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HomeMy WebLinkAbout0109 BAYVIEW CIRCLE - Health 109-Bayview Circle Osterville P A = 142 093 / Commonwealth of Massachusetts Title 5 Official Inspection Form ill Subsurface Sewage Disposal System Form - Not for Voluntary-Assessments M 109 bayview circle Property Address Duatre Owner Owner's Name information is required for Osterville Ma 9-10-13 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any ' way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out ` forms on the computer,use 1. Inspector: only the tab key to move your Douglas A Brown (J cursor-do not Name of Inspector use the return key. Douglas A Brown Inc Company Name P.O. Box 145 Company Address Centerville Ma - 02632 won Cityrrown State Zip Code 508-420-4534 S14297 Telephone Number License Number. B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9-10-13 Inspe s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the 'report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 0 1 . t5ins-3113 Title 5 Official I spa ion Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 109 bayview circle Property Address Duatre Owner Owner's Name information is required for Osterville Ma 9-10-13 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System consists of 3 cesspools that were found to be in working order at time of inspection with no signs of failure. Property is seasonal B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Assessing As-Built Cards , Page 2 of 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface.Sewage Disposal System Form-Not for Voluntary Assessments M 109 bayview circle Property Address ' Duatre Owner Owner's Name information is required for Osterville Ma 9-10-13 every page. City/town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational.System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced'" ❑ Y ❑ N . ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N FIND (Explain below), ❑ distribution box is leveled or replaced! ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain.below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will past; unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning i.n a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water http://www.town.bamstable.ma.us/Assessing/HMdisplay.asp?mappat=142093001&seq=1 9/24/2013; Assessing As-Built Cards Page 2 of 2 r 1 t . http://www.town.bamstable.ma.us/Assessing/HMdisplay.asp?mappar=142093001&seq=1 9/24/2013 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 109 bayview circle Property Address Duatre Owner Owner's Name information is required for Osterville Ma 9-10-13 every page. Cityrrown State Zip Code- Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. I , ❑ 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: 3 **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems:' 1. You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ; E ._ Z Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El Discharge or ponding of effluent to the surface of the ground or surface waters ®` due to an overloaded or clogged SAS or cesspool jr El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection. Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 109 bayview circle Property Address Duatre Owner Owner's Name information is required for Osterville Ma 9-10-13 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ®. Any portion of a cesspool or privy,is within 50 feet of a private;water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.363, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. . E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply Ell the system is located in a nitrogen sensitive area(Interim Wellhead Protection El Area—IWPA)or a mapped Zone,ll of a public water supply well - If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 109 bayview circle Property Address Duatre Owner Owner's Name information is required for Osterville Ma 9-10-13 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You'must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by.the owner, occupant, or Board of Health ❑ E Were.any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not 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? El ® 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. El ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information _ r _ Residential Flow Conditions: Number of bedrooms(design): ;. 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form. . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 109 bayview circle Property Address Duatre Owner Owner's Name information is required for Osterville Ma 9-10-13 every page. Citylrown State Zip Code Date.of Inspection D. System Information Description: System consists of cesspools in'line r . Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No 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: 2011---208 2012---187 Sump pump? ❑ Yes ❑ No seasonal Last date of occupancy: Date Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpo) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ .Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No 1 Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments' 109 bayview circle Property Address Duatre Owner Owner's Name information is required for . Osteryille Ma 9-10-13 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ .Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system Single cesspool t ® 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 l/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval: ❑ Other(describe): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Ford Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M s .109 bayview circle Property Address - Duatre Owner Owner's Name ` information is OSterville Ma 9=10 required for -13 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age�of all components, date installed (if known)and^source of information system appears to be original Were sewage.odors detected when arriving at the site? �❑ Yes ® No Building Sewer(locate on site plan): e Depth below grade` feet Material of construction:' - El cast iron '❑40'PVC- ❑'other(explain): Distance from private water supply well or suction line: feet Comments(on condition ofjoints, venting, evidence'of leakage, etc.): r . -'. , Septic Tank(locate on site plan):„ Depth below grade: feet Material of construction: ❑ concrete, .❑ metal ❑fiberglass ., ❑polyethylene' El other(explain) 4 If tank is metal;list age: years, Is age confirmed liy a Certificate of Compliance?&(attach a'copy of certificate) a ❑ Yes ❑ No Dimensions: Sludge depth: s t5ins 3/13 Title 5 Official Inspection Form:SubsurfaceSewage Disposal System-Page 9 al"i 7 Commonwealth of Massachusetts _ v Title 5 Official Inspection Fora` Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 109 bayview circle Property Address Duatre Owner Owner's Name information is Osterville Ma 9-10-13 required for - every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle e 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.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 2 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 109 bayview circle Property Address Duatre Owner Owner's Name - information is required for Osterville Ma 9-10-13 every page. Citylrown State Zip'Code Date of Inspection D. System Information (coot.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped'at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: *- gallons per day Alarm present: ❑ Yes ❑ No Alarm level_: Alarm in working order: ❑ Yes ❑ No - Date of last pumping: Date Comments(condition of alarm and float switches, etc.): r d � Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No,' t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 r f Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 109 bayview circle . Property Address Duatre Owner Owners Name information is required for Osterville Ma 9-10-13 every page. ' CityrFown State Zip Code Date of Inspection D. System Information (cont) - r 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.): Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No` Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): f If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 109 bayview circle Property Address Duatre Owner Owner's Name information is required for Osterville Ma 9-10-13 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: 3 ❑ 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.): cesspools were opened and found to be in working order last pool and second pool were dry at time of inspection there was only about 1 ft of liquid in the first cesspool Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 3 inline Depth—top of liquid.to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Eft Materials of construction block Indication of groundwater inflow ❑ Yes ® No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i 109 bayview circle Property Address Duatre - Owner Owners Name information is Osterville Ma 9-10-13 required for - every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): system showed no signs of failure at time of inspection house appears to be a seasonal residence Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 109 bayview circle Property Address Duatre Owner Owner's Name information is required for Osterville Ma 9-10-13 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately 1 E t5ins-3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 r r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 109 bayview circle Property Address Duatre Owner Owner's Name information is Ostervllle Ma 9-10-13 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar f ® Shallow wells Estimated depth to high ground water: . greater than 5 ft feet , Please indicate all methods used to determine the high groundwater elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) Ti Checked with local Board of Health -explain: k. ❑ 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. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 f Commonwealth of Massachusetts H Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i 109 bayview circle Property Address Duatre Owner Owner's Name information is required for Osterville Ma 9-10-13 every page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D(System Failure Criteria Applicable to All Systems)completed E System Information—Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTABLE LOCATION log &N VI P- W 61 r(14 - SEWAGE# VII,LAGE ASSESSOR'S MAP&LOT I9 Og- STALLER'S NAME&PHONE NO. ' EPTIC TANK CAPACITY. CgE4 r'l CIENG wu_rrY:(type) CUSOM[I (size) O.OF BEDROOMS BUELDEROROWNER 17AIGSSAAJr 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 leac ' g facility) Feet Furnished by 274SpGo.t { r r • A r 5'7 a3 3 a http://www.town.bamstable.ma.us/Assessing/HMdisplay.asp?mappar=142093001&seq=1 9/24/2013 'z-rz=i"3.s/.'ma�i:«_a =�;���.s"1 i..g T° � y��q�•_7_z{ � u� i 3v rd _ '/_�, —EX ri_.0 E OFFICE �Ty+''„y.�}�s�_ '4TT4� s A c 1t )� pg 5��7 - � 1 e aim*.v�.�Fa_.d`� 14 DAR'`iilf&` '7' nYr' 'y;" r;��AII �9 PRla.$a��,l�IGN L3 TT'T'i P 1; CIAI, UNTSYPECIIPIONN FORM —NOT FOR V OL t JN7ARY ASSESSMENTS S S ST-)WACE SEWAGE DISPOSA—SYS- M t ORPM I�AR'I'A CED�y.RC� �N o93 00 / P:'opei ty Address: t �'_ c Y i eu3 �s Ow—ner's Name: VZ Owner's ddr�: - o _. Date of Inspection: �� �" Name of Inspector_ r -- Company Namne: ?'-lading Address: ;r' x T'eievhone Number- CERTIFICATION S T ATT.+_; o certify That I hays rso lly uis-i,ei:ied take sewage dispvsai system ar this address and that tare information reported below is w ae,accurate and complete as of the time of the i��:c�vn The inspection was performed based on my training aria experience in the propel'function and mai_n_tenanre of on site sewage disposal-systa-.m.e.T.am D ,IP approved system inspect-or pors;g. nt to ion 15.340 of'Tide 5(310 C-AIR 15.000', :die system: 4 Passes Conditionally Passes Needs Further cvaivation bti the Local Approving Authority g (� a3a1C-Tis{Pvfsi�>At''s Fails ' IP o 'S V The system inspector shall submit a copy tsfthis inspe"ai ou;epos,to tfie Approvunj Author-my(Board of Health or DEP)1A-. in 30 days of completing-this inspection.it the system is a shared sys`.em or has 2 design fiv--v of 10,000 gpd.or greater,the inspector and the system owner shall submit the retxwrt to the appropriate:rggion I office of?� DEP.The originai should be sent to the system ruiner and copies sent to the buyer,if applicable,and the approving ?rotes and Comments ****"flits report only describes conditions at the time of inspection and under the conditions of.use at that time-�This BT/CltP!`?ann w 4 s.s8.is i.w...aim _aa _— ajlje 6_.aurt der th -ectnva. - ssvc G '"i133 V,. :FFG si'9t=F41 vtr`Fii{}i'=i iE7 Ti ioi iiiC fia3itFiC iiitUrt ifaC SH.iF@'�'ifT(sil fid eat, conditions of use- Title 5 inspectio,�Form 6115P000 paoP; vaaQ 7 of 1 1 OFFICIAL PqSPECnON FORM—NOT FOR VOLUNTARY A.SSESSAaNrS SUBSURFACE SEWAGE I" 'O pS S I SI'� $1€��!FOB P . �EY.�R f tr — ssec­ - 'M aC A I ON ;contlj�;e^j Property Address: � ` C Data'of Inspection: €uspection Summary: Cheek A B C,D or R i psi WAYS compieie ail of Secfion D A. XI have:rat io-;md;may information which indicates!fiat any of he failure cniteria described in 31.0 CNN 153 nr in I 10 CW i ii '40 ";ct- dnv f;D;irra CriteHa not eVahrated arP jnd;; at a iwln v Comments, R. Syos em Conditionally Passes: One or more system components as descrF in tine"Conditional Pass"secti to be regiacea or repairer-The system uum completion of the revilac:ement or repair,as approved'u, e Board of Health,will pass. Answer yes,no or not determined',Y,N,,ND)in the ;ur the followe*�-mired"p3.ase e.rniairr 'Ihe septic tank is metal and over 20 years old*sir the •tic taWk(whether metal or aot)is sh�Iy unsound-exhibits substantial.infiltrating or ex-fiWration nr T-ailwe is imminent_Systems v"ll pass fiisue4 ion F. _ : L a r e the Board of 1 e' a��_=S i�lti tL�a complying sic t ad` cued h�i '�Iealth- �!i ITtEt + C�2k�� 1L 3^a�S 1t$rl Tlon 3:FF is S Ify soup-,not lea_KnL;i if a ite3lSfate Csi f-6 iadEa ce indicating g that the tank is less than 20 years old is ble_ I�.1J�n1Jldtji: Observation of sewage isaelcup o re�c out lijea state water level in the diau fb�on iron due to' ken O 4 a 2' visa...Y, ., c ,na....aAll s' oped��if0 cccczs dR iuxa;`v�.0="^u vas Lyn.vyawau w asz Y`�"ia:s{.vc.� t appro-val of Boa/Health'),Health): broken s)am�d ? r :k Yem ved istr;' ion box is died or replaced ND eXniairr- The Sys more t 4 times a year due to brokers Orl obsUUcted r= s)_T System Wrinazc incrsectione roam of Neelth)-os en pgxp (,g j are replacedn _nacTion is re—nu-,ved N exp ai ' 2 . sera:of 1 OFFICLj, INSPF-cuoN FORS_NOT FOR VOU va a;v r'�v ar-W kyr- S Y S!EM !NSPIE— SON F0 PAURT A - - i'ER UICA a ION(continued) Property:address. Q c I vwiaer: I`rte of Inspection- � C Further Evaluation is Required by the Board of'Realth- �nneYiitinnv av:M<TiA z = evaluation by Board I ti a-it??j_^ :der to determine : uiia'SVSteiii r��iBre i:uu''ler ei% a rt;P �, o :c_ failiiij to protect public health,safetZ or the environment. i $> Sy rem-will recc n��Incq ¢^mr£i v aaesia¢�s Ueiei UCS IIi aCCOrtla 2 ii$$h S3§►Sr?Ff4' x�3t3S�t}��}ih2t the system is not function ng is a manner which will protect pas c health,safety and the envirnnmentt — Cesspool or privy is with�tn 50 fit of y Ste"ai. •tea':�T ` Ccssp001 or FINS, is u tthin 50 fer.of a borderhig v ,etated wetlasid or a salt marsh z. System will fail unless the Reard of Hea farad Public INAter Supplier,;{an 'j determines that the cyctom is .^t-_-M EC i'u a M211H.1`iuiat Pam' the pubilic health,safety and environment, _ 4lie systern has a septic tank an it absorption system(SAS)acid f-he SAS is within 900'feet of'-e Zrface water su.p sly or tribg= !�iV -i SB..i iG4'v tlG'FCGi supply. 3lie system•has a septic t4and SAS apid the SAS is wiIa:ln a Zone i of a public water suppiy- _ -rhe systetr has a septic and SAS and the SAS is within 50 feet of a private eater supply weii. _ iile System has a se c tangy and SAS and the SAS a5 lees than 100 fPYf hs�t 50feet nr mnrP fir�p±a Private water supply wel '.Method Bled to demnAnine distance sr a iris s stem passes the well:eater analysis,performed at a DEP certified laboratory,for coliform 'Gilatei:a aril voiatil6 rEaltl_C Gompi?ILtIdS BIItfIC3tes t.ar ti;e weD?s f-ee f_'''o--p c,+<l'i?'or fTi^2 resat faCilii�Qis s r•- .. aoFiia i¢.aiv"r`,�ii aTz."ti.iiiluate nitiojCti IJ eaiiai iU tli lC5$isiali 7peAi,ar tivided that no am-her failure criteria gggereo.A copy of the analysis:rust be attached to this form- a. Other, 3 r -P' UN FOB- ' SUBSURFACE SEWAGE DiSFUSAL SYSTEM W SPEC—110T.4-YORNI Property Address: Date os inspection: D. System Failure Criteria applicable to all systeps: yoru must indi a`=yes"or-=no"to ea :n of the r"o;Et fora spections: Yes No DdtifiLLis3 Ui sCww LIEU iQc311LV i3i SYSiCm C'hi(iI�7S1GArs.C1FZG to OVerFi76.tiGii or clogged SAS Es=w.GJ.l�voF _t Disewirge or pending of effluent to the sturaee of the gTound or surface waters clue to an over€kWed or -t cloeaed SAS or cesspool -.,..._ C+.�+:..l'....:.7 1......7 ai....7',.�...'1.. b- .-a tlet��n-.,e t dL%--ttc=c,%,e loadeJr7 o cle-a- ti''S S r �T.�ii[{.Lii�ii2i:Fv YLl 75F LLFb distd utiaiF WA¢'Jc+ere•.i - r �v, .--. o- cesspooi Liquid depth in cesspool is less than 6"below invert or available rol*me,�js less,harm'r day flow Number �.- eq�jLr�1Sumr ing�Y2`1TP t4:Arn-Q hmes in the fast year NO■ due to cloned or obsh cued B�S).itlumbe9 of timers pumped Any poasn ofthe SAS,cesspool or privy isbelow laigtu gd duster elevation. Any�lnrtgnn of rpgcnngl or privy is within 100 feet of a surface water supply or tributary to a surface r"wer supply. Any p €`-�..-of a cesspool or privy is widlinn a Dme 1 of a pzublic wel;. —_ Anv Dortion of a cesspool or nriw is within ail feet of a-private water supply well_ A::y portion--fa, cesspool_or privy is le=i then 11W feet but greater than 50 feet from a private water niy well with no ac,6:piabie'Wae�a iT W!y-`�15-7'. "��` = 'eE� '�'- � performed at a DEP certified laboratory,for ccK-y-m bacteria and volatile orgaauie� indicates that the wale is free from pollution from tit facility and the presence of 2mmoniz __.__6_ a¢_..�a�*--u—5..a,:., prnareOde that no other WARM criteria daisrogeri a-ad mils ate laws as--is equ2-1 t--O �+y�rt�t<-..•< are teiggered.A copy of the anal-Isis must be attacked to his sores-.] _ ——j'1 tee.�sy;cm k;.s.;l;ave Bete;;•,_;_,,° ++m'_nrie or +ore of the above failure criteria e)st as described in 310 CR�`Rr .15-303,therefore&a sy s.jU system owner should contact the Goad of Hea€"f to determine whit:will be necessary to correct the faRure. :;. Large Systems: I o casncidered a 1-arve qv-stein the system a serve a facia-ty Wft a design of 10,000 gpd to 15, OW gpd- Y Qu-mast indicate Y ether yes`-or`?row each of tract aiF f€; !-the following criteria aDDIV to 1 egos m addition to 1*e c ntam above) y -00 the system is wi 'u 400 feet of a surface tit*nicing water supply — LLB SySii Wl[iiiti Lc`iif LGCi Vi d L`tuuiaiy :hs a ac:.zaaa, uFlLn. p e s egg!is located in a nitrogen sera,itive area(qnte�Wellheaad Pro�i~ction Area-��h.'�t�;as a ma cd H ill a�3idbilc wa—vu SPP F we" - you' a anslvered'Yes"t0 any question in s ors L the system is Mris deren a signi�s�nt�� ���dwea�a cL...."' C....w:....Tl 1... ♦8.n 1.—& rctPs h---{ni ed T e oowr -or o+pe!!tt:1i ashy iorgv S�°3"T.. Fm consideM`a. Yes .San.LiRtL'e iJ Rs+vi'�.:a.-a,tees=,v j xa —lees-+.�.w. _ r----- t threat Wider Simon or ecl under5ecuon D shall upgrade te system it= 'or wuh 314 t UR l 04. the system owner should contact the a}p--W.priat:.regional Office Of the Departmen•-T 4 f OFFIC. .UNSPE CTION FORM-N OT FOR V OLUjN- Y Ei E TS _ c(�ggTBDC'T<TSDIF�`pp��` yP A d+ ` $dy�+9> q CIF�s'6 ����s-SID'9' 11MI6': FOR, t93T'-�iia-i+8�t�i..E s'SE AVEIE,3nIS OSL"L vT n 3 E.M.IM A Hid..3c.a6i^� & �.+gs, PART B 11TTTS/1T�4'TCT A Proms, Address: �(}�j C ae,`4 ✓! Owner Date of prct-ion: Q '-heck if the foil owing ha we iJe?n&ne.You Mn St indii—c�"Yee or"no"ae to each of the fn�lrnv L-,g_ Yes No — camping information was provided by the owner,occupant.or Board of Health Were any of the system components purnped out in fhe previous two weeks? Has the,system received normal flows in the previous Ewo week period? •\ Have l`2a ge volu-mNes of-W—w the Sy^stw'�".r�^.�'�h.or as�rt of Chic ittcnf.rfi[!31? — Were as built pia--of the syster,t obtained and examined?(Ilf d y were not avaiPabie note as IA-1 — Was die-facility or dw--!Ung itrspected for signs of sewage baek:.=p' Was the cite inspected for cigis of break otlt? Were al'$systemm components,exci'udmi °,the SAS, iocated on site _ Were the septic tank mar-holes*�^ov°tired,owed,and the interior of the mA-inspected for the conditionAtie a—fnes or tees,inateriai of ConisLr 3c�on,dimensions,dWfl Csf hill£!"," ::vFsa'��i a4d I,—-c^`'"^ Was the facility owner(and occupants if different aon owner)provided with in:brmatien or-me prop" YIIa7i4i�iaTlt:�Ut Ji.Et7Jtil iiiLL 3eV"$gG ailSii:3j i Jy3a:.u:� : The size and location of the Soil Absorption System(SAS)on the site has bmLn determined b?-led on_ �, EXis ing Sf4FZniiu4�ii- 4i E ie,a'✓lan a Board of Beall . _ tje_tPrn i„Pri in the tipiri(if any pf the failure criteria related to Part L is at issue approximation of distance is amacceptable)[31.0 CNIM 15.302(3 )F 3 Page 6o al a Casa i v Property Address: 'l�y Date of inspection FLOW CONDIT I3�C7<79�At'8'gAF j�j�/ i.txsaaa'c.t G.vevewnea{uesiaael- s.erlril`rer t7s i drt3F3fnS idcruai): .. ` . i��116N Isous cased on 310 C ;5:203(for examp.1e: 110' d x of bedrooms;: Number of current residents; '_ems.esidence lha=e a garbage grinder(yes or no) ;afzndry on a separate sewage system{yes or no)- [if yes separate inspection required Laundry system insvected Nes or no)- AV Seasonal use:(yes or no?: v atet i3iet.:a iGQiiiai ,1£sv�i eUOR:i_Siisi.L-year sus llage(gpQ Sump Pump(yes or no):N" Last date of occupancy: COMMIERCIADMUSTRIAL Type of estWlishmentu Desion flaw(l aee_d an 310 CNa 15.20z� c is of•yip-flow(seat:.fn'—o:�s:; eta). Lgrese-4 preset:*:yes or no;: Industrial waste holding tank fat(ves or no)- M Aar one ulsclt to- -ttie 5 system(yes _ Water meter readL43gs, avaiiabie: Last elate of oec cvluse_ GENERAL INFORMATION, "GUrce of information: . Was system pumped as part of the inspection iyes or no',. if vPS�vnlitlne nnmruori oa_lTrtnc— nau wa�c g�tantisy rn m ri(�gefgit Zeti` %easolt for P:ftriping; T` PE OF SYSTEM S ptic'�"�r,disc bm on box,soil:absorption system Single cesspool Overflow cesspool privy .3hareu STae!R(j�es ue i�i�j(sf yes,ai`MC Pf e:i oii5 inspection records.'t MY! . __ittefovative Alteruutive technology.Attach a Copy of the current operation and maintenance contract(to be obtained mom system owners ` f ` I.% Attac a copy of the DEP appro ui Other(tiesc6bei_ ,pproxi:nate age of ail components,date installed(if known)and source of informati6W Were sewage odors detected when arriving at the site(yes or reoj:�d b l OFFI rl AL!N.SPE'.0 e'i'ON FORM_14-1AT VnU VnI T"NT AD V AZ�-Q -yam C'�41'l1LfY- ss - - 3 . S STEi'�8�•`i;i'.1/i_i RNIA pi WN ;Icontunued j Ptor erg, . ddr Owner: � 4)2te of inspection: BIYALD NG SEWER(locate on site plan? Depu'l Mow g aue: j k - Nlatena:S of onstluctilon-_Kcast uUri 4'PVC - 'o ar ff`.X£Dla7P_): 1 fismncP_.ftom� a •: : I:—Cru it 3i3 i3G linor:o� ,veni.mg,evideacc o— ieauage,etc-)-iL::ea25 J2 Qi4i g3 S E FTC T ANK—`€locate on S=te pl-) Depth below ode: __ ac =vethylene iviu"s.Gi iB.P Gi c.c�i'iSii ail ffT:_COitE€etF^theta:`1t .'4as __.__ram>, �otner(explain)____- if taTA is metal list age:__ is age confirn?e _ a L.ei-flfcafe of Compliance(yes or no):`f attach a cop,of . r6A��in�1t6� i"�iftieasS�oZfs: . Sludge depth: T3i staince from ton of ch,A. to fa: ^?`?of outlet tee o itM-11-c9uies3- f.;istLnze froth top of semi-,t top of outlet tee or bare Distance from bottom of am to bottom of outlet tee-or baffle: How W Te d-;t ^3Sd0€ et�z =i3ne 3 Comments(On ouirn no,re-commendations,iniet and outlet tee or rtie condition,Structunral integrity.liquid. iuid levels as related to Dull very,evidence of leakage.etc.)-' GREIA-EE TRAP:D. R s `3VLIIiL VlE SEiL�iali� Dept:h below g3aade: *.r aterial of rnnstric_tir�- concrete gnwtu! fiiiiwgai a noiy t}viertp? other k xplai-a): _— is} Scorn thici ffess: Distance t7orn top of sour a to top o�'t)ii"cfi. tee-or bffle: _ Distance frorn bottom of scum to"o -tn of outlet tee or bathe: Bate of last€�umDin_g: C)lnsn«nr t^? 3�T11t7L�3g$per :sealdat?^.?3S,--let a'? O'.?4 22e or2? econdition,5??41£L23r31 eTSPtom'.7y liquid levels as rei'ated tooutlet fuvetg,e denee of leakage,etc,j: f y ' e MPE N F'�RN � F?'raF ,a ass: a s := s-araz:r� Ti;.rJ.. ..t~`�. 1n - SUBSURFACE SEWAGE DISPOSAL SYSTEM S"MO14i 3lfi'n-o P Prol_rty Address- Owner- Date of josvpVcdor: � 'Y'UGHT or HOILDING TANK- - Dlt wt beio:#r grade: M ena of consuuction: cot)cre$e 3'±?Ctaf „3 •�4�<=.h� ,a. , -ashy: gallon- Design Flow: as _.M. ; Alarlm presuf eyes or no}: J Alarm:€tee;:_ Aja: m wor:�u def Date of last Domed IR: �o dyes or nod: Co enL rcnndhtior :ad—ann aM.dffl=swkchies,etc_,: I TIM fU itON BOX:. of _ sent must be omned]Elomte on site plan,) P�kpnj�i , 1;1 ,T`Ile 1 ��.�>e j 2 At =e=its(Hole if l is morel and disni'€ on to outiets eqq� ,any evic� ix of solids carryover,any evidence of leakage into c out of Y.eic.): f't MP ! NIIB 'R: cote Gn site npl_n� Pumps in working or' Nes for noi:. LEatlns in W0-kino r ;yeS^r no j: pumps v i¢ttaz i;� noi,L udiciEali3 (3€ im'i c3IaTS!t?ety ()__dition t1 P'`3r"l LtCtedt_.Y_'-e-a�,et -T . P 9 o: L m vs $-P ice--af6. • 1 VA1-cB.S $ %0 ' .$.3�€,�s•K,VA g'.�71 a�_':.r_.R" �T r� g� PART C ne _. _ Property Address- v C t rl"vi-e— Owner: n- . i)ate of ins ceiota; (locate on site Plan,excavation not reoltiresf) Hf SAS nor,located explain why: Type M leaching pits,number._ jepching chambers, , f�cc:fiiii=galferiPs,rqummr, €eachinv trenches,number,length: leaehnig feeds,tiumber,dLmensio^-s: innovauveratternative system Typeiname o;technology: Cor.unentss(note condition of soil,signs ofhydranllIC faikire, level of ponding,damp soiI,.condition of vegetation o_A sus- ryd o (' c, tti v �. 4C SSt`4_i€ LS: ki?sspool must be pumped as part of irspec:ion}(locate on site plait; Number an,-'foP_flgunatiren: �J i V` l Depth—c p of liquid-to inlet,invei€: - Depth ofsofids layer- Depth of scum layer: ® }} ... (( G_ rNime=i0as Of ok Materials of construction: t/r'It ik1 e- G iricao of toi:i:uwater III OW(yes or noj: �S C(i7TlLStPB1fG(dtl14P f'AnC3itiort of soil,c,a if by--kz i" F.'2 inm,oi i`......:e, .. union o' rtativii, �.. ii:y4i i.i:t i. Sv rl 3fi iic 1(l (\�( 1 �Q 14, C ��: C:P- lorcate on site pla i3 Materials of Coot-nict'on: , tii,4iatr'iillUilS_ . - Depth of solids: Comments CJonditi soil,Signs of hyd:'a.Wic'Failn—re, ;ewe,ofpondir.-,tL'-;d;{ttion oft;Qcetat:o.:,etc.): an-max a "EkICIIAL ._ _ NSPE :_ION FORM-NOT FOR VOLL g ARV ASSESSNWINTS UTBRIS d-V Qyc-i$�$Yi Ti'��'C'�lSi'�•p �'67 v+wi� aiwTct Y?,/^�e's'+�l1l,T Tc.-wsan� �. a �� o rav-a: sna sr x n'.3€ 1�3t fii�i SpE. a Sys f @ 3'fl4 sa rdjq PART C SvS 7i EA ai e�a vaga}vat a �t(S i�i3AttetT Property Address: Owner: Date of Inspection: Provide a sketch x4'r.3.e..a..agc disposal y s_ x osa�ji u3� caul JrJ:clii i€C;tiUWg W"s'sv ?+ QC twopermanent;e$eren a ian¢ c or benchtraks.I,ecaie all wens within 100 feet.Locate where public water supply eaateas the building.. —7 Q 7 - r . . / r r �f: Y, e I tom ` �� I Y RT t- Pro .p erty Address:: i 6 Owner: Date of Inspection: 'RIO SITE �X Slope sw-f=ce water•"� Check cellar �3 shallow weiis 6L/� Estimated depth to ground Nvat:r-_fee; Please indicate(check)all Methods u,;ed to rlete7rriin,-rho hiatt or^—ei vs?ter piovatinn• ni._•__s vzs:auscu LFi3ui�j35ie,-ti decii� ia�is O??r?corft-�' •• P^ � t_ �c gs• i ._ Q �-% observe::site(abutting PrOPeMiolsservation hole within ISO feet of SAS-) Checked with local Board o} 461M-e:p's_phn: Checked "•L SlTvQ1 Li�4.Q.iQivi$ ins allefs-(attach CiCcurn"+enmrorit Y Accessed USGS database-explain: You must d escin ow yot:estabuisheA Pffie, gh ground agate eaevaU°ta: Cr a(/64 11e- 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 RECEIVED Property Address: 109 Bay View Circle Osterville, MA 02655 NOV 1 0 2003 Owner's Name: Deborah D'Alessandro Owner's Address: TOWN OF BARNSTABLE HEALTH DEPT. Date of Inspection: October 31, 2003 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Map: 142 Mailing Address: P.O. Box 49 Parcel: 093 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 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 15.006). The system: ✓ Passes Conditionally Passes Ne s Further Evaluation by the Local Approving Authority Fa s Inspector's Signatur)subm Date: November 4, 2003 The system inspector s a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 109 Bay View Circle Osterville, MA Owner: Deborah D Alessandro Date of Inspection: October 31, 2003 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: 109 Bay View Circle Osterville, AM Owner: Deborah D'Alessandro Date of Inspection: October 31, 2003 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 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 109 Bay View Circle Osterville, MA Owner: Deborah D'Alessandro Date of Inspection: October 31, 2003 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 I Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 109 Bay View Circle Osterville, AM . Owner: Deborah D'Alessandro Date of Inspection: October 31, 2003 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner, occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection•? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ Were all system components, excluding the SAS, located on site? ✓ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? ✓ Was the facility owner(and occupants if different.from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ Existing information. For`example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 109 Bay View Circle Osterville, MA Owner: Deborah D'Alessandro Date of Inspection: October 31, 2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 2 Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system (yes or no): No [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: Weekend use 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 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: A cesspool was added in Feb. 9188 Were sewage odors detected when arriving at the site(yes or no): No 6 f ' Page 7 of 1 I OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: . 109 Bay View Circle Osterville, MA Owner: Deborah D'Alessandro Date of Inspection: October 31, 2003 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) Cesspool acting as a septic tank Depth below grade: 12" Material of construction: _concrete _metal _fiberglass ____polyethylene ✓ other(explain) Cesspool block If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 5'W x S'T x 7'6"bottom to grade Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle: -- Scum thickness: 2" 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: 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.): The cesspool was dry, and 6"ofsludge was present. No outlet tee was present. The cover was 12"below 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 i Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 109 Bay View Circle Osterville, MA Owner: Deborah D'Alessandro Date of Inspection: October 31, 2003 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: None (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..): PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of I I OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C h SYSTEM INFORMATION (continued) Property Address: 109 Bay View Circle Osterville, AM Owner: Deborah D'Alessandro Date of Inspection: October 31, 2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: 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: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): One overflow cesspool(#2)was 5'W x 5'T x T bottom to grade and was dry. No outlet tee was present. The cover was 10"below grade. The newer cesspool was 5'W x 6'T x 9'bottom to grade and was dry. There did not appear to be any signs of failure. The cover was 20"below grade. 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 I Page 10 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 109 Bay View Circle Osterville MA Owner: Deborah D'Alessandro Date of Inspection: October 31, 2003 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. Q a s� sb 3 y F3 10 r Page 1 I of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 109 Bay View Circle Osterville, MA Owner: Deborah D'Alessandro Date of Inspection: October 31, 2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25 +/- 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 maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using the Barnstable topographic map and Cape Cod Commission water contours map the maps were showing approximately 25'+/-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 and/or this report. Il yov� - (��� — 0No.--•-•- F�a THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliratinit for Bi-tipwial Oork,g Tomitrnr#tnn Frrmit Application is hereby made for a Permit to Construct ( k o tepair ( an Individual Sewage Disposal System at: ('—" 1.... .. t --------- ------_--------�Q- --------------...------------..._......--•--•-------•---....--- Location-Address or Lot No. �' -r ..................•._...__.......•._....-...............-. ----------- ---- - --------- ------------------------------------------------------ _1 - O ncr ,.� dres Installer Address Type of Building Size Lot................ Sq. feet ---------- ,., Dwelling— No. of Bedrooms----------- ----------------------------Expansion Attic ( ) Garbage Grinder ( ) a`4 Other—T e of Buildiu .-__.- No. of YP g ---------------------- persons____...._..___________...-.. Showers ( ) — Cafeteria ( ) d Other fixtures W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacitv------------gallons Length---------------- Width.--------------- Diameter-..----_-__.-- Depth................ x Disposal Trench—No. ....................: Width-------------------- Total Length------------_------ Total leaching area....................sq. ft. 3 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. I----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ 4q Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ a' .--•----•--------------------------•---•--••••-•---------••--•--•--•----------•-••--•----••-----•---.......................................................... 0 Description of Soil......................................... ---------------------------------------------------------------------------------...----------------••-••-----•----- V ...................................................-•--- - --- ------------- --- ------------------------------------------------------------------------- ----------------------------- ----------------- U Nature of Repairs or Alterations—Answer when applicable------------- cS__---- -----------------`--. -- --------------------------------------------------------------------•-------•-••....... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Envir mental Code—The undersigned further agrees not to place the system in operation until a Certificate of Co nce he been issue by the oard of health. Signed ----- --- -------------------- -- -- -- - --------------- ,,,,' U Dare Application.Approved By ...... - L/�"-�' --------------------- --------_------------------- --------. ..---~c--�-.:S..S Dare Application.Disapproved for the following reasons- ------------------- ------------------------------------------------------------------------------------------------- ------ --------------------------------------------------------------------------------- �, Dace Permit No. ...............� -� — 1_5w ---. Issued .-------. ..-^---..L.—.�? -... ----------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Cger#ificate of CTamplian e CIT IS TO C� TIFY, That the ndividual Sewage Disposal System constructed ( ) or Repaired (zl }y ✓� .,.� �2wCsr � � C.b ......... :.G� - - --------------------------------------------- ------ s In. Ile -- ------ . at _--- , ' -,. '"- .. 1 _�-c----------------- �r�'C v ✓' 1 t C has been installed in accordance with the provisions of TI fI.E 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. -------Y.17-./�'"G ...... dated ......' THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE----- ---------...�.. ..-.$� -... Inspector --........... - ..... Nr cle THE COMMONWEALTH OF MASSACHUSETTS ty, n r BOARD OF HEALTH by3 �- . � - TOWN OF BARNSTABLE V No. ...... ----•- FEE........................ Rfgl"1. l Tonlit m#iuu rrutit Permission is hereby granted. �c-_.... ... c.!Cs, to Construct ( ) r gepai�r �✓nIndividual Sewage tsposal System (�G �_ CU°! >► . e .�, . � k,�t*f , O.S'L v'j ` atNo..•• --- • - ---------------- ---------- f Street as shown on the application for Disposal Works Construction Pe met No---- - ---"'I"--- Dated........... -----•�'"........... .- -. --- /1 �j C Board of Health DATE......_..... ` I .......................................... _ FORM 3650a HOBBS 6 WARREN.INC..PUBLISHERS I No. _....... Fk$. •-•.................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABL.E .4��..x ��t tltrttti�tDt fttr Di'vipmiMl Wark.5 Tdtititrurtion Frrmit tf Application is hereby made for a Permit to Coristruct, ( )`or Repair ( an Individual Sewage Disposals System at• .................. -A--.................. ........................................... - I Location- Address J or Lot No. r C'L✓l '`��. `:-e_....�v^.CiILS G S^ G.�_.E..._S Address t n = ............�ib� 1 _ 4 1 Installer Address v UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms--------------------------------------- ----Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons________________________ Showers ( ) — Cafeteria ( ) Otherfixtures -• ------------------ -------------••••------•--•-••......--•••--•--•-.......--•-•• 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 ( ) � Percolation Test Results Performed by........................................... .......................... Date........................................ Test Pit No. I-----t----------minutes per inch Depth of Test Pit____________________ Depth to ground water....................... f� Test Pit. No. 2..... .........minutes per inch Depth of Test Pit__--.-.--•.___-_-_-: Depth to ground water.:'-........... d O Description of Soil.......................... t x U --------------------------------------------------- != ......_ f ----------------- w w.: U Nature of'Repairs or Alterations—Answer when applicable______________�� �,__.___... _�•�--_-_-_ ........ z f.........;.__. , Agreement. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Envir$ ental Code—The undersigned further agrees not to place the system in operation until a Certificate of CoiyTp ce has been issue by the oard of health. L SignedQ- ""` .....f ....... ` Date Application.Approved By ---------------------- % '''° ..... --r z- -�-----'--..................... ................Date �.S-........ Application.Disapproved for the following reasons- -------- ---- -------------------------------------------------------------``.... ..... ...... ................. . ...... ......... .................... ......- /� R Dare Permit Igo. .-.. 4"'C.. " - Issued ..-........ ............. 1_--------7-5---------- Date r .Y TOWN OF BARNSTABLE LOCA' ON I' —1 y V/tw Gl rL SEWAGE # VILLAGE 0 fiGrV I I ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. t~?FPTIC TANK CAPACITY WSAO4) `LEACHING FACILITY: (type) C S 6V[J (size) 1.10.OF BEDROOMS B d//J�. ��fCSS/an�f- UII.DER OR OWNER U 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 leaching facility) Feet Furnished by Tn SAGI�ro.t �0 t � A C� 3 a g. S7 Sa ASSESSORS MAP N0I 9 PARCELNO: CERTIFIED SEPTIC SYSTEM REPORT FAPR '1 A2® 1995 HEALYH�T. LOCATION TOWN OF BARSWLE 109 BAYVIEW CIRCLE 6 S'I`�V t k-(E- MAP 142 PARCEL 093 001 PREPARED FOR SELLER. MR. & MRS . EDWARD THORGERSON MR. PAUL GROVER KINLIN GROVER PROPERTIES 4 WIANNO AVE OSTERVILLE, MA 02655-2027 BUYER 4 MS . DEBORAH A. D 'ALESS'AND 72 WATERSIDE DRIVE CENTERVILLE, MA 02632 PREPARED BY HILLIARD HILLER, JR. 41 MAPLE AVE CENTERVILLE , MA 02632 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property la, �yv/Fsc� G/,QGGF Owner's name Lczri�2p T/1oRG�/IS,c,v Date of Inspection PART A CHECKLIST Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. _LI-1 None of the system components have been pumped for at least two weeks . and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or'--as- part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. 6o,11 44yv!/I �G�� s p,r-e-171r /,moo 031-1;2y The facility or dwelling was inspected for signs of sewage back-up. 4,,," The site was inspected for signs of breakout. All system components, la;p luding the SAS, have been located on the site. The Qa.,, - ..v - -- were uncovered, opened, and the the septie-tank was- nspeeted far endition of baffles or "Icitulicit Of COT'Struction, diwt::j1ZD.LU11::i, depth of liquid, depth of siudge,-e h erseula- _J,� The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. 7-171C SAS "?/V> Fx/r/'1i vEQ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. I F SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential 3 number of bedrooms _2a number of current residents _W. garbage grinder, yes or no _A/,> laundry connected to system, yes or no _A,V�, seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: 5.A.7 Last date of occupancy GENERAL INFORMATION Pumping records and source of information: `L/1S System pumped as part of inspection, yes or no if yes, volume pumped /Sob 644 Reason for pumping: l 55 PoOGS - PU`r.�ivG Type of system Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool 3 i�rAL Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) Approximate age of all components. Date installed,' if known. Source of information: �O Sewage odors detected when arriving at the site, yes or no r SUBSURFACE SEWAGE DISPOSAL SYTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : y (locate on site plan, if possible; excavation. not required., but may be approximated by non-intrusive methods) If not determined to be present, explain: Type leaching pits and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool , p 1 , number Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) Ala 4��2S S�G,�s .yo�eo �/��y L/TG E /av/C /,v dolls T&Z �"r �LOGd i,fJTo G /95 Tf/�.f�f Gr// /.G✓ CESSPOOLS (locate on site plan) : number and configurationa-- - depth-top of liquid to inlet invert. - depth of sol ids layer depth of scum layer dimensions of cesspool materials of construction indication of groundwater o � inflow (cesspool must be pumped as part of inspection) tia. Comments: (note condition of soil, signs of hydraulic failure, level' of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) Qy[D / [z Al 1 e" OvTl,4'�- 1,v�i�if Tdr'E �ou� /�/{-9G/��.yl� G 3 /6 ?b !>.� h' F�GY�Gr PRIVY: .47 � (locate on site plan) materials of construction dimensions depth of solids Comments: (note condition of sOil, . signs of hydraulic failure,- level of pondin condition of vegetation, recommendations for maintenance or repairs,etc. ) RECOMMENDATION FOR: 109 BAYVIEW CIRCLE CENTERVILLE, MA ADD TEES TO THE INLET AND OUTLET PIPE IN THE FIRST CESSPOOL . ADJUST THE LENGTH OF THE BOTTOM OF THE TEES ACCORDINGLY. THE FIRST CESSPOOL SHOULD THEN ACT AS A SEPTIC TANK. ADD A TEE TO THE INLET PIPE IN THE SECOND CESSPOOL . THERE ALREADY IS A TEE ON THE OUTLET PIPE . THIS CESSPOOL SHOULD THEN ACT AS A DISTRIBUTION BOX. DETERMINE WHY THERE WAS ONE INCH DEPTH OVER THE OUTLET INVERT DURING STATIC CONDITIONS IN THE SECOND CESSPOOL . THE FLOW INTO ALL THREE CESSPOOLS WAS EVEN SO THE LIQUID WAS GETTING THROUGH . THERE COULD HAVE BEEN SOMETHING IN THE PIPE BETWEEN CESSPOOLS OR THE PITCH WAS WRONG FOR A SHORT LENGTH . r vUBSURFACE SEWAGE DISr)SAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to .at least two permanent references landmarks or benchmarks locate all wells within 100 ' /o� l3�Y�/Ew ci/1ccE �Q dTE T/a i _ ca DEPTH TO GROUNDWATER depth to groundwater yC.s`o 5 s 37 7s 37<��l3orro�i cv- i- — method of determination or approximation: sYys �q ,G� � �L'y. of �'vve 7a GQcrii.� c.�irTE/! �.�o�i R/�3?,y 7?9/dG,E "U/✓�S ��'p GiiP7Y/1 ?f�3C.� l�5 GS cvRRE' Ti�Ji1/�H i w ,�`I �cwl G - 3 G f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �. PRRT C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined" , explain why not) Al Backup of sewage into facility? l Discharge or ponding of effluent to the surface of the ground or surface waters? c� Y' Static liquid level in the a: ` - '- ' = -- -- above outlet invert? L16T4--40 LC vE 6. /1' �9 P1CQTlfI L o.SSr�Z�GT7o'.� O/Q A.�/ (�iaG�1��� �.�'cT/��/ aF �iTC iY /v •n/�oC ,S- y Liquid depth in cesspool -<6" below invert or available volume< 1/2 day flow? Required pumping44 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is .any portion of the SAS, cesspool or privy: /V below the high groundwater elevation? Al within 50 feet of a surface water? within. 100 feet of a surface water supply or tributary to a surface water supply? _� within a Zone I of a public well? /✓ within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? . Al within 50 feet of a private water supply well? Al less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well water analysi for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector H/G(-11?,eQ H146,­-4 JX Company Name Company Address 1-// Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and manitenance of on-site sewage disposal systems. Check one: I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 115. 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15. 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector' s Signature Date /�o�75� Original to system owner Copies to: Buyer (if applicable) Approving authority l ' ASSESSOR'S MAP NO. �.:PARCEL o L0C`ATION SEWAGE PERIA-1T N0. l V I L.L:A.C E / IN T:. LLER'S NAME a ADDRESS iln s U ll D E R OR OWN[It DATE Pf` RMIT ISSUED D A T E. C0MPLI-ANC''E ISSUED Iz — (')2N Y n KEY NUMBER <2122 > NAME <THORGERSEN, EDWARD > B-C: 1 B-C 2 B-C 3 B-C 4 STREET P 0 BOX 193 CITY OSTERVILLE ST MA ZIP 02655-0193 REF 1 REF 2 PHONE ( ) - REF 3 REF 4 METER NO. < 1984> _ * DATE READING CONS STREETS, BA VIEW:-.CI NO. 109>, 12 31�94 2 �25� CITY OST 0 L10 ST LOC 0 }_ PHONE (508) 428-8131 1118�94` 1068 9 Y 23 0.6rr 30h.:94 1045 21 ROUTE NUMBER 14 1 123 /9,3 1024 51 SERVICE DATE 05/21/59 y 0.6.; -3.0, 93 973, METER DATE 11/18/94 946 r -- CAPACITY 7 0 36 92 904 �2 26 STYLE T10 SIZE 1 RATE SCHEDULE KEY PIT PLASTIC NOTE RR RIGHT SIDE ADDITIONAL CONS 0 ALTERNATE MIN 0 i I ASSESSOR'S MAP NO. PARCEL O L - 2 0 / L YC A T ION SEWAGE PERMIT NO. A�9 Lzdrle fir- �9 ILLAGE 4 093 ool 1NSTA LLER'S NAME 'S ADDRESS S UILDER OR OWN EN �4 DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED I , � ��� �,.� � c�d \ c>` � � �� •O' ��. \!�7 .O i � i � � ..% .. � �, �� � %' �� � . -�.:.�. —� — p � 'I � � n J, ' / G' ' ASSCORS MAP NO: id y PARCEL N0: 3 �� Fes$..... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH -----_....T.own--- -------------OF.....:......$arnstable----------•----------••••--•-_...` Appliratiun for BiBpati al Works Tunitrurtivat rantit Application is hereby made for a Permit to Construct ( ) or Repair gX) an Individual Sewage Disposal System at: .1D9...-B-a-Y.uiaw..Qirm1e---Qsteryi 11e1 Mass . -----------------------•----...........------•--•-----.....-------••-••......------.......••••-• Lccation-Address or Lot No. •I Ike F�� 5� ..........................................•---...................... ..........--...................................__.........................................._..... Add W Owner ress Installer Address Type of Building Size Lot-------------_------------Sq. feet Dwelling gg—No. of Bedrooms.............3__.--------_-_--_.-.___-__-Expansion Attic ( ) Garbage Grinder ( ) aa Other—r e of Buildiil —Type g ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) - Otherfixtures ---------•••-----•-••-------•-•••---------•••••......-----•---•--•--•••......-•----••............. 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 ( ) Percolation Test Results Performed by.......................................................................... Date....................................... W Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-..-__-_.---------_-__-- 04 ..................................................:.-...............................................-••••--•---•••-•---•--•••-•---......• ------------------ O Description of Soil.......S.and---&-•-Gr..&v&l-........................................................................................................ V .........•••••••---•••-••-•-•-------••--••---••-••----•--••.••••---•-------------•--••...---------•----...-•-••--•---•-•-----•--•-----••••---••-•---•-••-••-••---••---•-----------------.... W U Nature of Repairs or Alterations—Answer when applicable______._p_&x-&---ee-sspa©-l----pack-ed..-i•n.---st.one_. ..........................................------------------------------------------------------------------•------------------------•-•---------------•------------------------------------------•••--- Agreement: " The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of ii�1:" 5 of the State Sanitary Code=The undersigned further agrees not to place the system in operatiori.until a Certificate of Compliance has b n ' Ry the board of ealth. Signed � - ..._ A lication Approved B Date PP PP Y L� t� >.r--�............................. ------------� Date Application Disapproved for the following reasons-----------------------------•----•------------•-------------------------------------------......-•---.....----- ...-----••......••---•......•-•-•-••---••••. Date Permit No........4?tsS..n.........1?.................. Issued------------------------------------------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ------...Town... . .---.....OF..._......Barnstable_............................................ Alipfiratiou for Uhipasal Works Tomitnuliott 1hrmit Application is hereby made for a Permit to Construct or Repair)tX ) an Individual Sewage Disposal System at: 1.0-9... Q ix .................................................................................................. Location-Address or Lot No. T4ia-rge r-s-av...................................................................... .................................................................................................. ' Address 0.7er J-P-Mac4mbar.............. ................................................ ................................................................................................... Installer Address Type of Building Size Lot............................Sq. feet U Dwellinp -No. of Bedrooms...........a..............................Expansion Attic Garbage Grinder Other— fype of Building ---------------------------- No. of persons__...__...__......__._....._ Showers Cafeteria Otherfixtures ....................................................................................................................................................... Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth....._.......... Disposal Trench—No. .................... Width....._...._.._____.. Total Length.__.............._.. Total leaching area....................sq. f t. Seepage Pit No_____________________ Diameter___.___..___........ Depth below inlet......_.........._.. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ 1.4 Test Pit No. I________________minutes per inch Depth of Test Pit.................... Depth to ground water___:_________-__.-_____. G%, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 .......................................................................................................................................................... 0 Description of Soil.....Sa-n - d...&..jS. r..3.Vej............................................................................................................................. U ........................................................................................................................................................................................................ W -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable._.._..I--6 X_ _8...ae- ,91-- -1 .'s 43ne.... -----p,3_C_:jc_9d----i-,.- t - .......................................................................I................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b en/*"' ied by the board of,health. Ossl"Signe T%366,�&44�..1 'KI; ------------------------------ ---1­2-44/-84------- ate ......... ;� — Application Approved By................ ........... ............................. ............/__ --.6. .......... Date Application Disapproved for the following reasons:................................................................................................................ ......................................................................................................................................................................................................... Date PermitNo.......FA......I....21?------------------- Issued------------------------------------------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............T.awn...............OF..Barn�table................................................... (Errfifiratr of (Eautpliattre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired XX) by...........J—P-Mar-ambax:....................................................................................................................................................... Installer at...........................10.9---Bayvi aw---C-i-r-c-Lev---JO-s-ter.V11-1-a..................................................................................... has been instilled in accordance with the provisions of ITTIE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No...... ........... dated________________________________________________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 0....F ...........Toiin ....... ...................OF...��;�.Kqstable ................................................................. N ... FED...2 Disposal Vorkg T-Ronstrattan prrufit Permission is hereby granted.........j.s.P...Ma_C.OMber.................................................................................................. ....................... to Construct or Repail an Individual Sewage Disposal System at No!P!�---A 5-AY Y i e!T...C.iAle) Osterville - .............V....................................................................................................................................... Street -------- as shown on the application for Disposal Works Construction Permit N Z)99'_� Dated----- - ---- ..P......... .................... ...... F ---------------------------------------- Board of He t DATE................................................................................ FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS