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HomeMy WebLinkAbout0025 SMOKE VALLEY ROAD - Health 25 Smoke Valley Road Marstons Mills _ A= 097-037-002 �\ f C Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 _C 25 Smoke Valley Road Property Address ri=: Jeff Ehart Owner Owner's Name 01 information is 3_ required for every Osterville /MM MA 02655 5-6-19 . page. City/Town State Zip Code Date of Inspection a 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. Inspector Information on the computer, James D.Sears ; S use only the tab JAME key to move your Name of Inspector cursor-do not Capewide Enterprises ��•,c+„ ,o:'a use the return Company Name , �' TIF ..• OF k�►e/y. � 153 Commercial Street ���''��i„ I N Sp�����`°�� `r l�l Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails OZOLZ4-99- 5-6-19 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Form Inspection p fF o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Smoke Valley Road Property Address Jeff Ehart Owner Owner's Name information is required for every Osterville MA 02655 5-6-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The system is a 1500 Gal. Tank D Box and three chamber's. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form `jlo1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Smoke Valley Road Property Address Jeff Ehart Owner Owner's Name information is required for every Osterville MA 02655 5-6-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 1) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Fig Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l< e 25 Smoke Valley Road Property Address Jeff Ehart Owner Owner's Name information is required for every Osterville MA 02655 5-6-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well*'". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: fi 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑. ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 25 Smoke Valley Road Property Address Jeff Ehart Owner Owner's Name information is required for every Osterville MA 02655 5-6-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in anampffM is less than 6" below invert or available volume is less than 1/2 day flow -4 i1401-41G ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Smoke Valley Road Property Address Jeff Ehart Owner Owner's Name information is required for every Osteryille MA 02655 5-6-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form �7e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ., . 25 Smoke Valley Road Property Address Jeff Ehart Owner Owner's Name information is required for every Osterville MA 02655 5-6-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Description: 1500 Gal. Tank D Box and three chamber's. Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): 2017-271,000Gal2018-444,000Gal's Detail: .Sump pump? ❑ Yes ® No Last date of occupancy: Present Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form .8 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Smoke Valley Road Property Address Jeff Ehart Owner Owner's Name information isequired or every Osteryille MA 02655 5-6-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No, If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Fls Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a u 25 Smoke Valley Road Property Address Jeff Ehart Owner Owner's Name information is required for every Osterville MA 02655 5-6-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract to be obtained from system owner and a co of latest ( Y ) copy inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1998-268/5-2019-New D Box. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): ' Depth below grade: 3' feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH -40. 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Smoke Valley Road Property Address Jeff Ehart Owner Owner's Name information isequired or every Osterville MA 02655 5-6-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 26"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: 1500 Gal.Precast- H-10 Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 28" • Scum thickness 1" 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 17" How were dimensions determined? Asbuilt-Tape 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.): Tank at working level. Tank and outlet cover at 26" below grade w/inlet cover at 2". Two inlet tee's,outlet tee. No sign of leakage or over loading. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Smoke Valley Road v Property Address Jeff Ehart Owner Owner's Name information is required for every Osterville MA 02655 5-6-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass. ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form h Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Smoke Valley Road Property Address Jeff Ehart Owner Owner's Name information is required for every Osterville MA 02655 5-6-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 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.): D Box is 16"x16"-3' below grade w/one line out. Box is New 5-2019 w/cover at 6" t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Smoke Valley Road Property Address Jeff Ehart Owner Owner's Name information is required for every Osterville MA 02655 5-6-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No' Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Smoke Valley Road Property Address Jeff Ehart Owner Owner's Name information is required for every Osterville MA 02655 5-6-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is three 500 Gal. dry well chamber's w/4'stone. Chamber's at 4'-6" below grade 6"water in chamber's. No sign of over loading or solid carry over. r 12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �fa Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Smoke Valley Road Property Address Jeff Ehart Owner Owner's Name information is required for every Osterville MA 02655 5-6-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 c Commonwealth of Massachusetts lip Title 5 Official Inspection Form is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 25 Smoke Valley Road Property Address Jeff Ehart Owner Owner's Name information is required for every Osterville MA 02655 5-6-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 5 S rn.� 1 o U q�T/ 7IJ/IOWI�OPHARAtSTABL$ LOCA'nON k4r / x a��[�/e✓ �SEWACE M VQ.LAG�' N. ASSESSOR'S MAP&40T„4Q7-d.i].ee1 _fV� Q�ISCAL & HONE NO,� SE nC TANK CAPACITY 1560 6&l L.EACEO G FACIL M:(type) x_- u c fd �..r+size) Sd 0 NO.OF BEDROOMS _ BL'ILDER OR OWNER PERMrrDATE: 6/- O-!ER_COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted GroundwAierTabte and Bottom of leaching Facility Feet Private Water Supply Well and Leaching Facility ((f any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching FacilityJ(if wetlands exist Feet within 300 feet o y Furnishodby —�� biR 'v 5', h 'F= ,.a' t15 a e 0 e N' • £Z'd LL6t7-LLb-809 sesiadjelu3epinnedeo d£9:£0'6LtiZAV Y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Smoke Valley Road +V Property Address Jeff Ehart Owner Owner's Name information is required for every Osterville MA 02655 5-6-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Na 10, Estimated depth toFigh ground water: feet e 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: 3-9-95 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: T.H.on Design plan 3-9-95. Bottom of chamber's at T below grade. Bottom of chamber's at 5' above T.H. Depth. .Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 h Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Smoke Valley Road `-` Property Address Jeff Ehart Owner Owner's Name information is Osterville MA 02655 5-6-19 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included J� f �d /V a Gw t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 -: 03 No.. --- Fn$. .... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliratiun for Disposal Works Tonstrnrtiun runfit Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal System at: LU...1.2$.... MOKES...YA.LL.E.Y....RQ. x,Z .ia'U.-'----- --------------------•-----------------------------•--------------------------•-•------------------ Location-Address or Lot No. MR...AND__MRSJEFFREY__.EHART ........................... 248OLDE HOMESTEAD DRIVE _M MILLS__ Owner Address W ,.a st ter..........-•----------------------------- ••--••-----•-•-•--••----------------------....-dress-....--•••---------------------....... Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.........4................................Expansion Attic ( ) Garbage Grinder ( ) Pk Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ------------------------- -----•--------------------------•-•-•-••-•-----•----------•---....--•••-•••--•-•--------......--•---•--•-----••-......•---- W Design Flow....... 10.............................gallons per person per day. Total daily flow.........440 gallons. WSeptic Tank—Liquid capacity 1500gallons Length__- Width... Diameter...................... Deppth _4 '.0_1_ x Disposal Trench—No. ...1............ Width.l3.�.-.-_-..... Total Length....33 . 5 ' Total leaching area..459 GPIq ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (X) Dosing tank ( ) aPercolation Test Results Performed by.-.-BAXTER__&___NYE__•________________________________ Date MARCH- 9___1.995 Test Pit No. 1----...........minutes per inch Depth of Test Pit-------1Q.'...... Depth to ground waterN/A_ _________ rZ4 Test Pit No. 2.... ..........minutes per inch Depth of.Test Pit-------10........ Depth to ground watei­R/A................ 0 --•-----•..............•-----•-•-----•------•-•-•-•--------------••-----------......---------...-•--......................................................... Description of Soil.....CLEAN MEDIUM SAND xD...---•-•-•-••----•------=-------------------------------•----•------------------------------------..........••--- W U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ----------------------------------•-------------------------------------------------••-------------•-••-••----•-------------•----•-•-•---•--•---•-•----•-----•-•-•••-•-•-••--•••------••...........•--•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Dis osal System in accordance with the provisions of TITLE 5 of the State Enviro nta de—The undersi d further agrees not to place the system in operation until a Certificate of Co iance ha e is e b e d of health. Sign e .. -fo^� Date ApplicationApproved By .. ... . ... .... .... ...... ..... .... ...4---- . ..-- ------------------- ....................................... ---- ....... --- ......------ Date ApplicationDisapproved for the following rear ----------------------------------------------------------------------............................................................... Date Permit No. -� Issued ---------- ... No... ay THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE , pphratiou for Dhip ia1 3uorkii Tomuurtiurt rantit Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal. System at: LOT.... 2$... MQEk:..._V.ALT2X...R4A,I? -�11 -------------------------------------•----._.-.--.-..---------._.------------_--.-.------- Location-Address or Lot No. .MR,.AND MRS...JEFFREY_..EHART-_,_,_„,,,,,,,,,,,,,,,,,,•_ 248,,.OLDE„.HOMESTEAD_,•DRIVE _MMILLS_ Owner Address W nst ..............................................Instal ._............. ......._... ...».-'•' - nstaller Address _ d Type of Building Size Lot............................Sq. feet U Dwelling No. of Bedrooms___......4................................� g— Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ---------------------------------------------------------------------- W Design Flow.......UD.............................gallons per person per day. Total daily flow__-____--440_-_.__-_.__.___.__....._..gallons. 9 Septic Tank—Liquid capacity 159.0gallons Length•_- Width__-4.'8". Diameter___................... Depth.... _�.0 Disposal Trench—No ...... .._............ Width_.13............. Total Length_...3 3 .5 ' Total leaching area__4 5 9 GPPq ft. Seepage Pit No....._.1........... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (X) Dosing tank ( ) Percolation Test Results Performed by..._BAXTER--_&-_NYE-•----__--•._•_-_-_--_- _ Date_MARCH 9 199 5 „ a 0-4 Test Pit No. ... per inch Depth of Test Pit------iD'._..• Depth to ground waterN/A_ --..... --- 44 Test Pit No. 2....2..........minutes per inch Depth of Test Pit------- Depth to ground waterN/A.............. a -•--•••-------•-•---------------•-•--•------------••---•----------••---•---......------•-•-......---......................................................... O Description of Soil_____ ...- CLEAN M-ED- -IaLTM SAND ------- --••---- x - ----------------------------------------------------------------------------------------------------------•--- W U Nature of Repairs or Alterations—Answer when applicable.............................................................................................._.. -------•----••-•--••------•----•------•---------••----•------•.................•---........-------••---......--•--------•----•-•-•-----•----------------•-•----•---•--•-•......-••-----....._.-.------ Agreement: 0 The undersigned agrees to install the aforedescribed Individual Sewage Disposal'System in accordance with the provisions of TITLE 5 of the State Environ'me-6 a1`0 de—The undersigned further agrees not to place the system in operation until a Certificate of Corr riance ha..lSee i s b�t�e b a,d of health. � Signe - .• - .................................. --.-- -- �r �© Date Application Approved By .�"...-. t- -----" e-�� ----- r 1-k------------------------ ----.Date...------------- Application Disapproved for the following rear - ------ --- ------------------------....----- -- ------.....:.. ------------------- .---------- ------ W ( (� �J.--f-_ .. f Date .. Permit No. /, : 11! ... ......... .... . Issued .. �..✓.... �___% o THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE tLPrttii ate of CIIlrltpltanre . THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repairedby ( ) ...........................................................-- -----. - - �V ..................... �.. 4 at . [ C� �r _/'Ay----- 0-1KC--- -------- ............................................................. --------- -------- has been installed in accordance with the provisions of TITLE 5 -f he State EEnvironmental Code as described in the application for Disposal Works Construction Permit No. ..-.-. .""..-- ...... dated ------------------------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. (� DATE .---------�----- - '!R Inspector 1. ----------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF' HEALTH TOWN OF BARNSTABLE No.. r.. } FEE........................ Disposal Varkii Tnndrudiou rrntit Permission is hereby granted............................. ................................................................................................... ------•--- to Constru t (-_-),or Repai, ( � IU 'I ivi ual S1e�j'a e/D�is �al Syst�- �} c, atNo.......�t/l..-•----.� ---- Y .- . _..V.. .! !........................................1 '/.- t1 L.................... --Street as shown on the application for Disposal Works Construction Permit N=.�v__J�c��Dated ,�....... ......tr�s............_. y DATE G �� Board of He t'h -- ---- ------- -- ---- FORM 36508 H0138S h WARREN.INC..PUBLISHERS I use Ij- C_ ' �- L?_ �`� o c A 3 s a 0 e a y, TOWN OF BARNSTABLE LOCATION EWAGE#43' 6 VII.LAG �E �c �,o,C/ /o/�S� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO.��.�ls�r SEPTIC TANK CAPACITY LEACHING FACIIITY: (type) - q�j,`,V ) Sp0 size NO.OF BEDROOMS BUILDER OR OWNER , PERMI TDATE:_ `3 0 - 22 -_COMPLIANCE DATE: — Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 wetlands exist within 300 feet o achi a ' 'ty) Feet Furnished by F C, p�`' ,j OWN OF BARNSTABLE LOCATION D ! e SEWAGE VII LAGE Sf ASSESSOR'S MAP & LOT U 97d 0l da; INSTALL NAME&PHONE NO.—J-C4tj I�ra iC�i SEPTIC TANK CAPACITY 6,41 LEACHING FACILITY: (type) size) ` SOO NO.OF BEDROOMS e,4 c tia C 7 � BUILDER OR OWNER A4,L AQ A) PERMTTDATE: /o -.I Q ` k-COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 wetlands exist within 300 feet o achi a ' 'ty) Feet Furnished by 1� US e t C-1 ® r No. l� `") Fee ^� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftpliLation for Mfsposar *pstPttt Construction permit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System kindividual Components Location Address or Lot No.dZ 5 SM 01<6 1/,r}LL6-y 0 Owner's Name,Address,and Tel.No. �,^ -rc Fla 4/ * .4N�� C—*44ZI Assessor'sMap/Parcel '] Q �j� '�"�'7� Po (3pX a-lo 76-triwCC� P''�,4 Installer's Name,Address,and Tel.No.j( ...((77—Vj�'z'7 Designer's Njame,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms ~ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) �k gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil .Nature of Repairs or Alterations(Answer when applicable) 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 ea . % Si Date Application Approved by C Date Application Disapproved by Date for the following reasons Permit No.20 19 ��� Date Issued 617,011 4 � � No. " Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftptiLatlon for Bisposal *pstem Construction Permit Application for fPermit to Construct( ) Repair( Upgrade( f) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. Assessor's Map/Parcel ymwy&:�Pn Dog WA Installer's Name,Address,and Yel.No.J� -t-' Designer's Name,Address,and Tel.No. CAp6WfD E f R� � NIA m Type of Building: Dwelling No.of Bedrooms )f�' Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) A/�Q--- gpd Design flow provided A/A gpd V. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. . Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: x 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 t Compliance has been issued by this Board of eal Si e Date Application Approved by / Date Application Disapproved by / Date for the following reasons Permit No. Date Issued , hb,y - --- --- � --- --- -- -- ---------- -- - --THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Qd X Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(X) Upgraded( ) Abandoned( )by at has been constructed in accordance with the provisions of Title 5 and the f r Disposal System Construction Permit No. © CC7 dated f � Installer C Designer #bedrooms Approved design flow gpd The issuance of this permit'shall not be construed as a guarantee that the system will f6ctio as designed. Date �/ "1 Inspector / v� . No. Feed }-- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Bisposal *pstem Construction hermit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) System located at = .'� 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 _ Date �i l� 7.h I al Approved by APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS LOCATION LcrT 1 �v�o>LC; �G is L�� �.� N0. o`•"'rry VILLAGE ���(I LLB / G(i✓S S D1 u DATE 4 :M1 4 APPLICANT_ �vuyvl E X G��"_• Li4 � FEE_ 11ADDRESS A,L A,FV:�_=2�� A LgAAV ti��' TELEPHONE NO. (Non-refUndablE ' ENGINEER_ jAK = \�_XL TELEPHONE N DATE, SCHEDULED (Applicant's signaturd) • AS SOR'S A • • o 0 0 0 o e o • e oO nT o NU:e • o o • • • o e • o e e • • • • • • e • • • • • • • • • • • • s o I e • • • • • • • e • o ••� • e e• o • • • • . SES D1P 6i L ��13Z oUL SOIL LOG SUB-DIVISION NAME `��03,p0 i.T t2 DATE_HA b� � TIME EXPANSION AREA: YES � NO__ M14 C L- ENGINEER:'N. • ' TOWN WATER) _PRIVATE WELL • - � BOARD OF HEAL? • - <- � �-"�� EXCAVATOR SKETCH: (Street name, etc. ,dimensions of lot, exact location of test holes and percolation tests, locate wetlands in proximity to test holes) - NOTES: �f LS'.ON ! —'•'.per •''J I':.� Q ! 1 ' bc J\(' AV ti .11111 PERCOLATION RATE:. 1�I �NIi1J', ��j 1�T� •'r sue.. r .--V r(.+ rc7�� �a ! � .� tt '.i d` .� � i f t..., I.e i `: >'[ r 4 T + 1 fE K r , {�a S +� • l p y TEST .HOLE NO; ;. ' k ._.= ELEVATION. HOLE NO: ELEVATION: 1 Z L� S 1 3 — 3 H4 Lrs ��� 4 Ci v' t1 4 _ (;t7A2S(� 5 5 SA�� 6 AgoAll 6 7 SAfio 8 8 ii,(�t) 9 9 SAW, 10 10 • 11 11 12 12 13 13 14 14 15 15 I$, 16 7 SUITABLE FOR SUB-SURFACE SEWAGE: LEACHINGIFIELD_"�LEAC 1-NG PITSL/ LEACHING TREN:CHE§ , UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS: NOTE: ENGINEEIRING PLANS MUST SHOW NUMBER-ASSIGNED-ON PERC TEST APPLICATION ' ORIGINAL: COMPLETED IN ENTIRETY BY P E_ Atvn n> mVRNED TO BOARD OF HEALTH COPY: RETAINED BY APPLICANT P; o TEST HOLE LOG DATES—:� yB—-- SOIL EVALUATOR:-e,-0e-w-C •.c 'F WITNESS:.:. �1 \ PERC RATE: c Z .�//Nub 10 1 • 7-0,0 . y� . l _ N Y3 y _ .00 - , 0 DESIGN DATA DAILY FLOW:(y)BDRM&z 110 GPD=yf�v GPD SEPTIC TANK:�f o GPD z?AO°/._�4Bo GPD USE:/54)-o GALLON PRECAST SEPTIC TANK LEACHING FACII.11'Y: 1 - NJUSE:_(3� 5-;(S S xZ ••. .$-ov ¢ G�j/�I�ccs L✓1 y'vv= STo.vF i CAPACITY: tn\ � / SIDEWALL:-!.3�Z x o.�_ /37.Go O BOTTOM: /3'x 33.Sxo, � TOTAL: yS Nb s' ,. GOIy NOTES: ,. c uv� -, 1. ALL PIPE TO BE 4"DIA.SCH 40 PVG w �Mo a26NC s r' 2. PIPE TO BE LAID LEVEL FOR 2.OUT OF DISTRIBUTION BOX. 3. RAISE ALL APPLICABLE MANHOLE COVERS TO WITHIN �40 EU 6"OF FINISH GRADE. 4. SEPTIC SYSTEM IS NOT DESIGNED FOR THE USE OF A 4- GARBAGE DISPOSAL. S. SEPTIC TANK AND DISTRIBUTION BOX TO BE INSTALLED ON A 6"LAYER OF STONE. _•l.eYZR ar 30r FZA3TO a OVZR 6. INSTALL GAS BAFFLE IN OUTLET TEL 3M.-I U.wASUD STM AM AROUND TOP OF FOUND. ' ��•7 @ EL. y�o•�� . . to, u• 3 yo.so � e.cm. y�pp 7v'75 SEPTIC SYSTEM PROFILE SITE SEW AGE PLAN GENERAL NOTES FOR I. CONTRACTOR TO BE RESPONSIBLE FOR THE LOCATION OF ALL UTILITIES,ABOVE AND UNDERGROUND.PRIOR LOT/ZS .S.�o.�� v�L�E �'�• \ TO ANY EXCAVATION OR CONSTRUCTION. OST�.. �/GG N1f�• C�i� S7zS-Y7J 2, SEPTIC SYSTEiVI To BE INSTALLED IN COMPLIANCE WITH PREPARED FOR 310 CMR IS.00:TITLSV.OT 3. ISDETERMINATION.TosEUSED FOR PROPERTY LIrrR i. 4. ALL DISTURBED AREAS TO LOAMED AND SEEDED. DATE: SCALE: / = 7 2a xouR NOTICE FOR ANY S. CONTRACTOR TO PROVIDE f REQUIRED INSPECTIONS WELLER & ASSOCIATES 1645 FALMOUTH ROAD CENTERVILLE,MA. 02632 ' I TEL: (508)775-0735 FAX: (508)775-0754 APPROVED BY: _ _ _ TEST HOLE LOG DATE: .+rr-lA VZ, 9, I9ys f�BYsi y8' SOIL EVALUATOR:_L4x�,c �') \ WITNESS:._..a. AV \ v I \ PERC RATE: ��72o,o .100 A / / Iy� __.__Nv Gr/,9>E,lZ E•ucovNTE?E.� °O �c 3 DESIGN DATA J DAILY FLOW: (y)BDRMS.z 110 GPD GPD SEPTIC TANK:�'�o GPD z 200%=cSvO GPD - �' 4) USE::/5o o GALLON PRECAST SEPTIC TANK LEACHING FACILITY: USE: \ / / CAPACITY: \ N SIDEWALL: / BOTTOM: /3'x 33.S x0�7 y 3zz.3 TOTAL: ��a��N`Of Mgs�q O� DANIEL E.SR �yG NOTES: CIVIL 1. ALL PIPE TO BE 4"DIA.SCH 40 PVC. �' c�a W.32686C y 2. PIPE TO BE LAII)LEVEL FOR 2'OUT OF DISTRIBUTION �O BOX. 19 3. RAISE ALL APPLICABLE MANHOLE COVERS TO WITHIN 6"OF FINISH GRADE sunvE 4. SEPTIC SYSTEM IS NOT DESIGNED FOR THE USE OF A -2A O � GARBAGE DISPOSAL. 4— 3L- 5. SEPTIC TANK AND DISTRIBUTION BOX TO BE INSTALLED ON A 6"LAYER OF STONE. 6. INSTALL GAS BAFFLE IN OUTLET TEE. 2•LAYER OF 3I1•PEASTONE OVER 3/6•-1 In•WAND STONE ALL AROUND I TOP OF FOUND. @L. el/ 5/0 7 E .C�� 10, 14' / yo.so y/ So 5�0.33 38.o . yo,o 0 • `'/o a yip. �s - SEPTIC SYSTEM PROFILE SITE ^- SEWAGE PLAN GENERAL NOTES FOR 1. CONTRACTOR TO BE RESPONSIBLE FOR THE LOCATION OF ALL UTILITIES,ABOVE AND UNDERGROUND,PRIOR [DATE �,a, TO ANY EXCAVATION OR CONSTRUCTION. CAPL SEPTIC SYSTEM TO BE INSTALLED IN COMPLIANCE WITH PREPARED FOR 310 CMR 1&00:TITLE V. �IDA/ Cv,�/Si';� )I jQAI 3. THIS PLAN IS NOT TO BE USED FOR PROPERTY LINE DETERMINATION.4. ALL DISTURBED AREAS TO LOAMED AND SEEDED. : --i�,L '• SCALE: / _ �c� S. CONTRACTOR TO PROVIDE 24 HOUR NOTICE FOR ANY REQUIRED INSPECTIONS. FT WELLER & ASSOCIATES FALMOUTH ROAD CENTERVILLE, MA. 02632 EL: (508)7754735 FAX: (508)775-0754 � APPROVED BY: