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Home My WebLink About0011 ADMIRAL'S LANE - Health Y1 Admirals Lane(Osterville) A=118-130` } .. 4, �t�r1 'Sf i f�, o rJ r, L r i t Commonwealth of Massachusetts. . W Title 5 Official Inspection Form- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C ,M 11 Admirals Lane-Assessor's Map 118 Parcel130 Property Address Kevin and Cynthia Kett Poo Owner Owner's Name * i Q} information is required for every Cisterville a MA 02655 June 17,2016 $; page. City/Town State Zip Code Date of Inspection PR Poo Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. , Important:When filling out forms A. General Information on the computer,use only the tab 1. Inspector: key to move your cursor.-do not David D. Coughanowr, IRS = use the return key. Name of Inspector Eco-Tech Rapid Response r� Company Name 155 George Ryder Road South + ' Company Address. Chatham MA'` 02633 City/Town State, Zip Code 508 364-0894 11328 a Telephone Number G License Number B. Certification certify that I have personally inspected the sewage disposal'system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector,pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system:„ ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority P—S June 17, 2016 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or . has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 Admirals Lane -Assessor's Map 118 Parcel 130 Property Address 0• Kevin and Cynthia Kett Owner "� :�:• Owner's Name information is Osterville MA 02655 June 17 2016 requiredfo�",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: ® 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 Notes==> 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, or specified by local regulations. 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. Removal of garbage grinder is recommended I 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 Admirals Lane-Assessor's Map 118 Parcel,130 :- Property Address Kevin and Cynthia Kett Owner Owner's Name information is required for every Osterville MA 02655 June 17, 2016 page. Cityrrown State. Zip Code Date of Inspection B. Certification (cont.) 0 Pump Chamber pumps/alarms not operationaL System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): . . ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Boara of Health): ❑ broken pipe(s)are replaced ' ❑ Y ❑ N ❑"ND (Explain below): obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or.replaced ❑ Y ' ❑ N ❑` ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑,ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which'require.further evaluation by the Board of Health in order to determine if the system is.failing to protect•public health, safety or the environment. 3 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health; safety and the environment: - ❑ Cesspool or privy is within 50 feet of a surface water - <' ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-,Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 11 Admirals Lane -Assessor's Map 118 Parcel 130 Property Address Kevin and Cynthia Kett Owner Owner's Name information is required for every Osterville MA 02655 June 17 2016 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, pi^ovided that no other failure criteria are triggered. A copy of the ancttysis 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 99 p El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments °,M s 11 Admirals Lane-Assessor's Map 1.18,Parcel•130 Property Address Kevin and Cynthia Kett Owner Owner's Name information is every Osterville f required for eve MA '02655 June 17, 2016 page. City/Town 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 wa - ter 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. El ® 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 rro'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 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. 7 ; 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 E]; Area-1WPA) or a mapped Zone II of a public water supply.well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13` Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 Admirals Lane-Assessor's Map 118 Parcel 130 Property Address Kevin and Cynthia Kett Owner Owner's Name information is required for every Osterville MA 02655 June 17 2016 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 b the owner, occupant, or Board of Health ® ❑ p 9 P Y p , ❑ ® 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. Z El 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Forme Subsurface Sewage Disposal System Form - Not for Voluntary Assessments.., M 11 Admirals Lane -Assessor's Map 118 Parcel 130, F,., '" Property Address 4 ,y Kevin and Cynthia Kett Owner Owner's Name information is required for every Osterville MA 02655 June 17 2016 page. City/Town State Zip Code Date of Inspection D. System Information Y _ Description: r. A system sized for three bedrooms was installed by John Aalto in'1'979. ` • - a Number of current residents: 2 Does residence have a garbage grinder? Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection 0' Yes ® No information in this report.) , Laundry system inspected? Y ❑ Yes ❑ .No ,Seasonal use? ® Yes .❑ No Water meter readings, if available last 2 ears usage e 421 gpd 9 ( Y 9 (gpd)):- s Detail: 2014: 117,000 gallons' 2015:190,000 gallons(Irrigation system in use). Sump pump? ❑ Yes E No Last date of occupancy: current 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? .: = ; }.r ❑ Yes ❑ ,No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins;3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 11 Admirals Lane-Assessor's Map 118 Parcel 130 Property Address Kevin and Cynthia Kett Owner Owner's Name information is required for every Osterville MA 02655 June 17, 2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: e Date Other(describe below): General Information Pumping Records: Source of information: Owner 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 P ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 f _ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary,Assessments 11 Admirals-Cane-Assessor's Map 118 Parcel 130 _ , z ,•_ s; . Property Address Kevin and Cynthia Kett Owner Owner's Name _ y information is required for every Osterville MA- 02655 June IT 2016 page. City/Town P p State Zip Code Date of Inspection, I, D. System Information (coat:) Approximate age of all components, date installed (if known) and source of information: Age: 36+ years. Disposal Works Permit for a new system was issued 11/23/79 (Permit#79-590 at Health Department). - Were sewage odors detected when arriving at the site? ❑ Yes ® No' Building Sewer(locate on site plan): -, a Depth below grade: 2.5 _ feet Material of construction: _ ❑ cast iron N 40 PVC other(explain): Distance fromprivate water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage,etc.)-, • t Sewer line appears structurally sound with no evidence of leakage or backup into dwelling. J .c r- Septic Tank(locate on site plan):' Depth below grader feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene Elother(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 Sludge depth: , t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Admirals Lane -Assessor's Map 118 Parcel 130 Property Address Kevin and Cynthia Kett Owner Owner's Name information is required for every Osteryille MA 02655 June 17, 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28 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? Design Plan 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. Removal of garbage grinder is recommended. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Vol u ntary�Assessments 11 Admirals Lane-Assessor's Map 118 Parcel1130 . . , Property Address r„Y i j • t Kevin and Cynthia Kett Owner Owner's Name information is Osterville MA 02655 June 17 2016 ' required for every � _ - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) T F `4 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): r Tight or Holding Tank(tank must be pumped at time of inspection) (locateon site plan): Depth below grade: Material of construction:. ❑ concrete ❑ metal ❑ fiberglass- .❑ polyethylene ❑ other(explain): Dimensions: . Capacity: gallons Design Flow: gallons per day Alarm present:-. ❑ Yes ❑ No. Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm,and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1.1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M s 11 Admirals Lane-Assessor's Map 118 Parcel 130 Property Address Kevin and Cynthia Kett Owner Owner's Name information is required for every Osterville MA 02655 June 17, 2016 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.): No adverse conditions observed. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation riot required): If SAS not located, explain why: l5ins•3113 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 11 Admirals Lane-Assessor's Map 118 Parcel 130 Property Address Kevin and Cynthia Kett Owner Owner's Name +. information is Osteryille MA 02655 June 17 2016 y required for every � - page. City/Town State Zip Code Date of Inspection D. System Information(cont.) Type: ® leaching pits number: 1 ❑ leaching chambers ., number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields .number, dimensions:' ❑ overflow cesspool number: ' El 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.): No evidence of surface ponding', breakout, lush vegetation, or other evidence of hydraulic failure was observed. A bucket of water was poured into the distribution box and was observed to pass through in a rapid and unobstructed manner, and could be heard splashing down into 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 4=- Depth of scum layer,- ; Dimensions of cesspool4 Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 c Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 11 Admirals Lane-Assessor's Map 118 Parcel 130 Property Address Kevin and Cynthia Kett Owner Owner's Name information is required for every Osterville MA 02655 June 17 2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts 3 u - Title 5 Official Inspection Form a Subsurface Sewage.Disposal System Form'- Not for Voluntary Assessments GSM 11 Admirals Lane-Assessor's Map 118 Parcel 130 y jf Property Address Kevin and Cynthia Kett = Owner Owner's Name information is a required for every Osteryille MA 02655 June W, H16 page. City/Town State Zip Code "Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters,the building. Check one of,the boxes below: ® hand-sketch in the area below Ej drawing attached separately ADM RAL SS vL AN L®C A VOnNlS —OF SEPTIC COMPONENTS 50 8 3 6 4-0 8 9 4, —DISTANCES IN DECIMAL FEET "^ A B13 ^ ;u 1 ° 2 33 26.5 a 27.5 36.5 NOT 3 �k -TO SCALE DRIVEWAY r { C D—BOX 3 LEACH PI T. THIS SKETCH IS ` F BEST VIEWED IN COLOR FORMAT "GALLON SEPTIC TANK 1000 3 r +r l iu `'rr ¢ p� ; EX§S TWO D WELL§NG., � y t t5ins,•3/13• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 11 Admirals Lane -Assessor's Map 118 Parcel 130 Property Address Kevin and Cynthia Kett Owner Owner's Name information is required for every Ostefyille MA 02655 June 17 2016 _ 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: 20+ 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 1979 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: Approved design plan on file with the Board of Health shows bottom of system to be 2.5 feet above the bottom of a witnessed test pit in which no groundwater was encountered. Town of Barnstable GIS Department records indicate that the property is over 20 feet above groundwater table. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -_Not for Voluntary Assessments ,M 11 Admirals Lane-Assessor's Map 1.18 Parcel 130 Property Address. Kevin and Cynthia Kett Owner Owner's Name information is required for every Osterville MA 02655 June 17, 2016 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 GEOHYDROL OGI CAL ' PROFILE - - NOT TO SCALE - - •� PRECAST LEACH -. - PIT BOTTOM OF LEACHING. PIT ' LEACHING JS A80VE HIGH GROUNDWATER GROUNDWATER ELEVATION PER GIS.MAPS t5ins•3/13; Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 t r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M �°~ 11 Admirals Lane Property Address James Wood Owner Owner's Name information is required for every Osterville Ma 02655 8/1/2011 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be alteredan aiij way. Please see completeness checklist at the end of the form. 5 Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: a key to move your cursor-do not Sean M. Jones use the return Name of Inspector ; key. �J Capewide Enterprises "ICI Company Name 153 Commercial St. Company Address Mashpee Ma. 02649 City/rown State Zip Code 508-477-8877 SI 4522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 8/1/2011 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. ell[ t5ins-11/10 Title.5 Official inspection Form:Subsurface Sewage Di I System•Page 1 of 17 Commonwealth of Massachusetts lopTitle 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Admirals Lane Property Address James Wood Owner Owner's Name information is required for every Osterville Ma 02655 8/1/2011 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: ® 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: The dwelling located at 11 Admirals Lane is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and a 1000 gallon leach pit.The system has been used seasonally for the past 6 years and is functioning well considering irs age. 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. El Y ❑ N ❑ ND(Explain below): t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page�17 - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Admirals lane Property Address James Wood Owner Owner's Name information is required for every Osterville Ma 02655 8/1/2011 page. CityRo State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑' Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to,protect public health, safety or the environment. 1. System will pass unless.Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments 11 Admirals Lane Property Address James Wood Owner Owner's Name information is required for every Osterville Ma 02655 8/1/2011 page. Cityrrown State Zip Code Date of Inspedion 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 isms•11110 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 11 Admirals Lane Property Address James Wood Owner Owner's Name information is required for every Osterville Ma 02655 8/1/2011 page. Cityr town 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 flils.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 ll 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 11 Admirals Lane Property Address James Wood Owner Owner's Name information is required for every Osterville Ma 02655 8/1/2011 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? 1 ® ❑ 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 gpd t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Admirals Lane Property Address James Wood Owner Owner's Name information is required for every Osterville Ma 02655 8/1/2011 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes 0 No Laundry system inspected? ❑ Yes ® No Seasonaluse? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes 0 No Last date of occupancy: current 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 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .'` 11 Admirals Lane Property Address James Wood Owner Owner's Name information is required for every Osterville Ma 02655 8/1/2011 . page. Citylrown State Zip Code Date of Inspection D. System Information (coot.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system El 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 "< 11 Admirals Lane Property Address James Wood Owner Owner's Name information is required for every Osterville Ma 02655 8/1/2011 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: original system installed 1979 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No 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. 10+ feet Comments(on condition of joints,venting, evidence of leakage, etc.): Joints ok, no leakage, vented through roof Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years. Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: 5„ t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y� 11 Admirals Lane Property Address James Wood Owner Owner's Name information is Osterville Ma 02655 8/1/2011 required for every -- page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 3.5' Scum thickness 21t Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers and tookmeasurements 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 does not need to be cleaned now but should be done soon and again every 2 years as maintenance. Outlet baffle is intact,water level was at bottom of outlet invert, tank was not leaking and was structurally sound. Inlet cover is on a riser 6" below grade. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass E 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•11110 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 11 Admirals Lane Property Address James Wood Owner Owner's Name information is required for every Cisterville Ma 02655 8/1/2011 page. Cityrrown 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 i 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �y 11 Admirals Lane Property Address James Wood Owner Owner's Name information is Osterville `Ma 02655 8/1/2011 required for every 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 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.): . Water level was at bottom of outlet invert, no sign of past hydraulic overloading. D-box was replaced in 2005 and was in good structural condition. Cover is on a riser. 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 forth:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °t 11 Admirals Lane Property Address James Wood Owner Owner's Name information is required for every Osterville Ma 02655 8/1/2014. page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 .❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At time of inspection the leach pit.had 4'of available leaching and no sign of past hydraulic overloading. Cover is on a riser 1' below 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•11110 Titre 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts lopTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Admirals Lane Property Address James Wood Owner Owner's Name information is required for every Osterville Ma 02655 8/1/2011 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of.ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding,'condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts ug11Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Admirals Lane l — Property Address James Wood Owner Owner's Name information is required for every Osterville Ma 02655 8/1/2011 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Y N1 Pr r 'TA N�r o A-t 2S o L 13y g-I .A q 13 2 20' 4 p.g©x A 3 33 P A'`f 2'6 13-1 3>o'W' t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts lopTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 11 Admirals Lane Property Address James Wood Owner Owner's Name information is required for every Osterville Ma 02655 8/1/2011 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20'+feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed:' Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour maps. Before filing this inspection Report,please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Fortis:Subsurface Sewage Disposal System-Page 16 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Admirals Lane Property Address James Wood Owner Owners Name information is required for every Osterville Ma 02655 8/1/2011 page. Citylrown 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 TOW�Nr OF BARNSTABLE ' CATION /A d r^%rA !B AfV- SEWAGE #0 LAGE 031�*—rV►IIj. ASSESSOR'S MAP & LOT t' v INSTALLER'S NAME&PHONE NO. GUM V SEPTIC TANK CAPACITY fWJGnI. c�ox, re.p A LEACHING FACILITY: (type) R7 I CM GAI (size) (;XG' NO.OF BEDROOMS BUILDER OR OWNER Pe-'rte �ucC" r Tr I z PERMTTDATE: d COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet ' Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by / \ l \qA A Q i ar �3 3 a 33 d� r,se� No. roco Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Y•, 0[pprication for Wgpogal *pgtem Cougtruction Permit Application for a Permit to Construct( ) Repair(tom) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. /1 �(h 1 f A',S ��. Owner's Name,Address,and Tel.No. STerv�� I Assessor's Map/parcel Installer's Name,Addr ss,a dTel.No. Designer's Name,Address and Tel.No. Fof� . Rue"Pus 'lope of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided 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) eSOX 09-P Jl r 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 Healt l Si Date l� l I d Application Approved b Date l l 7 l Application Disapproved by: Date for the following reasons Permit No. Date Issued No.. 5 '�P ' Fee Q 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: *` PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Z(PpYication for Di5po!pt �&paem Con5truction ferm-it Application for Permit to Construct( ) Repair(4upgrade O Abandon( ) ❑ Complete System ❑Individual.Components � Location Address or Lot No. /I A jbm(f A' S 1AA-1- Owner's Name,Address,and Tel.No. Assessor's Map/Parcel , I 3 O Pe.-I'e r 1 , 1 f U Installer's Name,Addrs, d Tel.No. Designer's Name,Address and Tel.No. 4 Type of Building: r Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures ' Design Flow(min.required) gpd Design flow provided W gpd, Plan Date Number of sheets Revision Date Title w. Size of Septic Tank Type of S.A.S. y Description of Soil " Nature of Repairs or Alterations(Answer when applicable) i OX &A 1 r '0 ` 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 Healt . x., S i ��n Date AppI ication Approved b} ` ., Date Application Disapproved by: Date for the following reasons Permit No. `.,," 176 1 Date Issued ,? i ———————————————————————————'=———— —————————— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS &X: �cPA,r Certificate of Compliance THIS IS TO CERTIF( that the On-site Sewage Disposal System Constructed ( ) Repaired (✓) Upgraded ( ) Abandoned( )by Va. at It A'Qm%r'Ai's IAA o STeru,I Lt- has been constructed in accordance 4g with the provisions of Title 5 and the for Disposal System Construction Permit No. .r QQ 5 dated I k l Installer 9 uy.(\ v Designer, W F #bedrooms Approved design.flow gpd The issuance of this permit shall not be construed as a guarantee that the syst m-will-functi "M- dned. Date 1 ' Inspector j —————————————————————————-- —————— —�——No. �(�) Fee/ THE COMMONWEALTH OF MASSACHUSETTS 'PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS _ i,5 o�aY:, gtem-�Cott�tructton Permit- Permission (3oX re��l r Permission is hereby granted to Construct ( ) Repair (kll_�Upgrade ( ) Abandon ( ) System located at AV l r~61 S /tA and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction must �b"ecompleted within three years of the date f is p i Date \ '`� I J Approved COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE.OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 11 Admirals Way Osterville, MA 02655 Owner's Name: Peter Lent, Trustee Owner's Address: 33 i715 Date of Inspection: November 1. 2005Cn f Name of Inspector: (Please Print) James M. Ford 2 Company Name: James M. Fordf w Mailing Address: P.O.Box 49 CD > Osterville,MA 02655-0049 a Telephone Number: (508) 862-9400 c� CERTIFICATION STATEMENT Ga m I certify that I have personally inspected the sewage disposal system at this address and that the i onnation reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: November.15, 2005 The system inspector shall subz a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the.system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 11 Admirals Lane Osterville, MA Owner: Peter Lent, Trustee Date of Inspection: November 1. 2605 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N;ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if.(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 I Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 11 Admirals Lane Osterville. AM _ Owner: Peter Lent, Trustee Date of Inspection: November 1, 2005 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has aseptic 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 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. 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: 11 Admirals Lane Osterville, MA Owner: Peter Lent, Trustee Date of Inspection: . November 1, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to'15,000 gpd. You must indicate either"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 11 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 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 11 Admirals Lane Osterville, MA Owner: Peter Lent, Trustee Date of Inspection: November 1, 2005 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ _ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS,located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)], 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 11 Admirals Lane Osterville. MA Owner: Peter Lent, Trustee Date of Inspection: November 1, 2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 1 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: _ Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: The septic tank was pumped after the inspection for maintenance 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 ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed on 1 112 6179-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 Admirals Lane Osterville, MA Owner: Peter Lent, Trustee Date of Inspection: November 1, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Continents (on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 2' Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 8" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions detennined: Measuring stick Continents (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert There did not appear to be any signs of leakage The tank was pumped after the inspection for maintenance GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping:. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 Admirals Lane Osterville. MA Owner: Peter Lent, Trustee Date of Inspection: November 1, 2005 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: eallons Design Flow: _ gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Cornments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-box was broken down. A new D-box was installed(Permit No 2005-561) PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order.(yes or no) Coimnents(note condition of pump chamber,condition of pumps and appurtenances, etc.): 8 i ! Page 9 of 11 j OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 11 Admirals Lane Osterville, MA " Owner: Peter Lent, Trustee Date of Inspection: November 1, 2005 I SOIL ABSORPTION SYSTEM(SAS): . ✓ (locate on site plan,excavation not required) If SAS not located explain why: j Type ✓ leaching pits,number: 1-6'x 6'(1000 gal. leaching chambers,number: I leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: ! Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): The leach nit had]'of liquid on the bottom The scum dine was approx. 2'up from the bottom There did not appear to be any signs offailure. The bottom to grade was 9' A video camera was used for the inspection Recommend removing the large shrub which was over the cover. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: i Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Connnents (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,.etc.): i I I i PRIVY: None (locate on site plan) I I Materials of construction: Dimensions: j Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ! i 9 T L Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 Admirals Lane Osterville, MA Owner: Peter Lent, Trustee Date of Inspection: November 1 2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. ------------- -- --------..__...--- ............--- L7 A- -4 O 3 / ;LS' 13 rIS a 33 a6 10 Page 11 of 11 OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 Admirals Lane Osterville, MA Owner: Peter Lent, Trustee Date of Inspection: November 1, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25+/- feet I Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: Topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high groundwater elevation: Using Barnstable topographic and water contours maps the maps were showing approximately 25'+1-to Around water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied,relating to the system, the inspection and/or this report. 11 07-12-2001 02:50PN CENT 03T FiREDEPT 50b?302385 P.02 Make application to local Fire Department. Fire Department retains original application and issues duplicate as Permit. .:Ue�iccx�nPrrtto�C.�vxs C�ix�u�c,P,6-- ./cJoa�x�a�Ct� �x�u�ataos APPLICATION and PERMIT e':_.� � for storage tank removal and transportation to approved tank disposal yard in accordance with the provisions of M.G.L. Chapter 148, Section 38A,527 CMR 9.00, application is hereby made by: Tank Owner Name(please print) Mr. George Lent X______.- tiwe rrg p•a1� Address 11 Admirals Line 0sterville, MA 02r555 ;�aa, toy swo r� Company Name Enviro-Safe Co.or Individual Enviro-ife i v.:.r Addre= P-0-'-BaX' 810, E.Sandwich, MA Address . 0* =�Bl P ens�h„- a _n�_53__ Sign atur® 'f pi ' fo lit) Signature(if applying for permit) T �" 0.lrCI Certified Qther FC�R.ertiGed C3 LSP 0 Ot0°r Tank Location 11 Admirals Lane Usterville $ma Add(O" "NY Tank Capacity(gallons) 2,000 ,Substance Last Stored heating oil' Tank Dimensions(diameter x length) Remarks: .. � _� C21 ��4 Firm transporting waste Enyi ro--Sa a State Lic.# 329 MA Hazardous wasternanifestA M.t',h88 ?730 E.P.A.# MAD985269323� Approved tank disposal yard 'turner Salvage Tank yard# 002 Type of inert gas Tank yard address 235 Commercial Street Lynn, MA City or Town Osta FDID# — Date of Issue . bate of expiration July 15, 20f)1 Dig safe approval number. 200118 0 8 0 7 b D Sate Toll Free Tel.Numbef-800-322-4844 Signature/Title of Officer granting permit -.___J After removal(s)send Form FP-290R signed by Local Fire.Dept.to U8T Regulatory Comprian"Unit,Qne Ashburton Place, Room 1310,Boston,MA 02108.161 S. TOTrIL P.02 07-12-2-001 02:5OP11 CENT OBT FiREDEPT 5067302385 P.02 Make application to local Fire Department. Fire Department retains original application and issues duplicate as Permit. d�LP�G� v 7 e�h.zaumxPrrzl'a�C-�'r�s�i�u�ced--�`� a�C�t�x�+ �7z APPLICAT10111141 and PERMIT Fee: for storage tank removal and transportation to approved tank disposal yard in accordance with the provisions of M.G.L. Chapter 14&, Section 38A,527 CMR 9.00, application is hereby made by: e Tank Owner Name(please print) Mr. George Lent X Address 11YAdm rats Line \ Ostervi11e,. MA_02rs55� sr MY Cornpanyhlame Einviro-Safe Co.or individual Fraviro-Safe _-- n�r pier Address'P•O:$O)C 810, E.SandtiiCh, MA Address ., 0 Bow R1(1� p.� Sanhaich_ B+1A 0 53 Signatur® 7 piyi fo tit) Signature(it applying for permit) M.Ir"CI Certified Other FC ertitied p LSP# . outer 11 A.dtnirals Lane ost.ervi-lle d Tank Location Sr•a adc•s� crY _ Tank Capacity(gallons) 2,000 _,Substance Last Stored heat i n g oil ' . ^T�_ Tank Oimensions((diiarnatter x length) Remarks: Firm transporting waste Enyi ro--Saf+e State Lic.# 329,MA Hazardous waste manifest# Mt�K88'?730_ E.P.A.# MAL985259323 Approved tank disposal yard 'turner Salvage Tank yard# 0012 Type of inert gas Tankyardaddfess 235 Commercial Street Lynn, MA City or Town Oste&xjj.0 FDID# . _Permit# , Date of issue a"?�e7001 Date of expitation July 15, 2001 Dig sale approval number. 20011808076 _ D Safe Toll Free Tel.Number•800-392.4844 Signature/Title of Officer granting permit — ------ After removal(s)send Form FP•290171 Signed by Local Fire Dept,to UST RegNatory Compliance Unit,One Ashburton Place, Room 1310,Bostop,MA 021 OB-1618. TOT,AL P.02 /-o7"' 7 Lb CAT ION SEWAGE PERMIT NO. Ad*" ,-a/s ti 7 �' ^CIO PILLAGE a= 30 INSTALLER'S NAME & ADDRESS. JOHN A. AALTO BACKHOE SERVICE 150 wainut street West Barnstable, Mass. 02668 9 UILDER OR OWNER 9- DATE PERMIT ISSUED DATE COMPLIANCE ISSUED rr'��SaP �rv�-e :r� s 70 No..---...........gad.... FED.3®................. THE COMMONWEALTH OF MASSACHUSETTS i BOARD OF HEALTH ....We✓ ._ i.......0F.../4! 461.0 ------... ........................ Appliratiun -for Big ristti Marks Tonstrurtion Vamit Application is hereby'made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: Location-Addrest or Lot No. '4 -9.1.I'.l-. ly,Ze ...... ------- ----�,,9 •----- owner Address Installer A Address � Type of Building Size Lot_. feet U Dwelling—No. of Bedrooms--a3--------------------------------------Expansion Attic Garbage Grinder elof 0 Other—Type of Building ---eolol$--------------- No. of persons'.._.-.-.___-_--_.--_---.-. Showers ( ) — Cafeteria ( ) Pa Other fixtures ------------------------------ - --- W Design Flow............................................gallons per person per day. Total daily flow.....-7.3-0----------------------------gallons. WSeptic Tank—Liquid capacity',__01&_agallonS Length---------------- Width................ Diameter:____...-.-.---_ Depth...------------- x Disposal Trench—No..................... Width-------------------- Total Length.................... Total leaching area---S s----_sq. ft. . Seepage Pit No--------------------- Diameter-------------------- Depth below i let_ ____ Total leaching area------------------sq. ft. Other Distribution box ( ) Dosing tank ( .... d a Percolation Test Results ?��er ormed by-----%� �t!'z!4_�. /�.� Date �� ,�7-0 Test Pit No. I-------9k _.__rnmutes per inch Depth of Test Pit................... Depth to ground water.:.----..-_--_.--.------ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-----------._-._-----_.. -----------------------------•- -------------•----•---------------._......._---- ------........................................................... Description of Soil_._".. D ��t2R9_.'---'®�� '4ri -�.-' ----------- D------------------------------------------------------------------------------------------------------------------------------------------- ------------- U W ----------------------••-•-------•-•------------------------------------------.............................................................-----------•----------••------------------------------------ UNature of Repairs or,Alterations—Answer when applicable.....................___--._----.:-------.._.--._ -----.:__--_._------.--.__._..____.-_..._ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sign--' --------------------- ----- ------------------------- Date Application Approved By... . . . .................. } - °. . .. ------- Date Application Disapproved for the following reasons_________________________________________ ............................... ..._......-•- ----••---------------------•----------------------......--------...-----------------------------------•----------------------------------------------------------------------------------------------- * r Date Permit No............................................•--------._.. Issued. I -•1q ----•----------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH rara' .C'.... . ..--............................ Appliratiott -fur Uiipuiittl Workii Tomitrurtiutt Vrrm t Application is hereby'made for a Permit to Construct X) or Repair ( } an Individual Sewage Disposal System at: Location.AddreX or Lot No. 1 Owner Address Installer Address d Type of Building Size Lot..W; r.. ....Sq. feet U a Dwelling—No. of Bedrooms--f......................................Expansion Attic eL-'Jp Garbage Grinder MO aOther—Type of Building __ ---------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures ------ -------------------------------------------------------------------------------------------------- W Design Flow...........................................gallons per person per day. Total daily flow--_.32-o-____-.--_..--..._--.----._-gallons. WSeptic Tank—Liquid capacity _,jm%ragallons Length................ Width.-----.......... Diameter---------....... Depth...--_--_-..._.. x Disposal Trench—No..................... Width-------...__--_--_-_ Total Length........_........... Total leaching area-.------_.__.__-----sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below ile -------- T-ota�l�ac lig aria. __ _._.._._.sq. ft. z Other Distribution box ( ) Dosing tank Z y ;c' y _! yP.. Date Percolation Test Results Performed b .___ ._/.,: :< _:i.___ ` . _ I_._ ...1 Test Pit Nb i��_.__';__ fiinutes per inch Depth of Test Pit-------------------- Depth to grout wa r._-__---------------- �,-. Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water--------------.--------- ------------------------------------------------------------------------------------------------------------------------------------------------------------ 0 Description of Soil -',-.:fi! -;, •.,?2= - _ ?_.._.a �r.P_.dA .�x_ Lf�Ee�a �--------------_-- V s _d'"sA '..>.r�-'fir�' ----------- -- --------------------------------------------------------------------------------------------------------------------------------- W ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------- U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------- ---------------. ----------------------------------------------------------------------------- -----------------•----------------------------- ----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signe , g. � ; ' - �:----- Hate� Application Approved B l ....- � . Date Application Disapproved for the following reasons---------------------------------- r ------....-•-----------••------•-------•-•-----------•--•-------------•-•--•---------------•--------•--••............•-------------------•-------•-.........----------------...--------...------------•-- Date PermitNo.---•-----------•----••-................................ Isguied........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH .....O F........... .' ....- 01rrtif iratr of ITTompliana TH/S 1 TO C "IIF� That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by ....� �)= ... ' -- - -........ --------------------------------------•------------- i � 1 Installer ' Z-a / / ' has b en installed in accordance with the provisio.' of A 7 I of The State Sanitary Co as dess�riyed in the for Disposal Works Construction Permit No--- __-___-_�_�_Y ............. dated.--.--. _j�.._.._ --------------- application THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY.- DATE................................................................................ Inspector------------------------------------------------------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT 1 .......... ........................................ ... ................................... No. J-•-• FEE. ........... Di_sVagtt Wrk on nArtiott rrmit Permission i h by granted......._.._ _ �.._ ..r. .. to Con stru ( i or Rep it (I1 ) Indi idual Se ;age Dispo Sy em at No.. d`G.t�....-: z. l�lG r f -•---- --------- �L;'�Z� �j� t� 'l��•-•• , r t as shown on the application for Disposal Works Const ction Per ' No.. . . .____ Dated_._- .T_"_ -_`%............... a 1 Board of Health ~ DATE............. d: 9 ------------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS oc EIC. S IV SZ EL, SZ , EL.If 77ISTEL vog. y I 1 w, 1 1 I � l �r�aE o snc� SI.q 3 Ity i 1 �,,y2'� Tsbv�c�� EL` u 1 � 1 gt.Sl•1 I AI q J M� I�oun.Df�7'/a tom: •S3.Z. I •r 3o'+ 0. 1 1 A* fill 1 1 / G [ tA,1o,', I,i ;•gAems. 026J7 Z0 7 N v Ate,.r Nar�"� �ZBVfj'y"YO MS �/936D O� CERTIFIED PLOT PLAN LOCATION !::� .V/ SCALE . /.�J::� . . . DATE '• PLAN REFERENCE D.J.. Lor ,Bo pK 3. . . GC. s7z.s- yo I CERTIFY THAT THE l SHOWN ON THIS PLAN IS LOCATED ON THE GROUND 1 AS SHOWN HEREON AND THAT IT CONFORMS TO THE SETBACK REQUIREMENTS OF THE TOWN OF S/G V/,4 /-�'w D -S�GV/� � 4.4.. . . . . • • WHEN CONSTRUCTED. L/N41:>1'9 DATE/-luG, ZnJ �979 PETITIONER: SS. REGISTERED ND SURVEY '459345 Z sNEb75 L. . . �.?..Z. ... . TOP OF FOUNDATION CONCRETE COVER CONCRETE COVERS e o 4��CAST IRON 12°MAX. 771r • PIPE (OR 12"MAX. EQUIV.)- MIN. 4"ORANGEBURG(OR EQUIV.) • PITCH 1/4"PER. PIPE- MIN. LEACH PITCH 1/4"PER.FT. PITT3/4" ST o.Q INVERT o aNG INV IN T o . v' SEPTIC TANK GIST. ¢ wV. EL.. . Z. . EL....,9.8.. >_ ° INVERT BOX ��. a!�?o.t?.. .. GAL. INVE T aEL... ,/�- INVERT w w a: 11/2 EL. 8 Gu- �' D EL. . .. . w o• • . . ° DIA. NaNE PROFILE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM NO SCALE M SOIL LOG WITNESSED BY : DATEAvG, 3�.!17'�TIME.!Q:.�✓`�!Q"f'J- /p�t.L /`yu BOARD OF HEALTH �`?�s. .C`• . TEST HOLE I TEST HOLE 2 T/lY� A��xP.•E"r ENGINEER G„ DESIGN DATA NUMBER OF BEDROOMS . . . . . 3o" TOTAL ESTIMATED FLOW . . 330. . GALLONS/DAY BOTTOM LEACHING AREA 78-S. . SO.FT. /PIT /88,Sc? Cpni�- SIDE LEACHING AREA . . . . . SQ.FT./ PIT S6►�+a GARBAGE DISPOSAL !4A!e. .(50% AREA INCREASE) TOTAL LEACHING AREA . . U7.00. . SQ.FT PERCOLATION RATE �5 :7�A-,'.7wa. MIN/INCH /Yk. .WATER ENCOUNTERED LEACHING AREA PER PERCOLATION RATE .�rV. . SQ.FT. NUMBER OF LEACHING PITS APPROVED . . . . . . BOARD OF HEALTH an/!9?-!L .S/7�E3, c /S/ 7Z)",S ? vF ►5'?ONE" ��l�T; DATE . . . . . . . THOMAS t`iCELLEY GO." AGENT OR INSPECTOR ENGINEERS-SURVEYORS 346 LONG POND DRIVE SOUTH YARMOUTH,.MA • �� J(k OFMAss'�C, r 0 r ��-A OF R4S�'� 02664 THOMAS �DMIC.�cS� L, �`• • EDwARa ��, K 7 /G pK�ELL A FSs�ONALti� PETITIONER 4'-it• - 12'-Z' a•-11- - z-0' S-0' X-D' 3-0W - 76• .. -.k ANDERSEN ANDERSEN AR281 AR287 4: ABOVE ABOVE ANDERSEN 4 ANDERSEN - e 4 CXISRSE ANDERSEN ANDERSEN NDERSE - A251 A251 Fp CX115 xis ANDERSEN .. 4BUILT-IN ' . A CABINETS A ' - APRON I 4 , F- A4 1 INSTALL NEW 2-1 3/4•x 11 TIS LVL' - ' j O CONT.HEADER FROM END TO END } 9 NEW ANDERSEN AT NEW O.H.DOORS.USE SIMPSON # ;D CX15 LSTA24 STRAP FROM EACH KING s ANDERSEN STUDY WINDOW ` STUD TO THE HEADER ON EACH \\ 8•B'x CH O SIDE OF THE DOOR FRENCHW!>OD (VAULTED CEILING) SEAT o 4 ``�� _ GLIDING DOOR » a .' ANDERSEN {.i -. ' - - `_ _ ___ CX15 REMOD. EXPAND. TS DECK GARAGE e r ' 9 .ANDERSEN - _. .ANDCX1ERSEN - AW251 ABOVE i 4'-0' - - NEW 3V x6r 1 FRENCHDOORS 4 , ,EXIST. . . EXIST. . .f W.I.C. . MASTER BEDROOM EXIST. _.. EXIST: .a , k22.-0r a i GARAGE FLOOR PLAN ._ LEGEND: , a ROOM FLOOR PLAN 1 „ » EXISTING WALLS... _ r� BED C= CONSTRUCTION TO BE REMOVED = e EW CONSTRUCTION. . H l _ • EW RIDGEVENT NEWASPHALTROOF .. - �`....," 72 ..SHINGLES TO MATCH` pg, CJ.. . - - EXIST ,.EXISTING - R NEW AZEK FASCIA.FRIEZE. - 1 r , - . 8 SOFFIT BOARDS TO MATCH - :,•. EXISTING SIZES ` TOP OFPLATE i -NEW AZEK CORNER BOARDS i » - TO MATCH EXISTING r- . - \ NEW AZEK t X 4 TRIM } 71 WJ 2•SILL x ' NEW SIDING TO ~ "" MATCH EXISTING FIRST FLOOR v SUBFLOOR RIGHT. ELEVATION . +� THE OESEGNER SwLLt BE NO16E0[F ANY - ERRORSORO JSSICNSAREFOUNDGN SCALE : DRAWING NO.: COTUIT BAY DESIGN, Lac NEW ADDITION FOR: .��°UC� oE.US1ARTOF E CONSTRUCTION 111E euxDea CONTRACTOR 1/4r._ ,tr-on 43 BREWSTER ROAD WxLRE RESPONSIRIEFORTHECONTENI .. NTHESE ORAW GS IF CONSTRUCTION KETT RESIDENCE COSIGNER STrtINEARNOTF1'ING THE MASHPEE ,MA. 02649 DESIGNER OF ANT EHRORSdiOWS D1S TI<SE DRAWINGS ARE SOLELY FOR-E°SE DATE : PH. (508)274-1166 OFTNEOWNERNOTMANYOTHEROSEOF 8 THESE°RAWINGS REOUWES 1HE WFur" FAX (50 )539-9402 �( � ADMIRAL'S LANE OSTERVILLE, MA :�oFCTURMC g�R°�°� 3/5/2014 ACT OFECTORAI COPYREGM PROTECTION