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K`���,b ;,r,�g�0 4 e'.x�. .�. �.�x-' dtC a'Tt'�� rs` .�s .. 3f'` .;�•t;+� °cao `�` .r ��_ �.r '��¢ .o� s .+'�" 'T° 'a, ar,� y'��. �._r. a�,�..,F. �.; sar "#^..A �a�f. u '#� ... .,d. �"4 ■°q ,(Dr n�, V.� !• f;F'9 � n . � ti. >i �y e _ •1 .�,.d .;.�.. Ye a ^T'}yj a.:n+p. ' ,,;,a '.�, �r Q �,.y..�'° ,. i .A7' -..RA cC fl ': l .N.4: Y .xs :i 7a��, Commonwealth of Massachusetts - ,. Title 5 Official s l nspection form - PI Subsurface Sewage Disposal System Form-Not for Voluntary Assessments,._ 10 Barnard Rd (AKA 110 Crystal Lake Rd) Property Address John Wendell Owner Owner's Name information is Osteryille MA 02655 4-17-19 required for every •---_ page. City/Town State Zip Code Date of Inspection 1 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. A. Inspector Information 61# -13906— Shawn Mcelroy Name of Inspector 'Upper Cape Septic Services Company Name - P.O. Box 73 l Company p y Address E. Falmouth MA' 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification. I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000);1 have personally inspected the sewage disposal system at theproperty address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and'ezperience in the•proper function and maintenance of on-site sewage"disposal systems:After conducting this inspectioniI have determined that the system: ® Passes ;2. .❑ Conditionally masses ,. _ ., •, *3.• ❑ Needs,Further,Evaluation by;the Local Approving Authority 4. ❑ Fails 4-17-19 - 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 has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 t c Commonwealth of'Massachusetts 3 Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r `c,,/ 10 Barnard Rd (AKA 110 Crystal Lake Rd) Property Address John Wendell Owner Owner's Name information is required for every Osterville MA 02655 4-17-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2,'3, or 5 and all of 4 and 6. 1) System Passes::• - ® I have not found any information which indicates that any of the'failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign failure. 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditionaipass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑N ❑., ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 i Commonwealth of Massachusetts. ,.j_ Title 5 Official Inspection Fora i. I,t Subsurface Sewage.Disposal System Form -Not for,Voluntary Assessments;a - 10 Barnard Rd (AKA 110 Crystal Lake Rd) Property Address } , John Wendell Owner Owner's Name information is required for every Ostefville ,;:. MA 02655 4-17-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes:(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level!in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with•approval of Board of Health): ❑ broken'pipe(s) ar`e replaced ❑`Y El ❑`ND (Explain below): obstruction is removed ❑'Y `❑N•„'',0"ND (Explain below): 'F ' ❑ distribution box is'leveled'o�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): 3) Further Evaluation is Required'by the Board of Health:• - t ❑ Conditions exist which require further evaluation-by the Board of Health in order to determine if the system^is failing to protect public jhealth, safety or the environment: ' a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts ' Title 5 Official Inspection Form IQ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Barnard Rd (AKA 110 Crystal Lake Rd) Property Address John Wendell Owner Owner's Name information is required for every Osterville MA 02655 4-17-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water - ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑The system'has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: , 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ' ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 i Commonwealth of Massachusetts ,'. Title 5 Official Inspection: Form. �} 'I Subsurface Sewage Disposal System Form.Not for Voluntary Assessments . 10 Barnard Rd (AKA 110 Crystal Lake Rd) , Property Address P Y John Wendell ., Owner Owner's Name information is Osterville MA 02655 4-17-19 required for every - page. City/Town - State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes,, No, . i' ' Static liquid level'in the distribution box above outlet invert due to an overloaded El Z or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less ` than"%'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 groundwater elevation. r ❑ ® Anyfportion of cesspool or,privy is within 100 feet of a surface water supply or tributary .to'a'surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public water supply ® well ❑ ~® Any portion of a cesspooi or privy is within 50 feet of a private water supply well. ❑' ®' Any portion*of acesspo'ol 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 ti. 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.]i The system is a cesspool serving a facility with a design flow of 2000 gpd- ' + ® 10,000 gpd. . z 0 ® The system faili.] 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., 5) Large Systems:To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to'15,000 gpd. For large systems,•you must indicate either"yes"or"no"to each of the following, in addition to the questions in,Section:C.4. E. _> ,; , A� Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7126/2018. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts a - Y Title 5 Official Inspection Form it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Barnard Rd (AKA 110 Crystal Lake Rd) ` Property Address John Wendell Owner Owner's Name information is required for every Osterville MA 02655 4-17-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) . If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. .Y 6. You must indicate "yes" or"no"for each of the following for all inspections: • •Y 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? ❑ Y ® 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? 4 - ® ❑ 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? ® ❑ Wasthe facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation\of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts ; . Title 5 Official Inspection Form i,01 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Barnard Rd AKA 110 Crystal Lake Rd Property Address John Wendell Owner Owner's Name information is required for every Osterville- • MA 02655 4-17-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual). 4 DESIGN flowbased,on 310 CMR 15.203 (for example: 110 gpd x#.of bedrooms): 440 Description: 11 • a • 4t 0 Number of current residents: Does residence have a garbage grinder?:, ,f , • :•,;,, ❑ Yes ® No Does residence have a water treatment iunit? _. ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection Yes ® No information in this report.) '� ' ''� Laundry system inspected? ❑ Yes Z No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: j 3-2019 Date t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 . Commonwealth of Massachusetts J / Title 5 Official Inspection Form wa ;Yi�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Barnard Rd (AKA 110 Crystal Lake Rd) Property Address John Wendell Owner Owner's Name information is required for every Osterville MA 02655 4-17-19 page. City/Town State Zip Code Date of Inspection D. System Information (coot.) 2. Commercial/Industrial Flow Conditions: rr. 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 Water treatment unit present? ❑ Yes ❑ No If yes; discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner--pumped 12-2018 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance t5insp.doc•rev.7/26/2018' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 i Commonwealth of Massachusetts ,, r Title 5 Official- Inspection Form ' � - bI Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments 10 Barnard Rd.�._� (AKA 110 Crystal=Lake Rd) Property Address John Wendell Owner Owner's Name information is Osterville, MA 02655 4-17-19 required for every page. City/Town a State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool I . ❑ 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. r ❑ Other(describe): Approximateage of all components; date installed (if known) and source of information: 2004 Were sewage odors detected when arriving at the site? ❑.Yes ® No 5. Building Sewer(locate on site.plan):• 18" Depth below grade: feet Material of construction:*' ❑ cast iron ' ®40'PVC '� ''❑ other(explain):"'' Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts L . Title 5 Official Inspection Form rr Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Barnard Rd (AKA 110 Crystal Lake Rd) Property Address John Wendell Owner Owner's Name information is required for every Osteryille MA 02655 4-17-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 12"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: , years Is age confirmed by a Certificate of Compliance? (attach a-copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal H-20 Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 2811 Scum thickness 0 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 16" How were dimensions determined? Tape 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 is in good condition with baffles installed and no sign of leakage. i t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 ram" Commonwealth of Massachusetts 1, Title 5 Official , Inspection Form � e i.F Subsurface Sewage Disposal System Form -Not for Voluntary'Assessments 10 Barnard Rd (AKA 110 Crystal Lake Rd):. Property Address F John Wendell Owner Owner's Name information is required for every Osterville MA 02655 4-17-19�- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene, ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping:, 1 ,•; ,. Date Comments (on pumping,recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid,levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: h Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 s Commonwealth of Massachusetts 3 Title 5 Official Inspection Form 4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r :r 10 Barnard Rd (AKA 110 Crystal Lake Rd) Property Address P Y John Wendell Owner Owner's Name information is Osterville required for every MA 02655 4-17-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert ,0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from field. t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 ram" Commonwealth of Massachusetts t - -,-rt-: i•. ,. Title 5 Official, Inspection Fora: rf Subsurface Sewage Disposal System Form.-Not for.Voluntary Assessments A . •;_ >r' s .�,.._� 10 Barnard Rd (AKA 110 Crystal Lake Rd)'. Property Address John Wendell Owner Owner's Name information is ill terve required for every Os MA 02655 4-17-19� r f- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): f Pumps in working order: ❑'Yes ❑ No" Ala'nis in working order: ❑ Y es El No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan,.excavation not required): If SAS not located, explain why: Type: i ❑ leaching pits '', number: ® leaching chambers - number: 4-Flodiffusers ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology- t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments :rJ •>' 10 Barnard Rd (AKA 110 Crystal Lake Rd) Property Address John Wendell Owner Owner's Name information is required for every Cisterville MA 02655 4-17-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Flodiffuser field in good working order with no sign of back-up into d-box or surrounding stone. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes . ❑ No Comments (note condition of soil, signs-of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 s Commonwealth of Massachusetts ;• • r : :t: ra, ,�, ,.; Title 5 Official Inspection' Forn1 }F �-[ Subsurface Sewage-Disposal System Form.-Not for Voluntary'Assessments., 1' r a !�!, 10 Barnard Rd (AKA 110 Crystal lake Rd) Property Address , John Wendell Owner Owner's Name information is required for every Osterville :`.!" MA 02655 4-17-19. page. City/Town State Zip Code Date of Inspection D. System Information (cont.) i, . , 4 ; , . .• w ' 13. Privy (locate on site plan): Materials of construction: a f Dimensions Depth of solids Comments (note condition of soil, signs•of hydraulic failure, level of ponding, condition of vegetation, etc.): f t5insp.doc•rev.7/26/2018. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts j� Title 5 Official Inspection Form h Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Barnard Rd (AKA 110 Crystal Lake Rd) + Property Address John Wendell Owner Owner's Name information is required for every Osterville '" MA 02655 4-17-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within I00 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: 0. r t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts 3 Title 5 Official- Inspection Fora • + g y hi Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 10 Barnard Rd (AKA 110 Crystal Lake Rd) - Property Address John Wendell Owner Owner's Name information is Osterville MA 02655 4-17-19 required for every ' page. City/Town State Zip Code Date of Inspection D. System Information (cont.)' 15. Site Exam: ❑ Check Slope , ❑ Surface water ❑ Check cellar ❑ Shallow wells , s Estimated depth to high round water: > - - 12 _ P 9 9 " ' feet I Please indicate all methods used to determine the high groundwater 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: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 I Commonwealth of Massachusetts 3 Title 5 Official Inspection Form %i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Barnard Rd (AKA 110 Crystal Lake Rd) Property Address John Wendell Owner Owner's Name information is re Osterville MA 02655 4-17-19 required for every q City/Town/Town page. Y State Zip Code Date of Inspection _ E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information-, For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included y• t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 18 of 18 ."Commonwealth of Massachusetts Title 5 Official Inspection Form — _ - Subsurface Sewage Disposal System Form Not for Voluntary Assessments l o :U���- ab_ ---- 110 CRYSTAL LAKE RD Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 --- Owner Owner's Name MA 02655 9/8/07 -------- information is OS_TERVILLE State Zip Code Date of Inspection required for City/Town every page. Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out F forms onthe computer,use 1• Inspector: Sy v o only the tab key to move your Michael DeDecko _----- ' ^ O► cursor-do not Name of Inspector use the return —---- Compass Realty Development Corparation key. mm,u. company Name P.O. Box 2384_ ___ iA Company Address , Ma I02649 MaShpee State =i Zip Code rennn City/Town i= '`" .�•, 508 -221- 5003 �� --- "•--- License Number Telephone Number r�« B. Certification - I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site., sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® r ❑ Conditionally Passes ❑ Fails Passes ❑ Needs Further Evaluation by the Local Approving Authority 9/8/07 Date Inspector's Signature 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 plicable, and the approving authority. and copies sent to the buyer, if ap ****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 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15 34 EVSUN•08/06 ' I Commonwealth of Massachusetts Title 5 Official Inspection Form _ _ = Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /Y. 110 CRYSTAL LAKE RD Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 — Owner Owner's Name information is OSTERVILLE MA 02655 9/8/07 _ -.- required for — State. Zip Code Date of Inspection every page. City/Town B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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 less is thanstructurally oldold is available. ofea ing and if a Certificate of Compliance indicating that the tank ND Explain: of sewage backup or break out or high static water level in the distribution box ue ❑ Observa tion 9 . System to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 34 EVSUN•08/06 Commonwealth of Massachusetts - - Title 5 Official Inspection Form s� Subsurface Sewage Disposal System Form Not for Voluntary Assessments 110 CRYSTAL LAKE RD ----- Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 Owner Owner's Name information is _OSTERVILLE MA 02655 _ 9/8/07 required for State Zip Code Date of Inspection ` every page. City/Town B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ '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: 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 on n determines in a manner which will pr tectlpubMchealth, 15.303(1)(b)that the system is not func 9 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 (andmanner lic Water Supplier, if any) protects the public health, determines that the system is functioning in a ma safety and environment: 0 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. Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 .34 EVSUN•08106 i Commonwealth of Massachusetts --_-_ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 110 CRYSTAL LAKE RD Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 Owner Owner's Name information is OSTERVILLE MA 02655 9/8/07 required for State Zip Code Date of Inspection every page. City/Town B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 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 El ® 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. 34 EVSUN•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 r a Commonwealth of Massachusetts ---_ Title 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 110 CRYSTAL LAKE RD S Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 — Owner Owner's Name MA 02655 9/8/07 information is OSTERVILLE Zip Code Date of Inspection required for State every page City/Town B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No .. ' ❑ ® 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 20009pd- 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 r 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. r . For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well }' If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section,D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 34 EVSUN•08/06 -Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments — /•' c 110 CRYSTAL LAKE RD Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 _= Owner Owner's Name , information is OSTERVILLE MA 02655 9/8/07 required for every 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? El ® 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 ® 0 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:.'A ❑ 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)] Page 6 of 15 34 EVSUN•08106 a Title 5 Official Inspection Form:Subsurface Sewage Disposal System• 'Commonwealth of Massachusetts -- _ : Title 5 Official Inspection Form -- - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments, 110 CRYSTAL LAKE RD Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 Owner Owner's Name information is required for OSTERVILLE MA 02655 9/8/07 every page. City/Town State Zip Code Date of Inspection D. System Information Residential flow Conditions: Number of bedrooms (design): .4 Number of bedrooms (actual): 4 — DESIGN flow based on 310 MR 15.203 (for example: 110 gpd x#of bedrooms): 440 _ 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑. Yes ® No Seasonal use? ❑ Yes ®, No Water meter readings, if available last 2 ears usage (gpd)): N/A ' 9 ( Y 9 Sump pump? ❑ Yes ® No N/A Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: �- Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): — -- Grease trap-present? ❑ Yes ❑ No . Industrial waste holding tank present? ❑ -Yes,❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date _ Other(describe): -- I 34 EVSUN•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 'Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ar 110 CRYSTAL LAKE RD Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 Owner Owner's Name information is required for OSTERVILLE MA 02655 9/8/07 - every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: N/A 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) ❑ Tight,tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: N/A Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 34 EVSUN-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 I c -Commonwealth of Massachusetts -_- Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 110 CRYSTAL LAKE RD -------- Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 . Owner Owner's Name information is OSTERVILLE MA 02,655 9/8/07 _ required for ---- every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 2 Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): — — Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): JOINTS TIGHT,YES VENTED,NO LEAKAGE. — _ -- Septic Tank (locate on site plan): Depth below grade: 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 1500 GAL.— 'Dimensions: 0„ -- — Sludge depth: 34" Distance from top of sludge to bottom of outlet tee or baffle --- 0" --- Scum thickness 12" ----- Distance from top of Scum to top of outlet tee or baffle - 14" ---- Distance from bottom of scum to bottom of outlet tee'or baffle --- r MEASURED How were dimensions determined? — — . 34 EVSUN•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments -- 0 110 CRYSTAL LAKE RD - Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 Owner Owner's Name information is _OSTERVILLE MA 02655 9/8/07 _ required for State Zip Code Date of Inspection every page. Cityfrown 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.): NO NEED TO PUMP, TEE'S 1NTACT,STRUCTALLY SOUND, LIQUID LEVEL EQUAL WITH OUTLET INVERT, NO LEAKAGE, - -- Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass - ❑ polyethylene ❑ other(explain): Dimensions: - Scum thickness — Distance from top of Scum to top of outlet tee or baffle ----- Distance from bottom of scum to bottom of outlet tee or baffle ----- -- Date of last pumping: date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): 34 EVSUN•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 i -Commonwealth of Massachusetts Title 5 Official Inspection Form iR -- - - Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1.10 CRYSTAL LAKE RD --- - Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH,RD, MA, 02632 --_ _Owner Owner's Name information is OSTERVILLE MA 02655 9/8/07 required for State Zip Code Date of Inspection every page. City/Town k D. System 'Information(cont.) Tight or Holding Tank(cont.) 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.): . r Attach copy of current pumpirig contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): EQUAL WITH OUTLET INVERTS 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 leakageInto or out of box, etc.): „ D-'BOX IS LEVEL AND DISTRIBUTION EQUAL, NO SOLID CARRYOVER, NO LEAKAGE. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 34 EVSUN•08/06 i -Commonwealth of Massachusetts - Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 CRYSTAL LAKE RD —. Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 Owner Owner's Name information is _OSTERVILLE MA- 02655 9/8/07 _ required for - every page. City/Town State Zip Code Date of lnspection z D. System Information (cont.) Comments (note condition of pump chamber, condition,of pumps and appurtenances, etc.): • I Soil Absorption System (SAS) (locate on site plan, excavation not'required): If SAS not located, explain why: Type: ❑ leaching pits number: — , — 4 ® leaching chambers number: ❑ leaching galleries w number: --- --- ❑ leaching trenches number,'length: ❑ leaching fields number, dimensions: _----- ❑ overflow cesspool number: ; . -- s ❑ innovative/alternative systemw r Type/name of technology: -- -- Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SOIL-GRAVEL/SAND, NO SIGNS OF HYDRAULIC FAILURE',•PONDING DRY,NO DAMP SOIL, VEGETATION - NORMAL. . 34 EVSUN•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 S i Commonwealth of Massachusetts _ Title 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments =s 110 CRYSTAL LAKE RD -- Property Address C/O DAVID HOLT,TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 — Owner Owner's Name information is OSTERVILLE MA 02655 9/8/07 required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration., Depth—top of liquid to inlet'invert Depth of solids layer. Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition,of soil, signs of hydraulic failure, level of*ponding, condition of vegetation, etc.): Privy (locate on site plan): - Materials of construction: — Dimensions •R Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): a 34 EVSUN•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 I f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 110 CRYSTAL LAKE RD Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 Owner Owner's Name information is OSTERVILLE MA 02655 9/8/07 required for — — State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) 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. L Sad 3 34 EVSUN•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 commonwealth of Massachusetts Title 5 Official Inspection Fora — — Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 CRYSTAL LAKE RD Property Address C_/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD_ , MA,.02632 — _Owner Owner's Owner's Name information is OSTERVILLE MA 02655 9/8/07 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells 32.9' Estimated depth to ground water: 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: a ❑ Checked with local excavators, installers- (attach documentation) z Accessed USGS database-explain: BARNSTABLE GIS You must describe how'you established the high ground water elevation: BARNSTABLE GIS f - ---- 34 EVSUN•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15. L THE Town of Barnstable ` OF 1p� Regulatory Services GAMS UBLE. Thomas F. Geiler,Director �$ �9. •�� Public Health Division ArFD MAC A . Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-8624644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automaticall a the number of bedrooms listed within this report. The actual Y rove pp p number,of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". �t If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. 1 i No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes / PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pprtcation for 33tgpozar *patent Construction Verna c` Application for a Permit to Construct O Repair( )Upgrade( )Abandon( ) "Complete System 0 Individual Components © a� Location Address or Lot No./� a Owner's Name,Address and Tel.No. Assessor's Map/Parcel "S ' 2. (_0A ger Installer's ,Address and el.No. 56 Y--7-1) D signe' e,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( ) Other 'Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ��� gallons per day. Calculated daily flow P gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Arlswer when applicable) l r 121YTR 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 Certifi- cate of Compliance has beenC' a by s Board th. Signed % Date Application Approved by Azi Date U Application Disapproved for See following reasons Permit No. - p'd y— Q&f Date Issued a. Q L y No. ()�)y—�1 Sri :: 4 Fee THE COMMONWEALTH OF MASSi HUSETTS Entered in computer: L--- Yes � cr PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zlpprication for Migpogal *pgtem Congtruction Permit Application for a Permit to Construct O Repair( )Upgrade( )Abandon( ) �rComplete System ❑Individual Components S Location Address or Lot No. / ak Owner's Name,Address and Tel.No. Assessor's Map/Parcel 0S , C� /A9-0 2f 0A cier Installer's N Address sand Tel No. �32q 5 _-•'�-7)- Designer' One,Address and Tel.No. _ci� �x ` 7 o2-lv7l Q rl .r M OZIob I 2 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 41!VjQ gallons per day. Calculated daily flow �i<<P gallons. -Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) i " Date last inspected: Agreement: i 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 Certifi- cate of Compliance has been t ed by his Board ofIlea'Yth. Signed ; ,. Date z Application Approved by .. !An / �_) Date VA/0-y Application Disapproved for&following reasons Permit No. 0 0 Ll- ok I Date Issued ;�A L/ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed(Y. )Repaired( )Upgraded( ) Abandoned( )by FAmh 4 h�� at �(ht�) -,t�ita�--- 01SIle//I//��� has been construct d in accordance with the proyisi of Title 5 and the for Disposal System Construction Permit No. 2 WU-QYI dated -to L,/ Installer V Designeec. v The issuance of this Uotq • shall not be construed as a guarantee that tti system wi.l nc�on as�desigine�d. Date Inspector - s _. .. No. 1(0L4-Qp l Fee = THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS migponf *pgtem Construction Permit Permission is hereby granted to Construct(/)Repair( )Upgrade( )Abandon( ) System located at If, r r and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of s�permit. r Date: 7� -U�/ Approved by TOWN OF BARN$TABLE .v LOCATION SEWAGE 4 VILLAGE �✓1� ASSESSO 'S MAP& LOT . INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY t 1 ►I LEACHING FACILITY: (type) y Q� - (size) '?A ��� X NO.OF BEDROOMS BUILDER OR OWNS PERMITDATE: O COMPLIANCE DATE: -� S 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 Feet within 300 feet of leaching facility) Furnished by LL I C� e we- r Town of Barnstable �OF1HETpy,O Regulatory Services Thomas F. Geiler,Director BARNSTABLE, 9�AMASS. ��� Public Health Division 'E039. A Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: Designer: L C Installer: L- Address: 07 ftf ivS4 Address: p® ®c &®K �J On `_-D"ew_ Pp�eAs was issued a permit to install a (date) (installer) septic system at ,\6 f 0 based on a design drawn by (address) 1,q 4�jVC; dated (designer) L-11 certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. (Installer's Signa ure) (De K gner' gnature) (Affix amp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. I Q:Health/Septic/Designer Certification Form L CENTERVILLE-OSTERVILLE-MARS'TONS MILLS FIRE DISTRICT 1875 ROUTE 28 CENTERVILLE, MA 02632 (508)790-2380/FAX#(508)790-2385 OIL/HAZARDOUS MATERIAL RELEASE FORM rr F.A.# _C��. ood7� LOCATION: ADDRESS OF RELEASE: DATE OF RELEASE:---itf PRODUCT RELEASED: f )i A Kj4XjjjLAit ESTIMATED QUANTITY .. A k1 fAAlt ICA CORRECTIVE�CTIOr TAKEWSY PESPONSIBLE PARTY: A V u I NOTIFICATIONS. FIRE DEPARTMENT: NO( DATE, , TIME: (` YESO( TE.11L..L.L�_ NATIONAL RESPONSE CENTER YES( ) NO DATE: --TIME:---- DEPT. OF ENVIRONMENTAL PROTECTION iSV,) NO( DATE: TIME: OIL.SPILL COORDINATOR: YES NOV) DATE' I -_ME. S TOWN BOARD OF HEALTH: YE YE NO(, DATE. IMEI_LLI� TOWN HARBORMASTER: S No K rmTE' TIME: OTHER AGENCIES: A,. COMMENTS: REPORTED BY: --DATE: WHITE COPY-FIRE DEPARTMENT YELLOW COPY-D.E.P. PINK COPY-BOARD OF HEALTH C-04..%l F0.11A 08 MM DD YYYY 01920 U �91 22 2004 2 04-0002724 000 complete '# FDID * State* Incident Date * Station Incident Number Exposure Narrative * * 1 Narrative: Caller Name : 301 OIC : FARRINGTON lmotte ; 2004/09/22 11:35:40 - 301 AT EVENT MANNING IS 1 lmotte ; 2004/09/22 11:35:15 OIL LEAK 275 GAL TANK lmotte ; 2004/09/22 11:38:36 HEALTH DEPT NOTIFIED, 15 ETA Department received call from Northeast Construction re: inspection of underground tank removal. Upon my arrival I met Scott Kraihanzel from Bennett and O'Reilly and ,6tated we have a leaker'. I entered the hole and strong odor of fuel oil come from 275 gal tank and pull sand from underneath and strong # 2 fuel oil smell. Tank removed in my presence and underneath of tank appeared wet and upon smelling dirt, again strong odor of # 2 oil. Mr 'F Kraihanzel got up into truck and scraped bottom of tank and metal in very poor condition with serious pitting and he stated believe leaking in a couple of locations. I notified Board of Health and they stated would send Donna Miorandi over within fifteen minutes. I secured scene and crew waiting for Health Dept and Mr. Kraihanzel stated he. notified DEP and had a number already. JMFarrington � I r COMM Fire Department 01920 09/22/2004 04-0002724 L �jIV4 .0 r - /�"'-4�<, "s.�a,.% 'titer , _ _ •v'' ' _, i f M, if ■Y r.� .t �� 1 1, r rt 1 i 111,#1 y! 11jrMllr' %I,. i �i ' r�// AT' ( 11 40 IV Is ' r I1 1'�1 1 ��i� " 1 Iy�r •1 r 'll /`r ti11 rl�r r a � o .• r � 1 ' 400v00 � � s to r 1 � f 1► AIP 04 � Is i( II D �`l1 ��� d� V qct n DATE:1 1 /26/01-_-- PROPERTY ADDRESS rY tal_Lake Road__ q Osterville, Mass. 02655 ------------------ On the above date, I inspected the septic system at the above address. Thi's system consists of the following: 1 . 2-6 'X8 ' block, cesspools. Split system. 2. See page 10 Based on my Inspection, I certify the following conditions: 3 . This is not a title five septic system. 4 . This is sewage system. ( split system 1 5::;,#1 grey water #2 sewage 6'. Pumped #2 pool at time of inspection. Heavy scum & solids layers were -present. 7. The sewage system is in proper working order at the present time. - / SIGNATURE:s`/ Name:_J_p _ Macomber ,1_r�______ ; Company: Joseph_P. Macomber & Son , Inc . Address:_ Box_66 _ --------------• RECEIVED Centerville , Ma.. 02632-0066 DEC 0 � �Uu1 • Phone: 508-775-3338 --------------------- TOWN OF BARNSTABLE HEALTH DEPT. THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tan ks-Cesspools-Leachflelds Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775-3338 775-6412 di� I Y COMMONWEALTH OF MASSAOHUSFTTS r 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: 110 Crystal Lake Road d Osterville,Mass. Owner's Name: J. Calder Owner's Address: Same Date of Inspection: 1 26 01 Name of Inspector: (please print) J.P. Macomber Jr. Company Name:Joseph P. Macomber & Son Inc Mailing Address: P.O. Box 66 rt-ntPr,krj11Fs Ma 02632 Telephone Number: 5 0 8—7 7 5—3 3 3 8 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system Inspector pursuant //to Section 15.340 of Title 5(310 CMR 15.000). The system: - Passes _7 Conditionally Passes _ Needs Further Evaluation by the Local Approving Authority _ Fail Inspector's Signature: end Date: The system inspector shal ubmit 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 tbe'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 I Page 2 of I] F= OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) , Property Address: 1 1 0 Crystal Lake Road Osterville,Mass. Owner: J. Caldeer Date of Inspection:11 /2 6/01 - Inspectio mmary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any info ation which indicates that any of the failure criteria described in 310 CMR 15.303 or in 3 10 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: _ _.The sewage system is in proper working order W ' at the present time. B. System Conditionally Passes: A/2) 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. y' A�kle eptic tank t metal and over 20 years old* or the septic tank(whether metal or not)is structurally - unsound,e i its su stantial infiltration or exfiltration or tank failure is imminent. nmtnent. 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: K servation of sewage backup or break out or high static water level in the istribution b due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health):' broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: , The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of I I OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1 1 0 Crystal Lake Road Ostervi e,Mass. Owner: J. Calder Date of lospection: 1 1 /2 6/01 C. Further Evaluation is Required by the Board of Health: 4/0 Conditions exist which requ re 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: IJJ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. AV The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. �! The system has a septic tank and SAS and the SAS is within SO feet of a private water supply well. &If The system has a septic tank and SAS and the SAS is less than 100 feet ut 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 S ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. ther: This is a split sewage system. There are two cesspools. #1 Grey water # 2 Sewage 3 I Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1 1 0 Crystal Lake Road Osterville,Mass. Owner: J. Calder Date of Inspection: 11 /2 6/01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No ackup 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 .va&6 'Static liquid level in th utribution box bove 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 �4.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 / y portion of a cesspool or privy is within 50 feet of a private water supply well. portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water y 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.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303.therefore the system fails. The system owner should contact the Board of, Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design now 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 system is within�200 feet of a tributary to a surface drinking water supply the system -_ y m is located to 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 I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST a Property Address:1 10 Crystal Lake Road s ervi e, ass. " Owner•J. Calder Date of Inspection: 1 1 /2 6/01 x Check if the following have been done. You must indicate`yes"or"tio"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? Yliave 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,�Xeluding the SAS, located on site? r //dVZ- Were th s eptic tankmanholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees, f 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)) tr 5 Page 6 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1 1 0 Crystal Lake Road Ostervi e,Mass. Owner: J. Calder Date of Inspection: 11 2 6 01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): X Number of current residents:_A Does residence have a garbage grinder(yes or no): S Is laundry on a separate sewage system. ,s or no):.� [if yes separate inspection required) Laundry system inspectehalable s Seasonal use: (yes or no) Water meter readings, if (last 2 years usage(gpd)): '�W Sump pump(yes or no): Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): X)4 gpd Basis of design flow(seats/persons/sgft,etc.): "to Grease trap present(yes or no):22 Industrial waste holding tank present(yes or no):,f Non-sanitary waste discharged to the Title 5 system(yes or no):1 Water meter readings, if available: 140 Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: .�.t/c° Was system pumped as part of the inspection(yes or no): 0 If yes, volume pumped: 0 gallons-- How was quantity pumped determined? Reason for pumping:_ TYPE OF SYSTEM , .414 Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Al0 Privy eO Shared system(yes or no)(if yes,attach previous inspection records, if any) /ZPInnovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from systej owner) Tight tank XlY_Attach a copy of the DEP approval 1f�Other(describe): Ap roxi of all components,date installed (if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 6 y Page 7 of 1 1 . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION (continued) Property Address: 1 1 0 Crystal Take Road Osterville,Mass. Owner: J. Calder Date of Inspection: 11 /2 6/01 BUILDING SEWER(locate on site plan) r/ Depth below grade: J / � ti Materials of construction: iron 40 PVC . 1/other(explain): �v7,0% e Distance from private water supply well or suction line: Comments(on condition of joints, venting, evidence of leakage,etc.): Joints appear tight.No evidence of leakage_ The GI24t system is vented through the house vents. SEPTIC TANK4&/&(locate on site plan) Depth below grade: Material of construction.0 concrete metal,/ fiberglassJ�bolyethylene ,!��Xother(explain) f1 If tank is metal list age: Is age confirmed by,a Certificate of Compliance (yes or no):_(attach a copy,of certificate) Dimensions: 19 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: !l Scum thickness: IVA Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: zo Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,.liquid levels as related to outlet invert, evidence of leakage, etc.): Septic tank is not present. GREASE TRABik�(locate on site plan) Depth below grade:N/p Material of construction;C concretgy metalf2fiberglass�Yy polyethylene other (explain): 140/ Dimensions: /9 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: �19 Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert, evidence of leakage, etc.): Grease trap is not prPsPnt 7 Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 1 0 Crystal Lake Road _ Os ervi e,Mass. Owner: J. Calder Date of Inspection:11 /2 6/01 TIGHT or HOLDING TANI4L(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: o?concrete At $metal V,44 fiberglass.,/4 polyethylene�other(explain): Dimensions: Capacity: gallons Design Flow: ,// gallons/day Alarm present(yes or no): Alarm level: .414 Alarm in working order(yes or no): Date of last um in P P g �� ,• Comments(condition of alarm and float switches, etc.): Tight or holding tanks are not present_. DISTRIBUTION BOXL�iUe_ (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.): Distribution box is not nrPcPnt- , PUMP CHAMBER(locate on site plan) ` Pumps in working order(yes or no): tb Alarms in working order(yes or no): &!�f Comments(note condition of pump chamber,condition of pumps and appurtenances`,etc.): Pump chamber is not present 8 Page 9 of 1 1 p OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 1 0 Crystal Lake Road Os ervi e,Mass. Owner:J. Calder Date of Inspection3 1 26 01 SOIL ABSORPTION SYSTEM (SAS):Zlocate on site plan,excavation not required). 2-6 'x8 ' blockcesspools. Split system. If SAS not located explain why: Located See page 10 Type d1,Q leaching pits, number: 0 leaching chambers, number: Ali? leaching galleries,number:� leaching trenches,number, length: O D leaching fields,number,dimensions: D overflow cesspool,number: A-)8 innovative/alternative system Type/name of technology: '/ ' "9Po Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Loamy sand to boney coarse sand No signs of hydraulic ` failure or on din .Soils dr Ve etation is normal. p v CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: , Depth—top of liquid to inlet avert: Depth of solids layer: Depth of scum laver: 4 Dimensions of cesspool: c5 Materials of construction: Indication of groundwater inflow(yes or no): 60 Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): Same as above Pumped #2 cesspool at time of inspection PRIVY,r(,�"ocate on site plan) Materials of construction: NA Dimensions: NA Depth of solids: NA Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy is not present, .- 9 Page 10 of 1 1 Ji OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 1 0 Crystal Lake Road s ervi e, ass. Owner: J. Calder Date of Inspection: Same 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. Slkousc�(' WA�ERLIT!J� sfialt , o. l � — I C9 Pock wall "I �5 z 10 Page 1 I of 11 t i OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 1 0 Crystal Lake Road Osterville,Mass. . Owner: J. Calder r Date of Inspection: 11 /2 6/01 SITE EXAM ` Slope Surface water Check cellar ' Shallow wells Estimated depth to ground water �d feet ` 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: . Checked with local excavators,installers-(attach documentation) - Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used: Gahretr ' & Miller Model. Groundwater above sea level. USGS.Observation well June .1992 USGS; 92-000-1 Plate #2 Tup of un • � fd 'eet • t. - Groundwater:?®Feet Below.Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore, the vertical separation distance between the borto Of the leaching pit and the adjusted groundwater table is ' feet. • 11 , )•t"t'i1 TV.-RtTt/t-.TT-S��J.R•rT.RT'T1tl1R•ITllft•.TTt.fIIllRrItTTTRnt1.t1A'lllVilrl �.T.T^TT"R"• .^..r... TOWN OFBarnstable BOARD OF.IIEALTII SUI)SURFACE SFHAOF DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION ^•Tt1 T•'.".'t-T.1tI.^.ITT\�1 T911 tiI.T1'I TiT]lT1/1•'I"If7' ��'T r"IlRR171'R1R^��tt1.'.R7 mm� ..�rrr•r•�. -..� -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRES$ 110 Crystal Lake Road Osterville Mass. ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME J. Calder • PART D"- CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr. . COMPANY NAME Joseph P. Macomber & Svrn Inc COMPANY ADDRESS P.O. Box 66 Centerville Ma 02632 SCrQvt Town or City S MI ZIP COMPANY TELEPHONE (508 ) 775 - 3338 FAX ( 508 ) 790 - 1 578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and omplete as of the time of �inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . it Check one . System PASSED f , The inspection «hick I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which- I have con vCted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form , Inspector Signature Date I� ne copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the 130ARD OF HBALTII. * If the inspection FAILED, the owner or"hoperator shall u pgrade ' the eyetem within one year of the date of the inspection , unless allowed or required otherwise as provided in 3.10 CMR 15 . 305 , partd .doc _ TOWN OF BAMSTABLE TO LOCA*nQ N Sfertj d ASStr goat's W LCO, a11�STA,I: tt'3 NAIdIB& iQtdFs N0 t SEI?`I C 'AN CR:PACITX C'c O UXLD1R opt of 13RRl�JTDA'ZZ. 'S.. �Sepgrat�ian IAi.SP�rt�Brtv�een kbo. lY1�XlmumA�(jp�tetl Gtaoudwatet Tahtero tue BmtamafsaG11 ees l lva c;ylt�t r Sapply�`J0 �s�t,elaltirAg Paciltty .Of imy cve>!s exist r a off,silts ac:;witl�sn�Otf freet of t��tuttg f�tlitp) �cei Est cy�Vlietlaa o d I.cac�nln�.t~aai tty:(tEs ny.WOWds exht ( vitlaia�3Qt3 fact Qf iattei»ps�`aaiixty) tsrnli6d'.by r: a t:c ......... ..e •w u u.Y4.�T.LL•.?.T.u..�ua.. '9:..... .. .. wN iY f r 9 l ���41_40WN OF BARNSTABLE F.v LOCA7qON — SEWAGE # VILL4 AGE /cllo 4� ASSESSO 'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) oQL,_) _ (size) NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: 3112 A COMPLIANCE DATE: 3 S d 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 Of Qlo WWI 44 TOWN F BAAN STABLE I;OCATION jGY SEWAGE # i ` ILLhGE ASSESSOR'S MAP & LOT I CIS INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS -� BUILDER OR OWNER 9d PERMITDATE: 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;300of c acili Feet Furnishe _ l!b C% Sfi�! lal�.c Dsftw 30, t 5 IBSI ��,,,► �' aj,via-A-A 05 ZNK to --_: r T� -_ ii L L�i.+_ c'17- .. _ r _ f. *L. - � 3 � > 1 .��L� _ Z.❑1� - .'[._ — +-_ --7'r'- -T r — _ "�( —�T' _ _— _ _ �TL' r.�T - �`i - �.J f�-t'._ h _ :+7-' fa.. v-��r �'.-��ri _ L + _- L=i1. =' . � 1}i• �- ,;* `'.f7l _— �_ -1-'iris ®®®®®® o Wild, eN rmi&hu.NE OE5A(IN r1t C ca)39&4M4 ! -_ ., ,'nd (y olz d Ed day ru, (,AO elfpkN O'SIGN � FA% (5)B)598-g149 � N • nes ra!Izb:e:r ,aree - \ns, EW6Y clkC 5. I v E�wvJu;R-.ws e-+.wL war�3eamk.na/z jzu�c::��ezi �s,b�z ® . Jvi f a1 etfat i+as 6 nad vraperzar e` 3a VIE14'S(Iw.s E%U vvw5IfE in v� od m,tzr 1 rata�ate, "`=..—_ �— � '•- Pb .de_E aw;A�-Eo aayar.-ao)G15 www,c..does:�!'s.b�z �I Gl:iseybn cra 4m 1,�rU oeoT Y.+i AREAS SQUARE FOOTAGE PIN15t06A5',Me,W AMA N/A G�N�pAL N01 5 5rFXORMe.,A i320 (' I.a vpx v,cur i xv ErAxvao 2m5l LX(12A..eeA: 1217 YLgrw of u.e+x fuc[ocxe�J=a4�n ux O ?P,EA N/A. 2 kIIRND fN545WtlyU l.:E r� n a JEIaGNS I : iA!,PIN 51'N CGR AWA. 170 NOT 5CALE THE t9PAWIN65 r 1x A;Al WA . I • FIUPP ao rsr, WC✓M-N LZCK5 288 2432 - 2<j2 E+YG6W+: C2% 2492 26663rte\ GELS `°°_' pACZ INb�X -- r I r \ a.+ • :l 3 ."."Ia+S1Af'ON NffP.gY AEN 2`iiMULiEL<� I� ./ y�^/. II�EPAa F=� r' 2, FkONT&kE..q ELEVATION5 3, LEFT&061-tT EL.EVATION5 3f7 OVEpVIEW5 �.. ; \" T y i' w�xxarAror SAmrh Yr, ami oz a,.c, FOUNDATION PLAN-CP0�5 SECTIONS i y 11.E St wr — /� u, f Ra w zo',•N= y 15T FLOOK PLAN WINDOW SCHEDULE \ k Y /�•� I x X Cam,.OIJMIJ.+si.!E.'wlf lP55 A�h M1E f.L«. 1660 "-26G6•. 226J 6 IL NM IXMSYfihR19-aF P¢.LCan MJVMRI C'ANOa«P44!V\E2�.uaw. 6, 2ND FLOOR PLAN-KITCHEN VIEWS � • I 3 'L.d«91T'FT.E:VLL51R< ,vR2A2°.'�'hIM `4 � kl �. _ Su°-0.A TR°Y.G'A.NRJ S+FP fO Df tip.3LP 0.Vf.D �� . rry I MC4 rM1lEkg2'XhGS A@^J+i.YAiSIAY Yr1fN Qb ..v 9aaU5LttE >• —26 z^„+ 'S068 G0. f��-� ... __ ____ _ .._ __ ___ __ _ _ II G,ILLi LS'1'E OG21L:5 OIG�EfLELfl1:1: 1 - 5 D42C�G:A1"ADu.,�..4vYU.Es 9, I. wearc>r.:e*er„�e 5ciu>f«,w" 10_ i5 M1Lyp 5 D M ttRGD SAl2 nJ 9P\fN2D ra frt DATE OF --- 1. �a A revMR FINAL ISSUE 12. I-------------------I feaGra NA>vrnc:;vE¢foceecu*aa 9amv nE°fw. y, /� . fir L� __ 1 I 55a:v,5.l.11!/TY:EGN S;iT:Jafi>1_GAI,. 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I 3.-y.. S,-a" a 3y 9;a" j�V2'. 12-. • — - ( �� �•���rT �G'I �f � � � ����� (�_i�l� Imo-. / ` :.+.a �_.......<_aw .� P WALK IN CLOSET \ 1_MA5TER f3ATN '� }6 nINING A �� KITCNSN �� 'rJl ILI' C5 \��I LALINYJI2Y\ �.:. i Z CAR GARAGE ,F t 4'-3' MA5T5R MP'OOM n DINING ROOM • ;� rwrws✓,w,u bae ------ NLR TO BC I?"O.C�-- M1iSMlA IiNOtR '' LIVING DOOM °r•�srsnrcur-xe �. l ._ I a(n�rvrz N^ctt;ewee i � o I 0. FOYU w a,a — �, wrewexyew o af•nso,.+ _ PATS OF FINAL 155AUE 4•-Ip' T�12" 3'-9'J2" a'-0' —�6'O' �<.'-0" 4` �a-0" ( t-0' �6'-0" �a'-0" !l'.C' _ -I/I/O-I SCALD UNLE55 N01W OTN512W15e IST FLOOR PLAN 5 i TOP OF LEVEL 2' MIN FOUNDATION 6" MAX ELEV 33.44 1.00' MIN, 3.00' MAX L RISER REQ'D 9" MIN, 36" MAX 0.17 3" SEEDED TOPSOIL, 2% SLOPE 2" PEASTONE tiN O 31.00 MIN q Bq 33.00 MAX 30.00 LF Y�Q ��f3,:::;::4 UNACCESSIBLTr = 1.17 - ® ® ® ti: :,< 30.25 29.80 == °: 3/4" TO 1-1/2"DOUBLE CRYSTAL 0.25 29.63 29.50 :A :- r, .r: 30.00 4`'" :°tr< > .!'Y"' .3;i :ti. ii .,, :`.'a WASHED STONE LAKE 0 ROAD 27.50REROUTE REAR INVE BARNARD UNDER SLAB, AND 0 32 5 7 ROAD COMBINE FRONT AND - . :.` .;::.: :' :.... 4. 0 x 4 6 REAR SEWERS WITH INVERT AT FRONT OF 1500 GALLON SEPTIC TANK DISTRIBUTION BOX BOTTOM OF TEST HOLE 21. ELOEV.E3 AT 0.8 OR ABOVE ST-1500-H"10 DB 1 O OR DB-5 83 LOCUS MAP A 6 GRAVEL ON NATIVE SOIL OR MECHANICALLY COMPACTED BASE 36 x 12 NOT TO SCALE GENERAL NOTES 1) ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO 310CMR15.00 THE STATE ENVIRONMENTAL CODE TITLE V: MINIMUM REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF SANITARY SEWAGE, AVAILABLE FROM STATE HOUSE BOOKSTORE 1-617-727-2834, AND TOWN OF BARNSTABLE RULES AND REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SANITARY SEWAGE. SEPTIC SYSTEM PROFILE 2) CONTRACTOR SHALL VERIFY LOCATION OF EXISTING UTILITIES. NOT TO SCALE CONTACT DIG-SAFE AND LOCAL WATER DEPARTMENT 3 BUSINESS DAYS BEFORE BEGINNING CONSTRUCTION. 3) CONTRACTOR RESPONSIBLE FOR OBTAINING ADEQUATE DESIGN CALCULATIONS HORIZONTAL AND VERTICAL CONTROL. NUMBER OF BEDROOMS 4 4) CONTRACTOR SHALL VERIFY ALL PLUMBING FLOWS'TO GARBAGE DISPOSAL UNIT NOT ALLOWED SOIL TEST PROPOSED SEPTIC TANK, AND SHALL LOCATE ALL OTHER EXISTING DATE OF SOIL TEST 02-02-04 SANITARY FACILITIES ON PREMISES NO LONGER USED AND PUMP, DESIGN FLOW AND FILL OR REMOVE SAME IN ACCORDANCE WITH LOCAL 4 BEDROOMS x 110 GAL/(BR-DA)=440 GPD. WITNESSED REQUIREMENTS. REQUIRED SEPTIC TANK CAPACITY (MIN)1566 GAL SOIL EVALUATOORR B.J. YOUNG 5) ALL COVERS OF SANITARY UNITS SHALL BE BROUGHT TO ACTUAL SEPTIC TANK CAPACITY 1500 GAL PERCOLATION RATE <2 MIN. INCH. WITHIN 6" OF FINISHED GRADE. ALL MASONRY UNITS TO BE LEACHING AREA REQUIREMENTS MORTARED IN PLACE. ALL PVC PIPE TO BE SOLVENT WELDED. --BOTTOM 0.74 GAL/(SF-DA) ELEV.= 32.91 rev 5 y 6) UNLESS OTHERWISE SPECIFIED, EXISTING AND FINAL GRADES ELEV. DEPTH HORIZ SOIL TEXTURE COLOR MOTTLING SHALL REMAIN ESSENTIALLY UNCHANGED. --SIDE 0.74 GAL/(SF-DA) 7) NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH LEACHING CAPACITY 32.6 0-8 8-27 B w LOAMY SAND LOAMY SAND 10YR 3/2 N DEEDED OR ZONdNG RESTRICTIONS AND/OR REGULATIONS. ((36'x12') + 2x(36'+12')x2') 30.66 10YR 6/8 0 OWNER/APPLICANT MUST OBTAIN SUCH DETERMINATION FROM xO.74 GAL/(SF-DAY)= 461 GPD 21.83 27-133 C MEDIUM SAND 10YR 6/8 N APPROPRIATE AUTHORITY. RESERVE 461 GPD E 8) EXCAVATE AND REMOVE UNSUITABLE MATERIAL BELOW THE LEACHPNG -INVET�T-ELEVATION FOR 5' AROUND LEACHING SYSTEM AND REPLACE WITH CLEAN SAND. 9) IF ANY DETAIL OF THIS PLAN IS NOT UNDERSTOOD, CONTACT DESIGN ENGINEER AT 432-6360. 10) 48 HOUR NOTICE IS REQUIRED FOR ANY INSPECTION OR CERTIFICATION REQUIRED. 11) SITE LIES WITHIN FLOOD ZONE C AS SHOWN ON MAP 250001 PERCOLATION TEST DONE AT A DEPTH OF 42"-54" 0016 D DATED 07-02-92. 21(� NO WATER ENCOUNTERED 32.73 LOT 26 , 15 295SFt , M 11.00 � 00 v 6 s . N 0 C;1:3 � AlUilAVIAR 12.00 # 110 ST APPROVAL ENGINEER STAMP 11.00 32.91 25.00 _ REROUTE REAR SEWER G UNDER SLAB. Date DESCRIPTION Drawn Checked R E V I S 1 0 N S 36.00 ,�/ SEPTIC SYSTEM REPAIR DESIGN .12.00 �� PROPOSED AT 110 CRYSTAL LAKE ROAD � 32 < 4.00 IN 2.00 32 OSTERVILLE SCALE: NOTED DATE: FEB 24, 2004 LA BARGE a RE Q R ENGINEERING & CONTRACTING,INC. 237 MAIN ST. -ROUTE 28 SITE PLAN P` WEST HARWICH, MA 02671 1 " = 20' (508)432-6360 BENCHMARK: TOP OF WATERGATE 10 0 10 20 30 ELEV 32.46 APPROX NGVD DRAWN BY: BJY CHECKED BY: TAIL SHEET 1 OF 1