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Home My WebLink About0048 BAY STREET - Health (3) _ 48 Bay. Street Osterville M A= 117- 034 j o ,I I TOWN OF BARNSTABLE LOCATION (A3 SEWAGE# (y I— VI ,LAGE ASSESSOR'S MAP&PARCEL f I-7 J INSTALLERS NAME&PHONE NO. (�� SEPTIC TANK CAPACITY LEACHING FACILITY.(type) 7 (size) 14p� D( (-a `®Q NO.OF BEDROOMS f FF '50-5 OWNER PERMIT DATE: (V COMPLIANCE DATE: cZ II 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 "a ility(If any wetlands exis within 300 feet of leachi f,F 'ry o4 Feet J �= io FURNISHED BY r (D� 9T . ,F �- 33' GJ No. W Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 0(pptication for Misposai 6pstem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 07 7' Owner's N e,Address,and Tel.No. Assessor's Map/Parcel %/-7— �3 O� ,¢ Sr Q f / / Installer's Name,Addre s,and Tel.No. (��2[/� 9-600 Designer's N e,Address,and Tel.No. pot]A0 R) Type of Butldi 7'// d fel °Z DwellingNo.of Bedrooms � t Si s .ftl Garbage Grinder J q g ( ) Other Type of Building ~ + No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) tS S C� gpd Design flow provided ��Qf gpd Plan Date Number of sheets Revision Date Title psi Size of Septic Tank ;, 15`y1pe of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) -- 1 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 of to place the system in operation until a Certificate of Compliance has been issued by this Board f 1 Signed ® ' Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. D Date Issued f ti N.c1l 1 \s. 'Fee 1 THE COMMONWEAUTaA�OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION , TOWN OF BARNSTABLE, MASSACHUSETTS Zipplitatton for Vsposif 6pstem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. W 4� �� Owner's N e,Address,and Tel.No. �O Assessor's Map/Parcel //7— D3/ /�Y� - ,(/ KI, ,¢ Sr Installer's Name,Address,and Tel.No. y)a W 2800 Designer's N e,Address,and Tel.No. 12ndAO I ]. glyw L S Type of Bud di ; Dwelling No.of Bedrooms Al Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of-Persons Showers( ) Cafeteria( ) Other Fixtures !, Design Flow(min.required) 5 (/ gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank 2�440A 7:41 -C Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Dat last inspected: Agreement: '+n 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'C/anot to place the system in operation until a Certificate ofCompliance has been issued by this Board of He It _ Signed Application Approved by i, vwc _ Date 3' ; Application Disapproved by "? Date for the following reasons e i Permit No. (7( _ . Date Issued � T111 F COMMONWEALTH OF MASSACHUSETTS ` BARNSTABLE,_MASSACHUSETTS ;<. . )vyt y d --—Certificate of Compliance k " THIS 1S"TO CERTIFY,t at the On-site Sewage Disposal system Constructed( ) Repaired(/j) Upgraded(- ) t AbandoAne�d( )by at /�� ( �� P has been constructed in accordance with the provisions of Title 5 and the for Disposal System'Construction Permit No. �1 a " Ddated 1.. Installer Isle, x;Designer c= # Approved g �� #bedrooms � - �' a r. r r r.c�r c A roved design flow � gpd The issuance of his ermit shall not be construed as a guarantee that the system will fix tion as de3jgned. Date } Inspector �(A j rY• No. d D IDs Fee 1b / THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal 6pstem onstruction permit M Permission is hereby granted to Construct( ) Repair( * Upgrade,( ) Abandon( ) System located at�/ L�L/� ,T o &Iew I Zl p and as described in the above Application for Disposat Syste onstruction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of il►e date of this permit. Date �� Approved by Bk 26784 Ps 43 afi 1476 10-22-2012 a 01 : 04P RESTRICTION". WHEREAS, Tiffany Swan Marloski formerly Tiffany Swan of 48 Bay Street, Barnstable (Osterville),Ma 02655 is the owner of certain real estate situated at 48 Bay Street in the Town of Barnstable known as Osterville, County of Barnstable, Commonwealth of Massachusetts 02655, hereinafter referred to as "the Premises",and more particularly bounded and described as Lot B 1 on a plan in Plan Book 198 page 91 and a lot containing 12,500 square feet as shown on a plan in Plan Book103 page 155;and. WHEREAS, Tiffany Swan Marloski as owner of the Premises has agreed with the Town of Barnstable as a precondition to the granting of a building permit for renovation and additions to the existing structures now located on the Premises to restrict the total number of bedrooms which can be included on any buildings located on the Premises. NOW,THEREFOR,Tiffany Swan Marloski does hereby place the following Restriction on the Premises above referred to in accordance with his agreement with the Town of Barnstable Board of health and Building Commissioner,which Restriction shall run with the land and be binding upon all successors in title. (1) The buildings as renovated on the Premises shall have a total of no more than Five (5) bedrooms. (2) This restriction shall continue in full force and effect until such time as the Premises shall connect to Town sewer or the premises can have more than Five(5)bedrooms as allowed as a matter of II!' right,at which time,the Restriction shall become null and void. For title, see deed of Joshua Kouri and recorded with Barnstable County Registry of Deeds in Book 22493,Page 181 J Witness my hand and seal this--- ,�v day of October 2012 Tiffany4Swnrloski Commonwealth of Massachusetts COUNTY OF BARNSTABLE On this 2Z day of October, 2012, before me, the undersigned notary public, personally appeared, Tiffany Swan,Marloski, proved to me through satisfactory evidence of identification, which was/were [ or[ ] , to the rs s ho e name(s) Ware signed on the preceding or attached document, and acknowle to at it voluntarily for its stated purpose. LIU Notary Public My Commission xpires ry - BARNSTABLE REGISTRY OF DEEDS , �`t "�� ,s; Commonwealth of Massachusetts Title 5 Official Inspection- Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �y"�� Property Address /�yZ:5� Owner Owners Name Information is r required for every page. Clty/Town State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When A. General Information filling out fors on the computer, I' L use only the tab 1. Inspector. I V key to move your cursor-do not Z,pW.-19P �9- Y7pW6 use the return Name of Inspector key. 1��7�Snc5'//Zt�5-}-- ,.Z/✓G Company Name � 9 �-- Company Address 1-qi I own �,�/�B/�—CiL��J State zip Code Telephone Num� Ucense 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 15.340 of Title 5(310 CMR 15.000).The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 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. t51ns•t1n0 �F SuD�l D� W naDeaton pe Dispoael System•pep 1 Of 17 • .a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4,g OJT Property Address Owner Owners NameInformation is required for every page. Citylrown State Zip Code Date of inspection B. Certification (cunt.) 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: � 5•t2 S �C oLKe �7��on� a i Gi/ B) stem Conditionally Passes: 1 /p ❑ O or more system components as described in the'Conditional Pass'section need to be �1 repla d or repaired.The system,upon completion of the replacement or repair,as approved by the Boar f Health,will pass. Check the box for es','no'or°not determined'(Y,N,ND)for the following statements.If'not determined,'please lain. The septic tank is metal an over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial i Itration or exfiitration or tank failure is imminent.System will pass inspection if the existing tank is re ced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if i ' structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than years old is available. ❑ Y ❑ N ❑ ND(Explain below): Nft-1Ilia Tors 5 OffMd tnepecQon Form:Sumaafeas Sewage Diaposd System Pape 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owners Name information is �Ydi ��S� �l—7-/Z required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt) B) System Conditionally Passes(cont.): PA ❑ bservallon of sewage backup or break out or high static water level in the distribution box due to ken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will passin-, coon if(with approval of Board of Health): ❑ broken i e(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is r oved ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box isXleveorplaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to bro 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( lain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain low): q111- C) Further Evaluation is Required by the Board of Health: ❑ Condl I 'st which require further evaluation by the Board of Health in order to determine if the system is fai I test public health, safety or the environment 1. System will pass unless Boiairdaf Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not fun ing 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 sa rsh t5im•11/10 ride 5 ortidai inepecllon Fartc Suhai+raoe sewage Wposal syete,n•Pap 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 23�, Property Addres�a"� Owner Owners Name reformation is �y/ A D2L Sf /(7- /Z I required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) �Ir 2 System will fail unless the Board of Health(and Public Water Supplier,if any) de Ines that the system Is functioning in a manner that protects the public health, safety d environment: ❑ The stem has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a su ce water supply or tributary to a surface water supply. ❑ The system s a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a s tic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank an AS and the SAS is less than 100 feet but 50 feet or more from a private water supply we '•. Method used to determine distance: '*This system passes if the well water analysis, pe ormed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence o mmonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure crite 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 Cl Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ 1,41� Liquid depth in cesspool is less than 6'below invert or available volume is less than'r4 day flow t5ins•11n0 Tien 5 akLli Inspection Font&marfaw SWAW OieposW System•Pays 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �- Property Address Owner Owners Name information IsE44,, v``� M.0- b2�5S %t--I- \Z required for every page. Cttylrown 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. ❑ N� ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑01d ] Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑4 ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ I* 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 colfform 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.] ❑ N�a The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ gj 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. t4 E) Large Systems: To be considered a large system the system must serve a facility with a des ow of 10,000 gpd to 15,000 gpd. For large syste ou must indicate either'yes'or'no'to each of the following, in addition to the questions in Section Yes . No ❑ ❑ the system is within 4 et of a surface drinking water supply ❑ ❑ the system is within 200 feet of a ry to a surface drinking water supply ❑ the system is located in a nitrogen sensitiv a(interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public r supply well If you have answered'yes'to any question in Section E the system is consi a significant threat, or answered'yes'in Section D above the large system has failed.The owner or op for of any large system considered a significant threat under Section E or failed under Section D shall up the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. cSms•»n o nee 5 Omdd Kspeabn Fomr Subswfam sewage asposm system•Fe9e s a 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owners Name information Is ��pw� P Ma- _ ozz.55- required for every page, Cityfrown 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 tltowner cupant,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? ❑ S 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? P9 ❑ Were all system components, a 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: RArSS.daJ9 q tx..0 SNgr-tr NtWK , ❑ 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): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): . 550 t5da•1 t/10 Tdo 5 Oftel trtepedbn fortrc SWaafaee Sewage Dleposal System•Pap 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4 5 3o--f 5r Property Address Owner Owner's Name Information is 41!�5TffP I L.-LE MA D Z4 5�_ 1 —'1—t 2— required for every page. CdyRown State Zip Code Date of inspection D. System Information Description: V.� L3 G q! �jo,� GOD L•fir C�1-/o /ODO �•�iT o'1 Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system?[f yes separate inspection required] ❑ Yes No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes 14 No Water meter readings,if available(last 2 years usage(gpd)): Detail: zo/D 3010�� y Zb// 216/ oOv G�r /Z�i S = /g7ZllJ� S2g153 4 ^ Z// � vs Sump pump? ��'/'� 73d vs� ❑ Yes No Last date of occupancy: , / L v�✓ � Urdu Date Commerciallindustrial Flow Conditions: Type of Es ment: Design flow(based on 31 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft, 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: 15Im•11no Me 5 Omdm mapacbm Fomr.Subaiar m sewage Oieposd system•Pepe 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address -:5W A.l Owner Owners Name information is II e required for every �54-e page. GtyRown State Zip Code Date of inspection D. System Information (cunt.) Q& Last date of occupancy/use: Date Other(describe below): 9 General Information Pumping Records: Source of information: R*A111( �� L e✓ Was system pumped as part of the inspection? ❑ Yes No If yes,volume pumped: gallons How was quantity pumped determined? N/0. I n Reason for pumping: S Type of System: Septic tank,distribution box,soil absorption syste 7-1974c _ow 0-01 'O ❑ Single cesspool . ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes,attach previous inspection records,if any) ❑ Innovative/Altemative 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): t5irro•11n0 Title S Oftal Umpedw fort Stmaarooe Sewage Dieposel System•Pape 8 of 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4P�`�dY sT Property Address Owner Owners Name Information is OZ�SS required for every 7T�✓1�� I I- 'i— 11i page. Cfty/rown State Zip Code Date of Inspedion D. System Information (cont.) Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes,� No Building Sewer(locate on site plan): Depth below grade: Z feet Material of construction: Pv�. �• +• Pyc. cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on cond''on of joints,ventin)evidence of leakage,etc.): (�fW Septic Tank(locate on site plan): Depth below grade: feet Material of construction: concreteaLL) ❑metal ❑fiberglass ❑polyethylene ❑other(explain) �c" 1500 14 tU +64 t6l�h �4- ID G" 1$UO� �{- ►o� ti'J3�/�� /�� V 1 1!1e4- I S'�t'Lt te✓ ?.Dsc� t 1)e�-�e v+-u�#- ��7'�12y �►1��-�u-F�e'T' Zo'r��d. t b"lei 14'f-Q l c ac�sr�.ISa( 2�}r,�k. - 14•{ w/ems hf 1A If tank is metal,list age: years Is age confirmed by a Certficate;�of Pompliance?(attach copy of certificate) `❑ Yes ❑ No NIA Dimensions: 5 Fi;X 1 t XW X"Y Y-6" A've 5v Ic - 5 n to t tc ::'� Sludge depth: Lk ~ t5ft•1 WO TU 5 Of 1dW MvecWn Fort Subartaoe Sewage UVOSar Sy$Wm•Pape 9 d 17 • II Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4 e 'BALe 5T Property Address Owner Owners Name Information is 05;eP-V t I Je Ma- l I- 1—(Z required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) „6C- ,, _ Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Cu�a ) �" Distance from top of scum to top of outlet tee or baffle N&scum Ia p AA (at N�4 � �O Distance from bottom of scum to bottom of outlet tee or baffle U How were ,mensions determined? klc9t N at re c.'Y % � lmod Commen (on pumping recomi�endatio s inlet and out�e ee or baffle condition structural integrity, liquid lev a as related t outlet inve ence of leakage,etc.): A-G < < C dry4rc,F:' -1-n N/a Grease Trap(locate on site plan): Depth w grade: feet Material of cons on: ❑concrete ❑me ❑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 t5irts•11110 Ttft 5 t7 kw hsPecdon Fomt Subanfaoe Sewspe Divoaal system•Pape 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owners Name information is required for every Cityfrown State Zip Code Date of inspection page. P P� D. System Information (cont.) Comm nts(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid leve elated to outlet invert, evidence of leakage,etc.): NSA Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth low grade: Material of co ction: ❑concrete etal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: J Capacity: gallons Design Flow: alions per day Alarm present: ❑ es ❑ No Alarm level: Alarm in ing order. ❑ Yes ❑ No Date of last pumping: Date" Comments(condition of alarm and float switches,etc.): NIA Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t51ns•»no nae 5 offidal hopedon Form Madam Swap Dq)u l system•Page t t of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4aua�LC 57 Property Address S�J o.rj Owner Owner's Name information is Sim 2V l t_l.tc MA o?.L 5S \1--t—lZ 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): y it V ,/VO Depth of liquid level above outlet invert 4 7 omments tote if box is level and distribution to outlets a ual n eviden� f solids ca ov n 4� q �Y o RY e► any evidence of leakage into or out of box,etc.): /h _Azle uIQ P=Chamber(locate on site plan): Pumps order. Yes No ❑ ❑ Alarms in working order. ❑ Yes ❑ No Comments(note condition of pump chambe , ndition of pumps and appurtenances,etc.): Soil Absorption System(SAS)(locate on site plan,excavation not required): 4SAQ-Wlocated, explain why: Zo, Ors 03,2 6 tyns•11r1g Title 5 O(lidd Inspection FomG Subaufaae sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address _ / cWN Owner Owner's Name information is required for every ✓� ��L� Z;Z�;S3- //' 7—/Z page, City/Town State Tip Code Date of inspection D. System Information (cons) Type: leaching pits number ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number,length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technolo y: Comments note coon of soil gns of_ _hydraulic failur ,lel o ndin d it n�fion of vegetation tc.): o d �/D lvDO ,�{/p /DUD 1r'GLO �GU � a d X G� Pdnd f��Gv►1L`-r S o1 GuY.e� w Ga✓ ✓76 ►4L Z4 y /Q Ce ools(cesspool must be pumped as part of inspection)(locate on site plan): Number and c uration Depth—top of liquid to inlet in Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Mm-11r10 Tift 5 Mid UuPec Fore[&&&9 aWe Sewage DiaposW Sy$Wm•Paps 13 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owners Name information Is required for every S�� +'/�-CL� / d�7 //— 7— /Z page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) NI4 Co ents(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.): r WA Priv to on site plan): Materials of constru Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure, I of ponding,condition of vegetation, etc.): t5ine•11/10 Tide 5 OftW hispeckn Form Sibsisface Sewage Disposal System•Pape 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Assessments Subsurface Sewage Disposal System Form-Not for Voluntary 4 e>13a--f k Property Address ( Owner Owners Name information is l�b►�yI Ll er M�. 0Z(,5S 11-1—S Z required for every page. C tyRown State Zip Code Date of Inspection D. System Information (cunt.) Sketch Of Sewage Disposal System:Provide a view of the sewage disposal system,including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate TWAS cJp,;� where public water supply enters the building.Check one of the boxes below: C�4) GU MJA hand-sketch in the area below drawing attached separately See- e++�"G" fLnn� I. CAS da l l v-z9-12 t nc.l v�e l D(L( -z-to rJ T A F-2 21a•t3' G-2 9•�� D_2 3•S' E'-2 z9.7- A-Z Z4.d'$-2 Z7a V- 3 I g.5, f-3 4 t-4- 4,-3 32•a- 9-3 33s 4.0. aa 40 ��G/• ST�wt •�� {5�vK »Aa �F ej2 3 3 t. C�rlwt: z F i FLA Pm D¢ V. d-51' DES 3 )61`f �'IT tZ_ E E T- t51ns•»no Tile 5 MW kWedion Fomc Subsiufaw Sewege Disposal Sysmm•Poe 15 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owners Name information Is 6911—t-MV1 u A CE �( DLL c� required for every Page- Cltylrown State Zip Code Date of inspection D. System Information (cont.) Site Exam: Check Slope [ Surface water �je,'v JrAS l t)• A).r)o. N w . �� o qa f I ` Check cellar (IV LY — Shallow wells dAQ_W1 aVe.- ;a&Y'j � > t3 " Estimated depth to high ground water. feet T„ trG A Please indicate all methods used to determine the high ground wate a evation: Obtained from system design plans on record(s7co}� cs 44 LQ lam- 1V-4 (S t1---74-19bZ ftq,�,(Z Nig If checked,date of design plan reviewed: —� Observed site(abutting property/ a te s -'feet df SAS) 0 [aJ Checked with local 13 rd of Health-explain: , � c.'es wl ❑ Checked with local excavators,installers-(attach documentation) Cl Accessed USGS database-explain: You must describe how you established the high groundwater elevation: l `5 a.w�IAyC� �r �ZO.S J L2atM c.u�VX C��'2 �i.�/�w�Xt�l6•t '>•�C+!(�1 r m o $•l� o a o In 2! 1efore'TIOng this Inspection Report,please see ReiloRompleteness Checklist orf7Mext page. tsm.•t tno Tine 5 on+dd hWedw Ferns subeur m sewage OieposW system•Pap 16 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address dwl�.1� Owner Owners Name Information is required for every L'/✓ " �� ( 2 puo sS (l- 7— (Z page. Criy[Town State Zip Code Date of Inspedion E. Report Completeness Checklist Inspection Summary:A,B, C, D,or E checked e" 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 t5 t•11/10 rise 5 andei Imoewo„Fortrc subaurtaoe seNaoe asposel system•Pam 17 of 17 28 BUMPS RIVER ROAD SYSTEM "C" EXISTING PIPE 15.55 N PROPOSED TANK INLET 15.33 PROPOSED TANK OUTLET 15.13 Locus qiNPROPOSED "D" BOX INLET 15.10 sr PROPOSED "D" BOX OUTLET 14.93 gPY Sj EXISTING LEACH PIT INLET 14.85 (H-20 600 GAL. (4'x6") / 1' STONE AROUND 92 20 M LOCUS MAP NOT TO SCALE: I E Aro2 A5 p6'5p',y" 26f . N EXISTING (BEDROOM/OFFICE) BENCHMARK PROPOSED 1,500 CORNER OF EXIST\ GALLON SEPTIC TANK CONCRETE PAD. GARAGE ELEVATION 18.17 0/ PROPOSED PROPOSED DB-3 a' CLEANOUT ti a+ TO GRADE SYSTEM "C" \ " EXISTING Op1�,p S.A.S To \ POOL S REMAI/ 0 SYSTEM "8" EXIS48 TING ROOO 4 BED. \ DWELLING SYSTEM 2 �V DECK ` oo. pp" 0 40 60 80 GRAPHIC SCALE: 1 INCH = 40 FEET { h40- lp r h� �asr- 6D 6Z&5-) l �f�/�5o r� p� w f�e-� rti✓ .'2•23..:�g---$7 � . �; 4�:g �NJ( I A/ I/ .e�'�-2 oj sf1� �78�J �1�.{ 0 3�)-9, l.�' ,3 SrNw�•l ka ��/ (� / /t��•2 / - . 9 , Cos 1 4 • 8� V4V P(e� . J : . •: t 3. 32:: : f I. 1 g dY �-� /322 741- L, r 57( y1. 4Uj/ ;yr 2. 3 `; 22, o7 19,43 - •. - 7 ,4-U 17. 10 S E4� Vim," 1 a 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: 48 Ba yltff—eelt---- f Osterville MA 02655 `�' '"' Owner's Name: Ka Welsh c� Owner's Address: 4132 S:'Rainbow Blvd: PMB 336 c Las Ve as NV 89103-3106 _ January 3 2006 Date of Inspection: cri C° > �73 -0 Name of Inspector: (Please Print) Jmnes M. Ford �� Company Name: James M. Ford 9 — r Mailing Address: P.O.Box 4 � Osterville MA 02655-0049 rn Telephone Number: (508186219400 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. 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 rther Evaluation by the Local Approving Authority Fails Inspectors Signatu re: Date:. January 6. 2006 , The system inspector shall sub a.copy of this.inspection report to the Approving Authority(Board of Health or DEP)within 30 days of complet g 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: 48 Bay Street Osterville, MA Owner: Kay Welsh Date of Inspection: January 3. 2006 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 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 48 Bay Street Oste_rville. MA Owner: Kay Welsh Date of Inspection: January 3. 2006 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 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 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 s Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 48 Bay Street Osterville, MA Owner: Kay Welsh Date of Inspection: January 3, 2006 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 '/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the 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 II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 48 Bay Street Osterville, MA Owner: Kay Welsh Date of Inspection: January 3. 2006 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 t Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 48 Bav Street Osterville, MA Owner: Kay Welsh Date of Inspection: January 3. 2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 Number of current residents: 0 Does residence have a garbage grinder(yes or no): n1a Is laundry on a separate sewage system(yes or no): n1a [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: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,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: Unavailable 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 ✓(2) 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: System A (newer system)was installed in 1986 date of installation for older system is unknown 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: 48 Bay Street Osterville, MA Owner: Kay Weish Date of Inspection: January 3, 2006 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: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: System A-2' : System B- 18" Material of construction: Both ✓ 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: System A- 1500 gal : System B-1000 gal Sludge depth: System A -2" System B-2" Distance from top of sludge to bottom of outlet tee or baffle: System A-30" System B-30" Scum thickness: System A- I' • System B- I" Distance from top of scum to top of outlet tee or baffle: Svstent A 6" : System B-6" Distance from bottom of scum to bottom of outlet tee or baffle: System A - 101, tem B- 10" How were dimensions determined: Measuring stick Comments(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 a pear to be any signs of leakage The inlet cover was 16"below grade System B was under a bush The inlet cover was to grade 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. S Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 48 Bav Street Osterville, AM Owner: _ Kay Welsh Date of Inspection: January 3, 2006 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene'_other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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 level with no solids for System A System B.did not have a D box PU.NIP CHAMBER: None (locate on site plan) . Pumps in working order(yes or no): Alanns in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 48 Be Street Osterville, MA Owner: Kay Welsh Date of Inspection: January 3, 2006 . SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type 1(2) leaching pits,number: Svsteijz A-4'x 6'(600 gal) •Svstem B-6'x 6'(1000 gal) 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.): The leach nit for System A was dry and clean The scum line was approxiinately 6"up from the bottom The cover was 12"below grade. Svstem Bs leach nit was drv. The cover was to grade There did not appear to be any signs o�failure NOTE The drain in the ara a floor goes to a se arate 600 al. leach it. CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 48 Bay Street Osterville. MA Owner: Kay Welsh Date of Inspection: Januaw 3, 2006 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. a Q O O ace Floor dq DrAt a , a 3 Q A a 1 3, 3-7 a 3�6 `q y �$ S y s S3 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: 48 Bay Street Osterville, MA Owner: Kay.Welsh Date of Inspection: January 3, 2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 15+/- 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: topographic and water contours tttaps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: I You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps the maps were showing Qi2roximately/5'+/ to ground 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 andlor this report. ,11 Gl/YJ4/Z'lt3b 1'L: 14 bbd4'LblbJb ALBERT J SCHULZ EP PAGE 05/05 CENTERYILLE-OSTERYILLE-MARSTONS MILLS ?r 03 FIRE DISTRICT Ay/f r^^�` 999 MAIN STREET OSTERYI LLE,MA. 02655 . '' 428-2467/FAX# - 69 420 50 OIL/HAZARDOUS MATERIAL RELEASE FORM F.A 400 LOCATION: ADDRESS OF RELEASE-n1-1 sh Residence -48 Bay -_Street Osterville, MA. 02655 DATE OF RELEASE: 7/30/90 PRODUCT RELEASED: AieSel ESTIMATED QUANTITY: Unkno_._ CORRECTIVE ACTION TAKEN BY RESPONSIBLE PARTY: Notifications NOTIFICATIONS; FIRE DEPARTMENT: YES (K) NO( ) DATE: 7/30/20_- TIME; 1-1:55 NATIONAL RESPONSE CENTER: YES ( ) NO 00 DATE: TIME: DEFT: OF ENVIRONMENTAL PROTECTION- YES ( ) NO( )4 DATE: TIME: OIL SPILL COORDINATOR: YES ( ) NO(Y-) DATE: TIME: TOWN BOARD OF HEALTH: YES (10 NO ( ) DATE: 7/3Q/90 TIME: - 11:55 TOWN HARBORMASTER: YES ( ) NO(K ) DATE: TIME: OTHER AGENCIES: , N/A COMMENTS: 1 ,000 gallon d'e 1 tank removed by Environmental lank Services. Tnc. Tank appears not to,hgVe leaked, however a large wet aze.a_was found on the tons .and sides of the tank probably due to overfilling And/or pipizig leaks. REPORT FILED BY: T.t Martj Anggaly DATE: 7/3n/90 WHITE COPY-FIRE DEPARTMENT YELLOW COPY-D.E.P. PINK COPY-BOARD OF HEALTH C.O.M.M. FORM 58 Ul/ rJ4/ZrJYJb 1Z.14 oudgzvinjb HL15tKI J ZDUNUL4 Lr f mur_ rJ4/ UO CENT ERYILLE--OSTERYILLE-MARSTONS MILLS FIRE DISTRICT 999 MAIN STREET OSTERVILLE,MA. 02655 428-2467/FAX-V 420-5069 OIL/HAZARDOUS MATERIAL RELEASE FORM F,A 400 LOCATION: ADDRESS OF RELEASE: Welgh Residgnga 48 Bay Street ` ngrervi 3-1e. M6 Q2655 DATE OF RELEASE: _ 7130/90 PRODUCT RELEASED: #•2 fuel ESTIMATED QUANTITY: Unkn v_m CORRECTIVE ACTION TAKEI4 BY RESPONSIBLE PARTY: Notifications NOTIFICATIONS. FIRE DEPARTMENT: YES NO.( ) DATE: Z430-190 TIME'. t l -%S NATIONAL RESPONSE CENTER, YES,( ) N0 00 DATE; TIME: DEPT. OF EWRONMENTAL PROTECTION: YES ( ) NO IX ) DATE: TIME:.._ OIL SPILL COORDINATOR: YES,( ) NO IX) DATE: TIME: TOWN-BOARD OF HEALTH: YES(.X: NO ( ) DATE: - -7110120 TIME:--LLL55 TOWN.14ARBORMASTER; AS:(: ) NO( ) DATE: TIME; OTHER AGENCIES: NSA COMMENTS: 1,000 gallon #2 £uel tank removed by Environmental Tank Services._Iuc. Tank gonears not--to-have leaked, however a large wet area was found on the ton and s.ides__of_ th% tank probahly dLe to overfilling andlor_.,Rjai g 1paks. REPORT FILED BY: -- ltr- Martin MarNaclY DATE: 71- 01gn WHITE COPY-FIRE DEPARTMENT YELLOW COPY-D.E.P. PINK COPY-BOARD OF HEALTH C.O.M.M, FORM 58 01/04/2¢,Ub 12:14 5084201536 ALBERT J SCHULZ EP PAGE 01/05 21E SURVEY FORM STREET ADDRESS OF PROPERTY BEING SURVEYED: 48 BAY S_T_RI:_£_T_OSTERVJl4Ll MBA 02655 OWNER: WELSH ADDRESS: 48 BAY STREET,OSTERVILLE, MA 02655 PRESENT FLAMMABLE PERMI D STORAGE AT PROPS TANK SIZE PRODUCT LOCATION AGE CONSTRUCTION 500 GALLON #2 OIL UNDERGROUND 32 YEARS STEEL UN KS REMOVED FROM_RROPERTY:. TANK SIZE PRODUCT CONSTRUCTION AGE DATE REMOVED 1000 GALLON #2 OIL STEEL UNKNOWN 7/30/1990 1000 GALLON DIESEL STEEL 12 YEARS 7/30/1990 SPILLS/LEAKS AT PROPERTY: DATE MATERIAL RELEASE APPROXIMATE SIZE OF RELEASE 7/30/1990 #2 OIL UNKNOWN 7/30/1990 DIESEL UNKNOWN INFORMATION PROVIDED BY: SHEILA LONGEWAY DATE;January 4,2006 C-O-MM FIRE DEPARTMENT 1875 ROUTE 28,CENTERVILLE, MA 02632 RECORDS OF UNDERGROUND TANKS ARE ALSO LOCATED AT TOWN HALL, HYANNIS, MA AND BARNSTABLE COUNTY COURTHOUSE, ROUTE SA,BARNSTA13LE MA. C-O-MM FORM#I3813 01/04/2006 12:14 5084201536 ALBERT J SCHULZ EP PAGE 03/05 CENTEFiVILLE • CSTERVILLE - MARSTONS MILLS FIRE DISTRICT UNIDERGRO[T► D TANK REGISTRY PROGRAM - ,tires c 5r G-79 Owner of Property: �Jo�n tA �r w �it/¢�S� Date of Installation: Address: —_. �. ST ..�QS �� Description: r' e__ _ 1�1PSe�_ Installer: Size: /� Certification; Location of Tank: />� INSPECTION INFOWWATION `�--- H DATE COMPLETED BY Site Inspection Air Test on Tank--Above Ground _, t j , i Air Test on Tank—Within Hole �� {✓, bC`Q � Test on Piping /7 ,�,� -�,, 1 Cathodic Protection Test :ontinuous.Monitorin9 Sys tern S Type yp Backfill Operations M Vent and trill Pipes Other: TESTING OF TANKS AND PIPING: EXISTING TANKS 10th 13th 15th 17th 19th 20th 21 st 22na 23rd. 24th 25th 26th 27th 28th 29thr.�_._�_._. (30) Removal NEW TANKS: 15t h 20th 22nd 24th 261h 28th (30) Removal Remarks: 01/b4/2006 12:14 5084201536 ALBERT J SCHULZ EP PAGE 02/05 • i CENTERVILLE o OSTERVILLE • MARSTONS MILLS FIRE DISTRICT UNDERGROUND TANK REGISTRY PROGRAM Owner of Property: �Lq w%Za Date of Installation: Address: yfA{�L T ui5%.>:.ti►!+►-'4 Description: Installer: U+�g, Size: Certification: Location of Tank: ur4w- INSPECTION INFORMATION DATE COMPLETED BY Site Inspection . Air Test on Tank-,Above Ground Air Test on Tank—Within Hole Test on Piping Cathodic Protection Test i Continuous Monitoring System Type Sackfill Operations Vent and Fill Pipes Other: TOWN OF BARNSTABLE -r LOCATION N ` A SEWAGE# XILLAGE ' ASSESSOR'S MA &PARCEL INSTALLER'S NAME&PHONE NO. ��q l {'Tt' SEPTIC TANK CAPACITY LEACHING FACILITY. (type) IDOa (size) NO.OF BEDROOMS OWNER T� ��tl&4 PERMIT DATE: 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 t�cGe.ah✓r �svo ' Q � o 0 0 � f3 f A2. 3- � A /D TOWN OF BA.RNSTABLE L&AT70N /d JSA\1 S7 SEWAGE # VIId,AGE QMfv,IL ASSESSOR'S MAP'& LOT (1 " 031 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1 S6o + LEACHING FACILITY: (type),:; A-n GGO OW (size) NO.OF BEDROOMS .5, 1 BUELDER OR OWNER 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 300 feet of leachi g facility) Feet Furnished by �nSpCCY,VN �0/ IA ' II GA(AT- p p act 0061 a a 3 Q A -a a 3�6 `/9 3 ys s3 ai ya ASSESSOR'S MAP N0. PARCEL C �y LVC A~T ION SEWAGE PERMIT NO. 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THE COMMONWEALTH OF MASSACHUSETTS BOARDOF HEAL f�....p?.........oF........... ��.- ...... ............................ 7— Appliration for UiuVnua1 Works Towitrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at .....................--•• �.• .................. �------......-------•--- ....................... ?'�.... .. ................................. p %Locat' Addres or Lot No. p� -- Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms..._ -------:-_------_---•_•-------Expansion Attic ( ) Garbage Grinder Other—Type T e of Building .. No. of persons............................ Showers Pa YP g --------...-•--•---------- P ( ) — Cafeteria ( ) Other fixtures . ------------------------------------ Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. ..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter:--................. Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by-------------•-------•-•----..._..------•-----............•----••••--.... Date........................................ Test Pit No. 1.-._...........minutes per inch Depth of Test Pit.................... Depth to ground water------.-------.-_.-----. fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.--...-----............. 9 ---•-------•------------------------------•-------------------------------------------------- .------ ------------------------------ •••----•--------------•-•-- 0 Description of Soil.......................•-------------•--------------•---•-•---....-•---------------------------------------------------------...----------------•-..................... W c.� -----....--•---......-•----•----------------------•--•--•-----------.....•...--------------•-------------------•----------••----..._............--_.:_.. W V Nature of Repairs or Alt ra ons—Answer7h,,cn applicab ..-.� ........... .................... ........._._. Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iT:'Y.Sw. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is§.ue oard o ealth. ' ............. q Signed L e:l l _. e ApplicationApproved By................... ..••• •.• . .....................................:_—.. ........ ! V De Application Disapproved for the following reasons:..............................................................=............................................... -----------------•--•--------•••--•--•••-•-•••---...-•••-•••••-•-•-•---•-••••••-•••••••--•-•-••--•-•----•-••••-•••-••-•-•••••-•-•••-----•-•-----••••----••-•---••--•----•••---••-...----•-•••-••......•- L Date PermitNo.... ...... ------ Issued------------------------------------------------------- Date THE COMMONWEALTH OF MASSACHUSETTS �..� BOARD-j0F HEAL H -----• ....................... ................-- ------OF 5..A.4 .. -............................. Applira#ion for BispoiiFal Works Tomitrnrtion Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair (G%'j�an�Individual Sewage Disposal System at: r.............-.... r ----v+r Loca' Addres or Lot No. if �• wn sue• ddr s Installer Address UType of Building Size Lot----------------------------Sq. feet F., Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder a`4 Other—T e of Building No. of persons............................ Showers YP g ----------------•----------- P ( )--- Cafeteria ( ) dOther fixtures ------------------------------------------------•------•--•--------------••-------•-----•---•-------••-•--•---••--. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. W Septic Tank-Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x . Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) a -- Percolation Test Results Performed by--•-------------------••-••-•......-•-•---•--••-•----•------•---•-•-•-_... Date.---------------......--------•-•-...... 04 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ r, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water____--_____-___.-----__. a •-•••--•-•••••---------•----••••-••-•-•••--••••-•---•-•--•-•-•-....-•--•-----•----------------------........................................................ 0 Description of Soil.................................................................................................................................---.................................... x i W x - ------------ ----- - --- U Nature of Repairs Alterations—Answer when applicabe �� _______l s...`..tf''_ F A`2.............J?,t�.o� - 6 Agreement) The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITTLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is4ue4.� he.board of`health. ? _ r S> ned r_. .. a - ,r............ Application Approved By-•-•---•--•-- '- -.....'°'L_�,� ... ..z_ �............................................. -•-•-•_... -------(--- Date Application Disapproved for the following reasons:................................................................................................................ -----------------------------------------------•---------•--•------------.....-----------.....----------•..--•----•----...-------•-------•-------------------------------•----------------------•-------. Date PermitNo.------ = C.......---------r----1------. Issued....................................................... Date , THE COMMONWEALTH OF MASSACHUSETTS BOARD—OF HEALTH , ................................... Cprriif iratr of Tomplianrr THIS IS T CERTIFY, That-the- Individual Sewage Disposal System constructed ( ) or Repaired ( " by �''' ' - ,'� . "-- ..._ ,..! = ........ g ----.................. ----------------......•......---------............-----....------------........ t q t✓ g Install / f� at.----�'�`, --•- ..........:W.....---•-- S t - J ---- ------- ------ has been installed in ac rdance with the provisions of TIC-- of The State Sanitary Code. a descr' ;�Lin the application for Disposal Works Construction Permit iVTo-------C=a< .�.-Y dated-- - &TEE ....._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUAR THAT THE SYSTEM WILL FUNCTION SAT 'SF CTORY. DATE........................... = Inspector_... l�------•••---------•-----•---•.........................•.•----- THE COMMONWEALTH OF MASSACHUSETTS BOARDE OF HEALT / r ... :...:......................... ................... ......_.... Y NA.... ............... FEE........................ Billposa1 f. Permission is hereby granted _ Y ..................... ---L - .. ............................................... to Construct ( ) or Repair s an Individual ewage Disosal S tem atNo.. = p � :...._..... ! .......................................... Street �7Y q // � as shown on the application for Dispos Works Construction Permit No ..___.....Y:.._ Dated...... r (� r'C . .......................................... .......................................................... Board of Health _ DATE------...... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS LOCUS -DATA 28 � „ „ SYSTEM C BUMPS RIVER ROAD EXISTING PIPE 15.55 CURRENT OWNER TIFFANY SWAN { PROPOSED TANK INLET 15.33 PLAN REFERENCE 198-91/103-155 N PROPOSED TANK OUTLET 15.13 LOCUS q�� PROPOSED "D" BOX INLET 15.10 DEED REFERENCE 22493-181 sT PROPOSED "D" BOX OUTLET 14.93 f EXISTING LEACH PIT INLET -14.85 ZONLNG DISTRICT RC. — GP (H-20 600 GAL. (4'x6") / 1% STONE AROUND ZONE Il YES 2io s 23-7 FLOOD ZONE „C„ l p,40r E �o LOCUS MAP ( N o, ASSESSORS MAP 117 NOT TO SCALE: VIAPARCEL 034 I o-1 LOT AREA 56,482f .S.F. NEW TANK 162� LOCATION PLAN o6��'� 26tEXISTING t SYSTEM ��C" N (BEDROOM/OFFICE)` 4 U BAY STREET. BENCHMARK PROPOSED 1,500 CORNER OF EXIST. GALLON SEPTIC TANK I N CONCRETE PAD. GARAG\ ELEVATION 18.17 0 PROPOSEDOSTERVILLE, MASS DB-3 PROPOSED DATE: 10—29-12 CLEANOUT 6, TO GRADE SYSTEM „C., v: EXISTING f pd12 OWNcER/APPLICANT: s.A.s TO \ POOL TIFFANY SWAN REMAIj ° SYSTEM "B° t 48 BAY STREET EXISTING Roo 4 BED. OSIER VI LLE, MA 02655 DWELLING SYSTEM "A" \ (508) 776 13481 2� -DECK . SHEET 1 OF 1 PREPARED BY: �� N`L jHOF&fq o N I;_ Ss � qc E A S. SURVEY, INC. p��,pp , �o=s' EDWARDA. 141 R T. 6 A ��` - sTocn P . O. B O X 1729 0 40 60 80 No. a o 0 SANDWICH , . MA 02563 LA PH. (508) 888-3619 GRAPHIC SCALE: t0. 2 1 INCH _ 40 FEET FAX- (508) 888-2496 G J •TNGRouND Hai L PRo sC. ►D $ Poor . r. 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