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Home My WebLink About0226 CEDAR STREET - Health 226 Cedar�Street c * W;,Barnstable Me. i A 131 t q t r, TOWN OF BARNSTABLE LOCATION Q of C ASSESSOR'S MAP&PARCEL I ( .O �— IATss�R'S NAME&PHONE NO�socSa �� c ti SEPTIC TANK CAPACITY I SQ C-:> y, LEACHING FACILITY:(type) nn ('S (size) NO.OF BEDROOMS .� �"'� 3 OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 5 Feet Private Water Supply.Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) �� Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) f Feet FURNISHED BY t J 3r 131 ` � No. 0201 0 3 Fee / BOARD OF HEALTH TOWN OF BARNSTABLE 2pplicatiou _for Yell Con5-tructiou Permit Application is hereby made for a permit to Construct( ), Alter( ), or Repair( ) an individual well at: Location-Address Assessors Map and Parcel t'71(�,C:21 �Ck��l/�i C�C�`� �„�-Q.1✓ �� W l� O r Address I staller-Driller Address Type of Building Dwelling Other-Type of Building No. of Persons Type of Well Capacity Purpose of Well Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certificate of C m is c ha een ' 7,ed by the Board of Health. Signed t 1Date CW Application Approved By Date Application Disapproved for the following reasons: Date Permit No. Issued l /Gp < K✓ Date -------------------------------------------------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Motu "a"ce THIS IS TO CERTIFY,that the individual well Constructed , Altered( ), or Repaired( ) by c -n- e o&)a � i / Installer atp+a P has been installed in acco dance with the provisions of the Town of Barnstable Board of Health Private Well Pro ectic Regulation as described in the application for Well Construction Permit No. 3 L'fDated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector No. 03 J` Fee ` / BOARD OF HEALTH TOWN OF BARNSTABLE 01ppYicatiou -for Yell Couotructiou 3permit Application is hereby made for a permit to Construct( ), Alter( ), or Repair( an individual well at: GLocation-Address T— Assessors Map and Parcel I1 d r 1 Address I stalle -Driller Address Type of Building Dwelling Other-Type of Building No. of Persons Type of Well {,J I 1 Capacity Purpose of Well , (, Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certificate of Comp�liaannce has/lleen issued by the Board of Health. / Signed -'_�211, � / Date -Application Approved By zj L6CA� N" Date Application Disapproved for the following reasons: Date Permit No. _Jl)J '� Issued - Date BOARD OF HEALTH TOWN4OF BARNSTABLE Certificate of �oM ince THIS IS TO CERTIFY,that the individual well Constructed , Altered( ), or Repaired( ) Installer at has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No.�//� —�_"3 1-1 Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector BOARD OF HEALTH TOWN OF BARNSTABLE VeYY Cou0tructiou permit Fee No. '�{}�/ y Permission is hereby granted to r _ V �. Installer to Construct Alter( ), or Repair( an individual well at: No. Street as shown on the application for a Well Construction Permit No./"'//� — LJ Dated '�Date 1�} / 1� Approved By \ i 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 226 Cedar Street Property Address. Ed &Natalie Ostrom Owner Owner's Name information is west Barnstable MA 02668 July 13, 2012 required for every page. CitylTown 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: A. General Information When filling out forms the computer,use 1. Inspector: J U only the tab key to move your Patrick T. Sullivan cursor-do not Name of Inspector use the return key. Ready Rooter Excavating Company Name P.O. Box 89 Company Address Forestdale MA 02644 City/Town State Zip Code 508-888-6055 SI 12843 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 16.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority July 23, 2012 Ins o s Signature Date g The system inspector shall submit a copy of this inspection report to the A66r6ving AufhoritY(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared_syste'. or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall stSbmit 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. _WI ****This report only describes conditions at the time of inspection and under1the 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. ( � /7� LSins•11t10 Title 5 OffiVInnbsurface Sewage Disposal ISy •Page 1 of 1 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 226 Cedar Street Property Address Ed &Natalie Ostrom Owner Owners Name information is required for West Barnstable MA 02668 July 13, 2012 every page. Cityrrown 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as describ in the"Conditional Pass"section need to be replaced or repaired. The system, upon co letion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not dZars Ined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 yold*or the septic tank(whether metal or not) is structurally unsound, exhibits substa ial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing t nk is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass ' spection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that t 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 2 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 226 Cedar Street Property Address Ed &Natalie Ostrom Owner Owner's Name information is required for West Barnstable MA 02668 July 13, 2012 every page. Cityrrown state Zip Code Date of Inspection B. Certification (cunt.) B) System Conditionally Passes (cunt.): ❑ 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 ealth): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is level d 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 Require by the Board of Health: ❑ Conditions exist which requir further evaluation by the Board of Health in order to determine if the system is failing to prote public health, safety or the environment. 1. System will pass unl s Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the sy em is not functioning in a manner which will protect public health, safety and the enviro ent: ❑ 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .�° 226 Cedar Street Property Address Ed &Natalie Ostrom Owner Owner's Name information is West Barnstable MA 02668 July 13, 2012 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank an AS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank nd SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has aseptic tank and AS and the SAS is less than 100 feet but 50 feet or more from a private water supp well". Method used to determine di nce: "*This system passes if the 11 water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates sent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, pro ded that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/Z day flow t5ins•11/10 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 4 of 4 Commonwealth of Massachusetts AM. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 226 Cedar Street Property Address Ed &Natalie Ostrom Owner Owner's Name information is required for West Barnstable MA 02668 July 13, 2012 every 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.. El ® 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/CMR15.304. within 0 feet of a surface drinking water supply ❑ ❑ the wit ' 200 feet of a tributary to a surface drinking water supply ❑ ❑ the s I ted in a nitrogen sensitive area (Interim Wellhead Protection Are or a mapped Zone 11 of a public water supply well If you have answered°yequestion in Section E the system is considered a significant threat, or answered °yes°in Sectove the large system has failed. The owner or operator of any large system considered a signreat under Section E or failed under Section D shall upgrade the system in accordance witR 15.304. The system owner should contact the appropriate fQglrlrtal Office of the nppartment. t5ins-11/10 Title 5 Official Inspeclion Form:Subsurface Sewage Disposal System-Page 5 of 5 Commonwealth.of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 226 Cedar Street Property Address Ed &Natalie Ostrom Owner Owner's Name information is required for West Barnstable MA 02668 July 13, 2012 every page. Cityrrown 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 P septic tank manholes uncovered, opened, and the interior of the tank P 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 GPD t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,..�' 226 Cedar Street Property Address Ed & Natalie Ostrom Owner Owner's Name information is required for West Barnstable MA 02668 July 13, 2012 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 Private Well 9 ( Y 9 (gpd))� , Detail: Well located 140+-'from edge of SAS. Sump pump?, ❑ Yes ® No 'JanLast date of occupancy: Date 2012 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., c.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank presen . El Yes ❑ No Non-sanitary waste discharged t the Title 5 system? ❑ Yes ❑ No Water meter readings, if av 'able: t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 226 Cedar Street Property Address Ed & Natalie Ostrom Owner Owner's Name information is required for West Barns y Barnstable MA 02668 Jul 13 2012 every page. Cityrrown 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: No records found Was system pumped as part of the inspection? ® Yes ❑ No If yes,volume pumped: 1500 gallons How was quantity pumped determined? Site tube on truck Reason for pumping: Maintenance 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•I IM0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8 I L N Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 226 Cedar Street Property Address Ed &Natalie Ostrom Owner Owner's.Name information is required for West Barnstable MA 02668 July 13, 2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: System installed 06/07/2004. Certificate of Compliance on file at Board of Health. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 100+-' feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: fleet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: year Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 11.5'X 5.5'X 5' 1500 gallons Sludge depth: t5ins•11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 9 i Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ,. 226 Cedar Street Property Address Ed & Natalie Ostrom Owner Owner's Name information is regtrired for West Barns y Barnstable MA 02668 Jul 13, 2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 31" Scum thickness 5" 611 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Tape measure and dip tube. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet PVC tees in place. Liquid level at outlet invert. Tank pumped and cleaned after inspection. Recommend maintenance pumping every 2 years with full time use. Risers bring covers within 6"of grade. 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 um to top of outlet tee or baffle Distance from bott m 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 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 226 Cedar Street Property Address Ed &Natalie Ostrom Owner Owner's Flame information is required for West Barn y Barnstable MA 02668 Jul 13, 2012 every 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 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 226 Cedar Street Property Address Ed & Natalie Ostrom Owner Owner's Name information is required for West Barnstable MA 02668 July 13, 2012 every page. CityrTown State Zip Code Date of inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): 0,r Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box, etc.): One inlet, one outlet. Very light solids carryover. No high water staining over outlet invert. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pu 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 12 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 226 Cedar Street Property Address Ed &Natalie Ostrom Owner Owner's Name information is required for West Barnstable MA 02668 July 13, 2012 every page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2-500 gal ea.w/3.5'of stone. ❑ 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.): Leach chambers dry at time of inspection. High water staining 3"off base of units. No sign of past hydraulic failure. Riser on chamber brings cover within 67 of grade. 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 13 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 226 Cedar Street Property Address Ed &Natalie Ostrom Owner Owner's Name information is required for West Barnstable MA 02668 July 13,2012 every 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, gns of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-11/10 Title 5 Official Inspection Forth;Subsurface Sewage Disposal System-Page 14 of 14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage DhWm at System Form-[dot for Voluntary Assesments M Cedar Street Ed&Natalie Ostrom Owner O%nWs Nam W&MM&M Is West Barnstable MA 02WS July 13,2012 emy page- cWrc wn state Zip Cate Dade of Ua on D. System Information (cont.) Sketch Of She Disposal System:_Provide a view of the sewage dispml system,indudit 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 S IS. r , > 13 t t • c� 1 y � v iS1f�•11fl5 Tile 60Kiaaf k Rom SW=uFWe SVWW DMPMW Sim P8P16Of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments L yf 226 Cedar Street Property Address Ed& Natalie Ostrom Owner Owner's Name information is West Barnstable MA 02668 July 13, 2012 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑. Shallow wells Estimated depth to high round water: >5 p 9 9 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: May 2, 2004 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: ma.water.usgs.gov terraserver-usa.com You must describe how you established the high ground water elevation: Test hole to 12' found no ground water(elv= +-55)2004. Base of SAS @ elv=61.Adjusted high ground water @ elv= 33 (2004). No high ground water in area of system. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 16 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 226 Cedar Street Property Address Ed &Natalie Ostrom Owner Owner's Name information is required for West Barnstable MA 02668 July 13, 2012 every page. c4rrown 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 4 � Page. CERTIFICATE OF ANALYSIS Barnstable County liealthST R6�ratory Report Prepared For: Redld3QtD�R�ds� b/l�/21� 3: (5 Lynda Bryson LU J tl 1 f l/ Order No.: G0530079 Kinlin Grover GMAC Real Estate P O Box 156 DIVISION Barnstable, MA 02630 Laboratory ID#: 0530079-01 Description: Water-Drinking Water Sample#: 30079 Sampling Location 226 Cedar St.West_Barnstable,_MA Collected: 5/9/2005 Collected by: L.Bryson Received: 5/9/2005 Routine ITEM RESULT UNITS RL MCL Method# Tested LAB: Inorganics Nitrate as Nitrogen 8.3 mg/L 0.10 10 EPA 300.0 5/9/2005 LAB: Metals Copper 0.10 mg/L 0.10 1.3 SM 3111B 5/12/2005 Iron BRL mg/L 0.10 0.3 SM 3111B 5/12/2005 Sodium 13 mg/L 1.0 20 SM 311113 5/12/2005 LAB: Microbiology Total"Coliform Absent P/A 0 0 307 5/9/2005 LAB: Physical Chemistry Conductance 180 umohs/cm 1.0 EPA 120.1 5/9/2005 pH 6.4 pH-units 0 EPA 150.1 5/9/2005 Sample has higher than,average levels-of Nitrates. Monitoring is recommended(2-3 times per year)to establish any upward trends __ __� JJ Approved By- �1 ab Director) i RL = _Reporting Limit , MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable MA 02630 Ph: 508-37 -5 6605 Town of Barnstable y�P��FfHE r �� Regulatory Services Thomas F. Geiler,Director • BAMSTABLE, � A MASS. Public Health Division rEDu►'�" Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: 7-ocf Designer: VkViD D- COUGH I NOW K Installer: P R��N_ L Address: TRJ�06LC C1 tRaL Address: ®JB po�4 p C/P,s ghUDW1(_H 1 MA 02156 3 � _was issued a permit to install a On .(date (installer) septic system at e_ f eZAAW based on a design drawn by (address) �u l D pUG(�t i�IUD WR, RS dated (designer) V I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. / DAVID 0. (Installer's &pde F 2 ega'ta �p , (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form I I' y TOWN OF BA.RNSTABLE LOCATION SEWAGE # Olf'-,U, ' O VU AGE tk�", 1:z ! ®®ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �.1 - (size) J LEACHING FACILITY: (type) ) �� NO. OF BEDROOMS BUILDER'OR OWNER PERMITDATE: COMPLIANCE DATE: �a ` Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (1f any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by . ` 131 lit e�6� ��6 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS application for �Dizpogal *pztem Cougtructton Perron Application for a Permit to Construct( )Repair(L/)Upgrade( )Abandon( ) ❑Complete System 0 Individual Components Location Address or Lot No. e G Yr. ui �, Owner's Name,Adrrd��ress and Tel.No. Assessor's Map/Parcel ,}16 ef �'1�� 16& Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 367_og T4 f�!7` [4z.o/ 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 gallons per day. Calculated daily flow gallons. 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 Environme Code d not to place the system in operation until a Certifi- cate of Compliance has been issued by thisfl@ard of a SignedAl Date Application Approved by Date D Application Disapproved or the following reaso s Permit No. Date Issued iQ. _ i w Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: t Yes V PUBLIC HEALTH DIVISION - TOWN OFIBARNSTABLE., MASSACHUSETTS 01ppYication for Diopont *pitem Con!6truction Permit Application for a Permit to Construct( )Repair(lf)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 4 amw (/i M Yv' Owner's Name,Address and Tel.No. Assessor's Map/Parcel 131 , / OV6 C/ kxw Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 6[! Cowl Ayorr4 1-f 4o-7&4 Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type ofyBuilding No.of Persons Showers( ) Cafeteria( ) Other Fixtures c ti Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil r Nature of Repairs or Alterations(Answer when applicable) . 1 Date last inspected: 1_. Agreement: i „ :=-.•w The undersigned agrees t6 ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environme I Code d not to place the system in operation until a Certifi- cate of Compliance has been issued by this d of . 'a r Signed nY J 117 s.-- Date 6— +' Application Approved by Date - - - Application Disapproved for the following reasons f s4 1s Permit No. �. Date Issued U� r — / - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Cornstructd'i(+' `�i,Repaired ( -)jpgraded( ) Abandoned( )by _ c.VQ.�'`—'I tl III/ I / ` 4 at , f ha. }`e co,{istnrcted in accordance with the provisions of Title- and the for Disposal System Construction Permit No._ !Al ated Installer kA0 04 Designer W The issuance of this p t haWnot construed as a guarantee that the syfstern ill funct o_txas-designed._ Date Inspector \ -- —`-- ---------------------------- No. �! Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS r 1Wigpo2;a1 *pgtem (Construction Permit Permission is hereby granted,to Construct( )� pai7 r pgrade ) a�Tin,[ System located i ( & t and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Constru ion/mu�s�be co pleted within three years of the date of this ermit. Date:_. `7 Approved by �l TOWN OF BARNSTABLE . I ,,..�,&L.�ZZ L SEWAGE # . LOCATION '� VILLAGE 'S ASSESSOR'S.MAP & LOT rr INSTALLER'S NAME PHONE NO. 0�1 ® SEPTIC TANK CAPACITY LEACHING FACILnrY, �-4�+pe) "* - (size) � r� 1 \ NO.OF BEDROOMS BUILDER'OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: i Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility. (If any wetlands exist Feet i within 300 feet of leaching facility) Furnished by i1.O/1.'I a � 3 WEST BARNSTABLE MA CONTOURS EXISTING - - - - - - - 30 MINIMAL GRADING PROPOSED N �P O '$ PLAN REFERENCE LOCUS ye 22o rt BENCH MARK \ 76 PLAN BOOK 233 PAGE 19 m� TOP OF FOUNDATION ELEVATION - 74.65 \ / ASSESSOR'S MAP: 131 �ForR v —tom USGS DATUM ASSUMED UNPAVED DRIVEWAY �— -7A LOT: 16 STRFFr 172 LOCUS MAP / r 78��-- oM _J ' 70 NOT TO SCALE `VV �R ,�o "/ � —`� / 24fixl2.sftx2ft LEA GALLERY USE H-20 WTS L � � h ; ( / SOIL REMOVAL AREA - J ,� e WELL 28.2 ff C 76 � � � cy �(!1 J VENT PPE 64 rd O rrl ; LEGEND 7`I LOT 16 / ( 500 GALLON v AREA - 0.62 ac •- 6 / SEPTIC TAW / 64 /25.15 r► — H-20 D-BOX G �/88 ft 62 TEST PIT / EXISTM 68 CESSPOOL 1 70 PLAN SCALE: 1 in - 30 ft 72 NO OTHER WELLS WITHIN 150 FEET OF PROPOSED LEACHfgG GALLERY FLOW PROFILE - TOP OF FOUNDATION RAISE COVERS TO WITHIN 6 in OF FINAL GRADE VENT EL 74.65 - RAISE I COVER ON GALLERY PIPE AND INDICATE ON AS BUILT I ppV1D FINAL GRADE - 68.0 Gp11G�1 2- LAYER OF 1/8" # 10.93 D BQX 1,2- STONE.� 9 SEWAGE DISPOSAL S L SYSTEM PLAN /3- DROP USE H-20 Q p -TO SERVE EXISTING DWELLING p( FLOW LINE b- = �S NANCY HAYN 14' /� H-20 4a �As� PRECAST ? � �� 3/4--I I/4" LI � 226 CEDAR STREET WEST BARNSTABLE. MA BAFFLE :r,:+,?:rDRYWELL ?? ! e3v::: STBOTTOM OF 68.75 STONE LEACHING I SOIL ABSORPTION , 201 200� ECO-TECH ENVIRONMENTAL BASE 63.f3 SYSTEM_� GALLERY 43 TRIANGLE CIRCLE SANDWICH MA 0256 - 6 in STONE BASE 63.30 63.00 5 Tt+ I500 GALLON (END VIEW) s1.00 508 364-0894 40.5 SEPTIC TANK 85 rt vl 5 r► 12.5 r► ETE-1656 I MAY 20 2004 1/2 i b) 12 n THIS PLAN IS TO BE CONSIDERED A DRAFT PLAN UNLESS IT I 33.0 EST AL HIGH BEARS THE STAMP AND SIGNATURE OF THE DESIGN ENGINEER GROUNDWATER ORIGINAL PLANS INTENDED FOR SUBMITTAL TO THE BOARD OF HEALTH WILL BE SIGNED N BLUE AND STAMPED N RED. TEST: MAY 04 SOIL TEST LOG SOILEEOVALUATOR: DA ID2D.2OCOUGHANOWR , RS WITNESS REQUIREMENT WAIVED - NO VARIANCES SOUGHT DESIGN CALCULATIONS NO GROUNDWATER TEST PIT I PARENT MATERIAL: E ROGLACIALDOUTWASH DESIGN FLOW: 3 BEDROOMS X 110 GPD - 330 GPD ELEVATION - 68.10 i_ PERC AT 106 in 2 MIN/INCH IN C2 SOILS SEPTIC TANK: 330 GPD X 2 DAYS - 660 GALLONS DEPTH SOIL USDA SOIL SOIL'COLOR SOIL OTHER CONINSTALL 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED) - MAY USE H-10 (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING DISTRIBUTION BOX: USE 3 OUTLET H-20 D-BOX. 0-4 O SANDY LOAM 10 YR 2/1 NONE FRIABLE SOIL ABSORBTION SYSTEM: A 24 ft x 12.5 ft x 2 ft LEACHING GALLERY CAN LEACH 4-18 AP WOOD LOAM 10 YR 4/3 NONE FRIABLE A b o t - ( 24 x 12.5 ) - .300 s f 18-52 B LOAMY SAND 10 YR 4/6 NONE FRIABLE A s d w - ( 24 + 24 j 12.5 - 12.5 ) x 2 - 146 s f Atot - 446 sf 52-92 Cl LOAMY FINE 10 YR 5/2 NONE FRIABLE V t 0.74 x 446 - 330.04 G P D SAND 92-144 C2 MEDIUM SAND 10 YR 6/3 NONE LOOSE. 10% STONES USE A 24 ft x 12.S ft x 2 ft GALLERY. Vt - 330.04 GPD > 330 GPD REQUIRED GROUNDWATER ADJUSTMENT EXISTING GROUNDWATER LEVEL LEACHING GALLERY BASED ON BARNSTABLE GIS DEPARTMENT RECORDS INDICATED GW: 31.0 CONSTRUCTION DETAIL INDEX WELL: SDW-252 DRYWELL UNIT - USE H-20 AND VENT ZONE: B 8'-6-x 4'-10*x 2'-gP READING: APRIL 2004 2 ft EFF. DEPTH STONE LEVEL: 47.2 24.0 ft . 7 ADJUSTMENT: 2.0 ft NADJUSTED GW: 33.0 O ES M N to N 1) GARBAGE GRINDER NOT ALLOWED WITH THIS DESIGN L" m 2) ALL LINES TO BE SCH 40 PVC AND PITCH AT 1/8 INCH PER FOOT MINIMUM. 3) ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM REQUIREMENTS OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15) 8.5' 3.5' 4) INSTALLER TO VERIFY LOCATIONS OF ALLFUN.DERGROUND UTILITIES N07 TO 24.0 ft BEFORE EXCAVATING FOR SYSTEM. *< ` _ SCALE 5) EXISTING CESSPOOL TO BE PUMPED. COLLAPSED. ND FILLED. 6) ALL STONE TO BE DOUBLE WASHED ANDTFREE OF IRON. FINES AND DUST IN PLACE 7) LINES EXITING D-BOX TO RUN LEVEL FOR 2�' 0' BEFORE' PITCHING DOWN 8) ECO-TECH ENVIRONMENTAL RECOMMENDS THE,r.,PNS=TALL`ATION OF LOW FLOW FIXTURES AND APPLIANCES, AND BIANNUAL PUMPING."OF��T;H.E'SEPTIC TANK 9) SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR LOADING. DO NOT SEWAGE DISPOSAL SYSTEM PLAN PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. -TO SERVE EXISTING DWELLING 10) INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE STARTING WORK. 1 1) SEPTIC TANKS SHALL BE INSTALLED LEVEL AND TRUE TO GRADE ON A LEVEL N AN C Y HAY N STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON TO WHICH SIX INCHES OF CRUSHED STONE HAS BEEN PLACED TO MINIMIZE UNEVEN SETTLING 226 CEDAR STREET WEST BARNSTABLE. MA 12) THERE MAY BE OTHER CESSPOOLS IN USE. INSTALLER TO TRACK EXISTING SEWER ECO-TECH ENVIRONMENTAL LINE AND COLLAPSE AND FILL ANY EXISTING CESSPOOLS. 13) UNSUITABLE SOILS ENCOUNTERED WITHIN THE SOIL REMOVAL AREA ARE TO BR 43 TRIANGLE CIRCLE SANDWICH MA 02563 REMOVED DOWN TO THE MEDIUM SAND STRATUM AND REPLACED WITH CLEAN MEDIUM AND AND COMPACTED TO MINIMIZE UNEVEN SETTLING ETE-1656 I MAY 20, 2004 2i 2