HomeMy WebLinkAbout0209 BAY STREET - Health 2D9 B6
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Osterville
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Town of Barnstable
KAS& Board of Health
1639. A�O�cry f 200 Main Street-Hyannis MA 02601 Y
Office: 508-862-4644 Paul J.Canniff,D.M.D.
Fax: 508-790-6304 John Norman
Donald A.Guadagnoli,M.D.
January 11, 2019
Ms. Jane Everett
209 Bay Street
Osterville, MA 02655
,`RE ,Order to Repair or Replace Sepfic System iat 2'09 Bay Street Osterville u
f. J -
Dear Ms. Everett,
During the public meeting of the Board of Health held on December 18, 2018, the
Board determined the septic system located at 209 Bay Street, Osterville is
"failed" and needs to be repaired or replaced.
This septic system was inspected on November 8, Z018 by Sean M. Jones, a
certified Title V Septic Inspector for the State of Massachusetts. The system
consists of three cesspools and a precast leaching pit. The cesspools are
located within fifty feet of wetland. The approximate age of the system is
unknown. The first cesspool is constructed of red brick with a cover to grade.
Based on this information, the Board of Health determined in its professional
_ judgement, that the system is notfunctioning in a manner to protect public health,
safety, welfare, and the environment.
The system shall be repaired or replaced within two (2) years, on or before
January 1, 2021. Failure to repair or replace the septic system within the
deadline period may result in future enforcement action.
You may request an extension to replace the septic system if written petition
requesting same is received by the Board within-ten days of the established
deadline.
$-mc ly yoursAD -1
- ul J. nn
Chairman
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\209 Bay Street Osterville 01-11-
19.doc
t�
Town of Barnstable Barnstable
Inspectional Services AN&WOj
AWL , Public Health Division
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas A.McKean,CHO
FAX: 508-790-6304
CERTIFIED MAIL#7015 1730 0001 4987 9378
November 21, 2018
EVERETT, JANE D
209 BAY STREET
OSTERVILLE, MA 02655
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 2WBay Street, Osterville;MA was inspected on
11/08/2018 by Sean M. Jones_, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system"N�Further•Evaluatio
under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following:
• Cesspool is within 50 feet to wetland.
The final decision as to whether the cesspool system passes will be determined by the
Board of Health. The next Board of Health meeting will be held on Tuesday,December
18,2018 at 3:00 pm in the Town Hall, in the Hearing Room, 2nd Floor at 367 Main Street,
Hyannis, MA. You or your representatives are invited to attend this meeting and you can
provide testimony and/or official documentation, if needed.
i
PER ORDER OF THE BOARD OF HEALTH
T omas cKean, R.S., CHO
Agent of the Board of Health
\\toa\depts\IEALTH\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\209 Bay Street .
Osterville 2.doc
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'ice Total Postage and Fees EVERETT, JANE D
LJ I Sent To 209 BAY STREET -
O StreetandApCNo.;ordl OSTERVILLE, MA02655
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delivery. USPS®-postmarked CerliAd Mail receipt to the-
•A record of delivery(including the reciplents retail associate. -�
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for a specified period. delivery to the addressee specified by name,or
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Ps Form 3800,Apri12015(Reverse)PSN 7530-02-000-9047
Town of-Barnstable - Barnstable
: . Inspectional Services P
Public Health Division m
a
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas A.McKean,CHO
FAX: 508-790-6304
CERTIFIED MAIL#7015 1730 0001 4987 9378
November 21, 2018
EVERETT, JANE D
209 BAY STREET
OSTERVILLE,MA 02655
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at•209 Bay Street, Osterville,MA was inspected on
11/08/2018 by Sean M. Jones, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Needs Further Evaluation".
under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following:
• Cesspool is within 50 feet to wetland:
The final decision,as to whether the cesspool system passes will be determined by the
Board of Health. The next Board of Health meeting will be held on Tuesday,December
18, 2018 at 3:00 pm in the Town Hall, in the Hearing Room, 2nd Floor at 367 Main Street,
Hyannis, MA. You or your representatives are invited to attend this meeting and you can
provide testimony and/or official documentation, if needed.
PER ORDER OF THE BOARD OF HEALTH
T omas cKean, R.S., CHO
Agent of the.Board of Health
\\toa\depts\HEALTH\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\209 Bay Street
Osterville 2.doc
l s off. N �.
310 CMR: DEPARTMENT OF ENVIRONMENTAL PROTECTION l�r
15.303: continued
<ater
there is a discharge of effluent directly or indirectly to the surface of the grouni
F ough ponding,surface breakout or damp soils above the disposal area or to a surfacii
of the Commonwealth; 1
the static liquid level in the distribution box is above the level,of the outlet invert;
4. the liquid depth in a cesspool is less than six inches from the inlet pipe Invert or thf l l
i
remaining available volume within a cesspool above the liquid depth is less than'/z o 1
' one days design flow;
5. the septic tank or.cesspool requires pumping more than four times a year; ;
' A
6. the septic tank and/or the tight tank is made of metal, Compliance unless the owner or operator:, l
{ has provided the System Inspector with a copy ofri Certificate
rior toethe date of the. nspectiongl
that the tank was installed within the 20 year p _ P1 i
l
or the septic tank and/or the tight tank is cracked or is otherwise structurally unsound,.
indicating that substantial infiltration or exfiltration is occur rin extends or is b low the highs ?
and g ortion of the soil absorption system
{ <groundwater
7. a cesspool,privy or any p elevation; i
f( Cb) C ap able to cesspools and privies: _
3 '
1, cesspoo or privy is located: to.a surface water supply; i
t 100 feet of a surface water supplyor tributary
b• within a Zone I of a public well; E
!.
c..within 50 feet of a private water supply well; supply well,unless a '
uj d. less than 100 feet but 50 feet or more from a private water
ysis,conducted at a ce of fecal coliformblaboratory that is certified by the Department presence
j well water anal the the parameters analyzed,indicates an absenan fa,ive ppm. The
of ammonia nitrogen and nitrate nitrogen is equal to or less than f
laboratory's sampling protocols shall be followed and its chain of custody forms shall
' be signed and completed. If water well analysis is conducted,the System Inspector.
shall attach a copy of the chain of custody forms and the laboratory results to the
{i i System Inspection Form.
1.
2. Eval� nation of cesspools a prrvie otectwater resoul
ublic he lth and'safety, welfare and the
`A cesspool or privy is failing top P ensional criteria below the
X,(Iocal-ApprovingAuthdr
nvironment if any portion of it is within any of the dim
' ity in?its professional judgment determines the system is not
--— --� —
t �functiomng in a�rrianner to protect °� health and=safety welfare' they.
environment.j
a rthin 50 feet of a surface water;
�`'1`� ✓ b. within 50 feet of a bordering vegetated wetland or a salt marsh.
a'determination ursuant to'310 CMR I5:303(1)(b);the local Approving-?
a sh 1
In making P
� Authonry shall consider:
1. the condition,design,and treatment provided by the existing system;
2. the vertical separation of the existing soil absorption system from groundwater;
p
{Is{U.�� 3. the how rizontal separation of the existing soil absorption system from the water body;
Wr
ilea{( a'� 4. the soil characteristics of the site;and
the condition of the waterbody or wetland,including any sensitive use areas such as
` caches or shellfish beds.
(c) Evaluation of systems with septic tanks and soil absorption systems n drinking water
h i su plies: thin an of the dimensional criteria listed
portion of the soil absorption system is within y
in 310 CMR 15.303(1)(c) unless the local Approving Authority in its professional judgment,'
��•
,,; with the concurrence of the public.water supplier, if any, determines the system is
functlic heal
ioning in a manner to protect the
su ply or tributary th �to a surface water supply;
welfare and the ent
within T00 feet of a surfaceP
' ( 2. within a Zone I of a public well;
3: within 50 feet of a private water supply well;
4. less than 100 feet but 50 feet or more from a private water supply well,unless a well
ji: water analysis,conducted at a laboratory that is certified by the Department for the
ndicates an absence of fecal coliform bacteria,and the presence of
{ parameters analyzed,i The laboratory's
ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
Jfj Ik sampling protocols shall be followed and its chain of custo Alldy forms shall be signed and
j6 completed. If water well analysis is conducted,the System Inspector shall attach a copy
of the chain of custody forms and the laboratory results to the System Inspection Form.
4, f li Ih In making a determination pursuant to 310 CMR 15.303(1)(c),the local Approving
�I !q. i Authority shall consider:
310 CMR-554
4/21/06
itJ ; --- ---- ------
f
+ a
McKean, Thomas
` From: Malkus, Karen
Sent: Wednesday,December 12, 2018 1.:10 PM
To: McKean,Thomas
Cc: Crocker-, Sharon
Subject: RE:209 Bay Street
Attachments: SCAN-FILE_1of3jpg; SCAN-FILE_2of3jpg; SCAN-FILE_3of3 jpg
Comments regarding 209 Bay Street septic system
Map—Parcel 117-158
Generally the North Bay, at the end of Bay Street is a sensitive shellfish area. Currently,the MaDMF considers
the area's shellfish classification Conditionally Approved (This means "Closed some of the time due to rainfall
or seasonally poor water quality or other predictable events. When open, it is treated as an approved area"',
page 1-2) The Town has used the coastline near Bay street as a relay area for Quahogs and Oysters.
(See attachment page 3). Also,North Bay has had a history of Harmful Algal blooms that have led to closures
of the shellfish beds.
To make a clear decision about 209 Bay Street, I think it is important that we know the vertical separation of the
cesspool pits to ground water.
The wetland within 50`could provide some treatment of wastewater to protect North Bay.However; I think`it
would be best to have more treatment on-site with an upgraded system- ideally with a drip dispersal leaching
field.
Thank you,
Karen
Karen Malkus-Benjamin
Town of Barnstable Health Division
Coastal Health Resource Coordinator
karen.malkus a(),.town.Barnstable:ma:us
phone: (508) 862-4641
cell: (508) 857-6558
From: McKean,Thomas
Sent: Wednesday, December 12, 2018 10:12'AM
To: Malkus, Karen
Cc: Crocker, Sharon
Subject: 209 Bay Street
Please go to 209 Bay Street for an evaluation-of whether or not the Board should require the system to be
upgraded. The cesspools are located within 50 feet of wetlands. The report information is available on the
Board agenda files (see Sharon).
f
Barnstable Property Maps Page 1 of 1
i *
Parcel Details `' ` ,' .
Location
Parcel: 117158 ��= '
Address: 209 BAY STREET
Village: OS
Acreage: 2.8
x
Full Property Info • `
Property Photo
ju
s e � .
-
s
Owner& Mailing Address P
Owner: EVERETT,JANE D ''
Mail Address: 209 BAY STREET .L ' hry Rs
OSTERVILLE.
MA
02655
Assessed Value (FY18) •..,
Building Value: $148,900
Extra Features: $21,300 tl u
Outbuildings: $30,100 ., ,
Land Value: $1,710,500 � ;;_
Total Value: $1,910,800
Residential Exemption
Exemption Amount: $93,229
Building Details
Select Building u
Current
Aerial (2014)
Home Layers � Parcel... Parcel... 200ft
https:Hgis.townofbamstable.us/Html5 V iewer/Index.html?viewer=propertymaps&run=FindParcel&property... 11/21/2018
-
°� Town of Barnstable
MASS
Regulatory Services Department
TED MA'S
Public Health Division
200 Main Street, Hyannis MA 02601
Office: 508-862-4644 Richard Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
Feb 6, 2007
Rev. 5/11/16
DEADLINES TO REPAIR FAILED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000)
An"x"marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑ Discharge or ponding of effluent to the surface of the ground
❑ Pumping more-than 4 times during the last year not due to.clogged or obstructed
pipe.
❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
ONE (1) YEAR DEADLINE CRITERIA.
❑ Static liquid level in the distribution box above outlet invert due to,an overloaded or
clogged SAS or cesspool
❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation
❑ Any portion of the cesspool within a Zone 1 to a public well,
❑ Any portion of a cesspool within 50 feet of a private water supply well with no
acceptable water quality analysis. (This system passes if the water.analysis
indicates the well is free from pollution).
TWO (2) YEAR DEADLINE CRITERIA
❑ Single Cesspool
❑ Any"conditionally passed systems" (broken cover, relocation of a pipe;relocation
of a driveway due to H-10 components, etc)
❑ Leaching facility with standing liquid level at or above the invert pipe (per,Town
Code §360-20 h)
OTHER
Repair deadline: ,
Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc
Commonwealth of Massachusetts //7
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
209 Bay Street t ;
Property Address
Everett
Owner Owner's Name
information is Ostefyille Ma 02655 11/8/2018
required for every x
page. City/Town State Zip Code Date of Inspection �Z
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information (oq
on the computer,
use only the tab Sean M. Jones
key to move your Name of Inspector
cursor-do not S.M.Jones Title V Septic Inspection
use the return Company Name
key.
74 Beldan Lane
Company Address
Centerville Ma 02632
Cityrrown State Zip Code
� 508-658-3456, 774-248-4850 SI 4522
sean@smjonestitle5.com License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ❑ Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ® Fails
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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
t. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
v
209 Bay Street
Property Address
Everett
Owner Owner's Name
information is Osterville Ma 02655 11/8/2018
required for every
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:
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N . ❑ ND (Explain below):
t5insp.doc•rev.7/26/2011 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
L
Commonwealth of Massachusetts
Title 5 Official Inspection Form
e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
209 Bay Street
Property Address
Everett
Owner Owners Name
information is required for every Osterville Ma 02655 11/8/2018
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps%alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
El obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
209 Bay Street
Property Address
Everett
Owner Owner's Name
information is required for every Osterville Ma 02655 11/8/2018
page. Citylfown 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
l5insp.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
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
209 Bay Street
Property Address
Everett
Owner Owners Name
information is Osterville Ma 02655 11/8/2018
required for every
ate
page. City/Town St Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in 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 ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 fleet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
® ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 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 CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
�UR
Title 5 Official Inspection Form
b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
209 Bay Street
Property Address
Everett
Owner Owner's Name
information is Osterville Ma 02655 11/8/2018
required for every 'i
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the.appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
209 Bay Street
Property Address
Everett
Owner Owner's Name
information is required for every Osterville Ma 02655 11/8/2018
page. CityfTown State Zip Code Date of.Inspection
D. System Information
1. 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):
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: unknown
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I,o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
s 209 Bay Street
Property Address
Everett
Owner Owner's Name
information is Osterville Ma 02655 11/8/2018
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 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:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 8 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
l�
209 Bay Street
Property Address
Everett
Owner Owner's Name
information is required for every Osterville Ma 02655 11/8/2018
page. CitylTown State Zip Code Date of Inspection t
D. System Information (cont.)
4. Type of System:
❑ Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a 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):
3 cesspools and 1 precast leach pit
Approximate age of all components, date installed (if known) and source of information:
unknown
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron ❑40 PVC clay tile
® other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
<la Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
209 Bay Street
Property Address
Everett
Owner Owner's Name
information is required for every Osterville Ma 02655 11/8/2018
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
6. 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
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
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
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
.� 209 Bay Street
Property Address
Everett
Owner Owner's Name
information is Osterville Ma 02655 11/8/2018
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
209 Bay Street
Property Address
Everett
Owner Owner's Name
information is required for every Osterville Ma 02655 11/8/2018
page. Cityrrown 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
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.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
209 Bay Street
Property Address
Everett
Owner Owner's Name
information is Osterville Ma 02655 11/8/2018
required for every
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type-,
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length: .
❑ leaching fields number, dimensions:
® overflow cesspool number: 2
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
1
Commonwealth of Massachusetts
�a = Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
209 Bay Street
Property Address
Everett
Owner Owners Name
information is required for every Osterville Ma 02655 11/8/2018
page. Cityrrown 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.):
System has 2 cesspools and 1 precast leach pit overflows. Cesspools are within 50'of wetlands
resulting in a failing inspection.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration 1
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction red brick
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
First cesspool in system is constructed from red brick with cover to grade.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
209 Bay Street
Property Address
Everett
Owner Owner's Name
information is Osterville Ma 02655 11/8/2018
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
209 Bay Street
Property Address
Everett
Owner Owner's Name
information is required for every Osterville Ma 02655 11/8/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑ hand-sketch in the area below
❑ drawing attached separately
o
6 fib`'
AZ 7-7
r33 66
P
�d
P�"ice
Z 3
i
t5insp.doe-rev.7/26/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Bay
Street
.� Y
Property Address
Everett
Owner Owner's Name
information is required for every Osterville Ma 02655 11/8/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high 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:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
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
Commonwealth of Massachusetts
• Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
209 Bay Street
Property Address
Everett
Owner Owners Name
information is required for every Osterville Ma 02655 11/8/2018
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6 (Checklist) completed
I
® 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
TOWN OF BARNSTABLE
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ow
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THE COMMONWEALTH OF MASSACH, SETT
BOAR OF HEALTH
� ��^ Cs�C�n-S_......._. ... ..._. . .........O F. ............................ . .�................................
Appliration -fur 43biposal Worku Towitrurtiou Prrutit
Application is hereby'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
S at: -
---------.- �.......................................V ( z _-•••••-------------•------ ---. --•---..•.•--••-•....._...._...........--•---
oyc�tipon•AA / s or Lot No.
�M........ ...................•.•......... ••----••••--............................. .--------•---......--•---................
a l ` Owner Address
Insta er Address
d Type of Building Size Lot............................Sq. feet
U
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ___--- No. of persons____________________________ Showers — Cafeteria
Q' Other fixtures ......................................................
W 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....____--_-.--.-_-.__..
( Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water--.--.---__.---.--__----
P4 .
O
Description of Soil... ............................... ..
U ----------------------------------------------------------------------- ------------------•-----------------•-•-------- --••--------------•.......•----------------------------------------- ---
W ............................................-------------------------------------------------------------------------------------
UNature of Repairs or Alterations—Answer when applicable.-_----dtJ eQ.,.. _..jd'..!`0................f d ...... --------►..
----------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------- --------------.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be7n issued by the board of health.S. cLe
/
� -------•-••-• �-,-------------------••--
��// Date
Application Approved BY £i��/�1 �- ----------- ----Y-..... ---7.7-------
Date
Application Disapproved for the following reasons: •--------------•--------------------------------•...............47 :_.....••---------------
•--•-----•------•••--•-•--•-•-----•---------•----------------•----........-•••....................................................-----------••--...._....----------------------------------------•----
Date
PermitNo......................................................... Issued........................................................
Date
fy
No........1_?,�r_..... F��..........................._
THE COMMONWEALTH OF MASSACHUSETTS
4. EOARr. OF HEALTH
Applir ation -fear Dipplaiittf Works Cnomarurtion Vrruait
Application is hereby'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
S,ysLem at:
¢ >
oc lion• or Lot--• No.
Owner 4 Address
a .• .. -------------------------------------------------------------------
----------------------------------------
Inst ler Address
d Type of Building Size Lot....•_______________________Sq. feet
U Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons___________________________ Showers ( ) — Cafeteria ( )
dOther`fixtures ------------------------------------------------------------------------
W Design Flow............................................gallons per pet-son per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacitv------------gallons Length................ Widfli: __..__:._--- 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 ( )
'-, Percolation Test Resrlts Performed by-----------= ----_--•--_---- ------------------------------------- Date----------------------------------------
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-._._--__-______-._
�14 Test Pit No. 2................minutes per inch Depth of Test Pit------------------__ Depth to ground water------------------------
--------------------------------0 Description of Soil__= ................................
x
c, -----------------
W --------------- ----------------------------------------------------- ...........:............................. ------- -
U Nature of Repairs or Alterations—Answer when applicable.-...__ ' �' _ � "�._._.-.._.._._ � ._... *--
--------•--------------•-----------------------------------•------------------•--------••---•--•----------------••-----•------------------------------------------------------------- --------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has en issued by the board of health
ig
Date
Application Approved By-- r. ;:. "` 1"` T
Date
Application Disapproved for the following reasons:...................
=`
•-••••••••••-•----••----=------------------------------------------------------------------------------------------------------------------------------ -------------------------------------------
................�.- Date
Permit No.-----•________________•_:____.____- .... Issued=-- _:••--•--- -_-•_---.•---
rF
4Date
r
`S'
t
THE COMMONWEALTH OF MASSACHUSETTS
BOARD, OF HEALTH
}
..........................................0P..:. .�. ....... ,.............................
Trrtifirate a1f f�aa t �i�anrle
TeNis IS 0 CE IFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
4-
by - ___-•••--____.._•-•--__-__
�^ Installer
y
at ,beenlii ;--- �� 2 . __ •_-____..----••--.--..__.
1ias beentalled in accordance with the provisions of . `X of The State Sanitary Code as describtd in the
application for Disposal Works Construction Permit No..:___ `"s -----•---•--- dated........ ` �.............................
THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WI L F NCTION SATISFACTORY
�y
DATE .�' � V? nspeetor
o. .:., �� ..z �-e'-1.+HY+u r'....� a r:.,.:�n•s�r e, !:t• �� ro�. � w�.w '' �
x.t,:>_.,r��'?i.,i s,'aiM�.Lv..u•:,,..-v'.��y -.._.�-a sr?.=s"E��t$'�.-' �...s-s"w'�'.a�s*�:,'fit,`-:y.r... .. � _ ... . . .v s�, _sn_ r_ .�s _
�'�"�' S rr +tom"..�,1,,. ..,r. ti_ R .. • -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
:� F... /r.. .. ......OF... ! . it` s......._.. �'' ..
No.. ................... FEE---_.__....---__........
Yk �i��>a1 irk �n�ra��raarti�at �rranit
Permission is hereby granted_._.. ' _ "
to Construe �( ) orAV
it ( an,. dividual 5ewagsal System
at No. It
•-- ------------• -------------A.------------•--•--••--•••--------------------
Street
as shown on the app�is ion'fo DD sir posal Works Construction Perm o. . ...................................
._._ .>__ .../f" 7
led
7#
DATE.-_19......//------7.7-------------•-----•-•-•--••---••••-••--•• Board of Health -
FORM 1255 HOBBS & WARREN.. INC.. PUBLISHERS_