance top of scum to top of outlet tee or baffle:
Distance m bottom of scum to bottom of outlet tee or baffle:
Commen
(repo tion for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evils of leakage,etc.)
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM IINNF,O,RMATION(oontinued)
Property Address:
Owner. lcJ ry1 Jo� e l�GC/-/
Date of Inspection: r�
TIG T,,40R HOLDING TANK_
(locate site plan)
Depth be grade:
Material of n:_concrete_metal_FRP_other(e:plam)
Capacity: ons
Design gallons/day
Alarm lave
Comments:
(condition f inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth-of liquid level above outlet invert:
Comments:
(note if level and distribution is equal,B enoF of solids carryover,evidence of leakage into or out of box,etc.)
4don
ER:_
an)
g order:(yes or no) .
f pump chamber,condition of pumps and appurtenances,etc.)
(revised 11/03/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 02 0,5 /v 0 eq S'�tl-u! Ile-
Owner. tc)lrVl C !7
Date of Inspection: J
SOIL ABSORPTION SYSTEM(SAS):
(locate on sits plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Type: leaching pits,number:
leeching chambers,number:_
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number-
Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.) 1
iz G- 0 S t S 76
CESS _
(locate on site• lan)
Number and co tion:
Depth-top of to inlet invert:
Depth of solids r.
Depth of scum Is r:
Dimensicns of pool:
Materials of Co n:
Indication of 'at
(Cesspool must be pumped as part of inspection)
Comments:( condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
PRIVY:_
(locate on ai plan)
Materials construction: Dimensions
Depth of so'
Comments: (n condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.)
(revised 11/03/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
TEM INFORMATION(continued)
PmpertyAddres,
Owner. a�
Date of Inspection
SKETCH OF SEWAGE DISPOSAL SYSTEM:
inc^ude ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
J;
e
I
i
s S
boa G.oDt a m �Ly?6L
1 a
b jdk,i-c`
DEPTH TO GROUNDWATER
Depth to groundwater. '" feet ' II
method of determination or approximation: 6 W Tg s d 14. 6
(revised 11/03/95) 9
f
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M ,•''y 325 Osterville-West Barnstable Road
Property Address
Robert Domke and Jane Ryan
Owner Owner's Name y�A I
information is
required for every ��, M06h) '�'U h MA 02633 February 6, 2013
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When
filling out forms A. General Information
on the computer, I r l
use only the tab 1. Inspector: ''I
k om v key t move your
cursor-do not David D. Coughanowr, R.S.
use the re`urn Name of Inspector
key.
Eco-Tech Environmental
Company Name
43 Triangle Circle
Company Address
Sandwich MA 02563
Citylrown State Zip Code
508 364-0894 1328
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 inspe9c i n. The in�pectiQ
was performed based on my training and experience in the proper function and mairit Pance ofiD site?
sewage disposal systems. I am a DEP approved system inspector pursuant to Ration 15.3:40 of Z
Title 5 (310 CMR 15.000). The system: &:D
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority ._
" �+►K� �� -... ray
February 6, 2013
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.
I
l5ins•11/10 Title 5 official Insp io orm:Subsurtace Sewage Disposal System•Page 1 of 17
T
1
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
GSM 325 Osterville-West Barnstable Road
Property Address
Robert Domke and Jane Ryan
Owner Owner's Name
information is Centerville MA 02633 February 6, 2013
required for every ry
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:
Inspector's Note==> The septic system described herein is deemed to pass this Real Estate Transfer
Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-5. The
scope of this inspection is limited to health and environmental compliance and the septic system has
been evaluated according to the conditions observed on the day it was inspected. No estimate or
guarantee of system longevity is made or implied by a passing determination.
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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 325 Osterville-West Barnstable Road
Property Address
Robert Domke and Jane Ryan
Owner Owner's Name
information is ry Centerville MA 02633 February 6 2013
required for every ,
page. City/Town 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): � i
❑ 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
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 325 Osterville-West Barnstable Road
Property Address
Robert Domke and Jane Ryan
Owner Owner's Name
information is Centerville MA 02633 February 6 2013
required for every �
page. City/Town 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
i
Commonwealth of Massachusetts
4 W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
< 325 Osterville-West Barnstable Road
Property Address
Robert Domke and Jane Ryan
Owner Owner's Name
information is Centerville MA 02633 February 6, 2013
required for every rY
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
F
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
325 Osterville-West Barnstable Road
Property Address
Robert Domke and Jane Ryan
Owner Owner's Name
information is Centerville MA 02633 February 6 2013
required for every ry
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
330 9Pd
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
y d Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 325 Osterville-West Barnstable Road
Property Address
Robert Domke and Jane Ryan
Owner Owner's Name
information is rY Centerville MA 02633 February 6 2013
required for every ,
page. Cityrrown 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 75 gpd
9 ( Y 9 (gpd))�
Detail:
2011, 2012
Sump pump? ❑ Yes ® No
Last date of occupancy: not determined
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*
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
325 Osterville-West Barnstable Road
Property Address
Robert Domke and Jane Ryan
Owner Owner's Name'
information is Centerville MA 02633 February 6 2013
required for every rY
page. Cityfrown 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: agent
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 325 Osterville-West Barnstable Road
Property Address
Robert Domke and Jane Ryan
Owner Owner's Name
information is Centerville MA 02633 February 6 2013
required for every rY
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Age: 23+ years. Certificate of Compliance issued 12/22/1989. (permit#89-543 at Health Dept).
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Sewer line appears structurally sound with no evidence of leakage or backup into dwelling.
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: 8.5 x 5 x 6- 1000 gallon tank
Sludge depth: 2 in
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 325 Osterville-West Barnstable Road
Property Address
Robert Domke and Jane Ryan
Owner Owner's Name
information is Centerville MA 02633 February 6, 2013
required for every ry
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 32 in
Scum thickness 0 in
Distance from top of scum to top of outlet tee or baffle 10 in
Distance from bottom of scum to bottom of outlet tee or baffle 14 in
How were dimensions determined? Previous inspection report
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping not required at this time, but maintenance pumping is recommended every 2-4 years. Tank
and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was
observed.
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
wM °L 325 Osterville-West Barnstable Road
Property Address
Robert Domke and Jane Ryan
Owner Owner's Name
information is required for every Centerville MA 02633 February 6, 2013
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
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
325 Osterville-West Barnstable Road
Property Address
Robert Domke and Jane Ryan
Owner Owner's Name
information is required for every Centerville MA 02633 February 6, 2013
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert at outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-Box appears structurally sound and functioning as intended. No evidence of leakage in or out was
observed. Few solids in sump.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 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 325 Osterville-West Barnstable Road
Property Address
Robert Domke and Jane Ryan
Owner Owner's Name
information is Centerville MA 02633 February 6, 2013
required for every ry
page. Cityrrown 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.):
Soils above leaching pit appear unsaturated. No evidence of surface ponding, breakout, lush
vegetation, or other evidence of hydraulic failure was observed. An observation hole was dug into
leaching pit stone and no effluent contact staining was observed in the stone or overlying soils. No
standing effluent was observed to a depth of 2 feet below the top of the leach pit.
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
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
325 Cisterville-West Barnstable Road
Property Address
Robert Domke and Jane Ryan
Owner Owner's Name
information is Centerville MA 02633 February 6, 2013
required for every ry
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.):
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 Foam Not for Voluntary Assessments
325 Osterville-Vilest Barnstable Road
Property Address _
Robert Domke and Jane Ryan
Owner owner's Name
information is required for every Centerville MA d2633 February 6, 2093
page. CItylrown State Ztp Code Date oi'Inspection
D. SysteM- Information (Cont.) :_..
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two Ipermanent 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
2 � lq ;
Z tt
2q• 4 S.
T40K
D`' °X W
'I T
OSTMV It-LE - LEST 13A9tJSTPYat6 ROD
Isms a 11110 'Tiue 5 Qf 6ai Inspection Form:Subsurtaoe Sewage 0lspose!Swam.Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
325 Osterville-West Barnstable Road
Property Address
Robert Domke and Jane Ryan
Owner Owner's Name
information is Centerville MA 02633 February 6 2013
required for every ry
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: 30+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain.
Barnstable GIS Department records
You must describe how you established the high ground water elevation:
Town of Barnstable GIS Department records indicate that the property is over 30 feet above
groundwater table.
I
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 ,a 325 Osterville-West Barnstable Road
Property Address
Robert Domke and Jane Ryan
Owner Owner's Name
information is Centerville MA 02633 February 6, 2013
required for every rY
page, Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
9
0
NOTES:
MARSTONS MI
LLS
0
TO �D.E.O.E.
ALL WORKMANSHIP ,-AND MATERIALS SHALL 'CONFORM,
.2V MWAMUM Olt At 00CAY0 ON PLAN' I
�y
JITLE '5 B
RNSTABLF. RULES AND
THE TOWN OF,,;REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGF, OCUS
AND THE, REQUIREMENTS OF THIS PLAN.'
lo' um
ALL- COVERS 'TO SANITARY VkItS HALL BE BROUGHT TO
2. ROUTE 28
ON WITHIN 12" F FINISHED. GRADE. 28
RoU7
T.O. FOUNDA'n 8 ON. BLUENCsL,
3. ALL MASONRY UNITS USED TO BRING.COVERS TO -GRADE LANE
'001� MASONRY
SHALL E MORTARED IN -PLACE.
A ENTS OF. THE SANITARY SYSTEM SHALL -BE CAPASLE�
-4. LL COMPON
—10,LOADING UNLESS THEY ARE UNDER OR
4' PER fT. MIN. PlToi 11r-PER OF ITHSTANDING ..H
r LAY"'OF 10 FT. 'OF 'DRIVES OR PARKING AREAS. H-20 LOADING
now Lm
SHALL BE USED UNDER OR, WITHIN, 10 FT. OF DRIVES OR
PARKING.
0
17 141)
DISTRIBUTION EFFLUENT. PIPING FROM DISTRIBUTION BOX,SHALL ENTER LEACH PIT
BOX THROUGH SOMALI- OR TOP -ONLY. ENTRANCE THROUGH MASONRY LOCATION M.AP
EXTEN
SION WILL NOT BE ALLOWED.
LIANCE WITH DEM
7. NO, DETERMINATION HAS SEE'
oOo CAUON SEPIC TMK,,
: A 'RESTRICTION
S OR IONING -REGULATIONS. OMER/APPLICANT SHALL,
OBTAIN SUCH FROM THE ,APPROPRIATE AUTHORITY.
TEM PROf]LE,
POSAL �� -OF T, 81�' TAL AND VER11CAL CONTROL, �'SEE EVY, -ELDREDGE
B16TTOM EST HOLE
NOT TO scl" HORIZON
LE HIGH WATER LEVEL -,WAGNER -FIELD NOTEBOOK
A
CURRtNT,� ZONING 'INTERPRE ' IION: . , ,' DESIG CALCULATibNs,"
T
MIN. FRONT SETBACK 'FEET
NUMBER �OF. BEDROOMS
It—MIN., SIDE SETBACK -FEET GARBAGE DISPOSAL"-UNI
Its
REAR ,SE AlbK (1-10 GAL./BR,`/DAY, R.)
TOTAL ESTIMATED FLOW
TB
FEET
AL /DAY
�CAPACITYI. GAL_�
-�SEPTIC.,TA
' 'U REQUIRED NK,
TA
z .
ACTUAL,SIZE,OF SEPTIC NK
-LEACHING AREA REQUIREMEWS ,,
SIDEWALL �AREA
2.5
GAL/S.F
- _,BOTTOM ARE, G
1.0
PERCOLATION SOIL', TESTI'.�: �k AL/S.F. GAL
'LtACHI'
NG CAPACIIY�:(BOTTOM + SIDEWALL)
/2) --(1.0)
DATE OF 'SOIL ,TEST, , 2'' -AtSERVE,�LEACHING CAPACITY
WITNESSED ,BY,�
SAME-.
PERCOLATION TEN. CH
OBS
.2
'OBSERVATION HOLE OLE
ERVAnON H
ELEV. .,ELEV.=
-4.00,
cj
-0.00 TI ON:
LA
Mkl sr-_ Pp"ez
. ,LEGEND
t
EXISTING SPOT ELEVATION ONO
'EXISTING CONTOUR--- 00.w_"
E -
w
FINAL SPOT;ELEVATION 00.0
FINAL, CONTOUR
T ELEV.
No WATER� A WATF-R 'At ELEV. ,
SOIL TEST PIT LOCATION
W_W_
N WATER
. ...... TOW
SEPTIC TANK
zz
I 1� DISTRIBUTION BOX ,
WATER,,LEVEL ADJUSTMENT: m/A
PRIMARY LEACHING PIT ' �-O
LEACHING PIT
7L
TEST -DAE —WATER ,LEVEL
INDEX WELL
WATER LEVEL RANGE� ZONE
lo, 16P-8,�), INITIAL ISSUE
DEPTH
TO 'WATER LEVEL:fOR INDEX ,WELL
-DATE By
N0_ DESCRIPTION
FOR' THIS MONTH
-DESIGN
SITE, PLAN , & SEPTIG.�
WATERIEVEL ADJUSTMENT
10 HIGH ,WATER
T: t5*ZM 5TAB i-E -FICAD
..DEPTH
tIN
,'_,,MASS Ac HUS ETTS'.
FOR
4
GREENBRIER MVELOPMENT 'CO INC
_A0
C3
E3
APP
kOVM ,SOARC� ',OF H A
JOB NO , -1472
S(,ALE.
A
IEVY, EMREDGE &-lAGNER A8SOCIATES INC..
SITE . PLAN. ,
DAIT AGENT ARM= - ,PLO=
889 VtST TRk
Mkii, S tT �CENTERVUIE MA '62632
t4PiR 'rT.f