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HomeMy WebLinkAbout0082 BLANID ROAD - Health 82'Blanid Road Osterville: A =-140r-,' 065 I Commonwealth of Massachusetts /1/0' ow Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Blanid Rd r' Property Address L. Jeffrey and Kathleen Bochman, TTEE Owner Owner's Name information is Osterville MA 02655. 09-12-2019 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information sl# IL41 LID on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road Company Address Teaticket Ma. 02536 City/Town State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification ' I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title y-> (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 �-l019 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board_-'t . of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of " 3, 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate ' z regional office of the DEP. The original form should be sent to the system owner and copies sent to A the buyer, if applicable, and the approving authority. d 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 Title 5 Official Inspection Form pia Subsurface Sewage Disposal System Form - Not for Voluntary Assessments -ae 82 Blanid Rd u Property Address Jeffrey and Kathleen Bochman, TTEE Owner Owner's Name information is Osterville MA 02655 09-12-2019 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 31 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: This 3 bedroom home has a H-10 1500 gallon septic tank and a D-Box feeding three 500 gallon leaching chambers. At the time of the inspection there were no visible failure criteria found. 2) System Conditionally Passes: w. ❑ 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): l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Fora b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 82 Blanid Rd Property Address Jeffrey and Kathleen Bochman, TTEE Owner Owner's Name information is required for every Osterville MA 02655 09-12-2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will ass inspection if with approval of Board of Health): p p ( pP ) ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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: t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form tl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Blanid Rd Property Address Jeffrey and Kathleen Bochman, TTEE . Owner Owner's Name information is Osterville MA 02655 09-12-2019 required for every page. City town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal t 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 ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form �1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 82 Blanid Rd u� Property Address Jeffrey and Kathleen Bochman, TTEE Owner Owner's Name information is required for every Osterville MA 02655 09-12-2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems:.(cont.) Yes No El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow ❑ ® 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 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 I Commonwealth of Massachusetts ,� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 82 Blanid Rd Property Address Jeffrey and Kathleen Bochman, TTEE Owner Owner's Name information is required for every Osterville MA 02655 09-12-2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 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? a ® ❑ 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: Z ❑ 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 f Commonwealth of Massachusetts Title 5 Official Inspection Form etiI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u� 82 Blanid Rd Property Address Jeffrey and Kathleen Bochman, TTEE Owner Owner's Name information is Osterville MA 02655 09-12-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number.of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 plus GPD Description: Number of current residents: 3 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: In 2018 42,000 gallons were used and in 2017 48,000 gallons were used. Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts �n p Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Blanid Rd t;- Property Address Jeffrey and Kathleen Bochman, TTEE Owner Owner's Name information is required for every Osterville MA 02655 09-12-2019 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: t5insp.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 I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 82 Blanid Rd Property Address Jeffrey and Kathleen Bochman, TTEE Owner Owner's Name information is required for every Osterville MA 02655 09-12-2019 page. City/Town State Zip Code Date of Inspection 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): Approximate age of all components, date installed (if known) and source of information: 1 07-17-2015 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 4811feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town water 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 �n :• Title 5 Official Inspection Form .1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Blanid Rd u Property Address Jeffrey and Kathleen Bochman, TTEE Owner Owner's Name information is required for every Osterville MA 02655 09-12-2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 36"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: standard H-10 1500 gallon Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or'baffle 33" 1 Scum thickness 511 Distance from top of scum to top of outlet tee or baffle 13„ Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of the inspection the liquid level was at working level and the tee's were in place. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 r Commonwealth of Massachusetts Title 5 Official .Inspection Form <II Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u— 82 Blanid Rd Property Address Jeffrey and Kathleen Bochman, TTEE Owner Owner's Name information is required for every Osterville MA 02655 09-12-2019 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 t5insp.cloc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 �I Commonwealth of Massachusetts :. Title 5 Official Inspection Form ii� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments e, 82 Blanid Rd u— Property Address Jeffrey and Kathleen Bochman, TTEE Owner Owner's Name information is required for every Osterville MA 02655 09-12-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At the time of the inspection the liquid level was at working level and there were no visible signs of solids carryover or leakage. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 82 Blanid Rd Property Address Jeffrey and Kathleen Bochman, TTEE _ Owner Owner's Name information is required for every Osterville MA 02655 09-12-2019 page. Cityrrown 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: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 I Commonwealth of Massachusetts �n = ,�p Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 82 Blanid Rd Property Address Jeffrey and Kathleen Bochman,TTEE Owner Owner's Name information is required for every Osterville MA 02655 09-12-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection there were no visible failure criteria found. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .� � 82 Blanid Rd t, Property Address Jeffrey and Kathleen Bochman, TTEE Owner Owner's Name information is required for every Osterville MA 02655 09-12-2019 I page. Cityrrown State Zip Code Date of Inspection E 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 u 82 Blanid Rd Property Address Jeffrey and Kathleen Bochman, TTEE Owner Owner's Name information is Osterville MA 02655 09-12-2019 required for every page. CityTrown 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Assessing As,-Built Cards https:Htownofbamstable.us/Departments/Assessing/Property_Valu... GG TOWN OF B' TABLE LOCATION 0 . ,Lf/d(. SEWAGE#. �2_ D/S'"a NtLAGE: S&,c7Y. ` e ASSESSOR'S MAP&TARCFL r 17 INSTALLERS NAME&PHONE NO. r' C SEPTIC TANK CAPACITY /`5'00 14 LEACHMG FACILITY:(type). (f to A MI et` s (size) NO:OFBEDROOMS OWNER..2AJ e . TA r I e R PERMIT DATE. 7-I:7 I S COMPLIANCE DATE' Separation Distance Between the: Maximum Adjusted Groundwater Table to the.Bottom of Leaching Facility; Feet; Private Water Supply Well and Leaching Facility Of 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 BXge�b.'v is a' s� i 013 Q 1,1 r _ .. Doi .► / err P/V 1 of 1 9/11/2019,6:05 AM Commonwealth of Massachusetts =. Title 5 Official Inspection Form �i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 82 Blanid Rd Property Address Jeffrey and Kathleen Bochman, TTEE Owner Owner's Name information is Osterville MA 02655 09-12-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 14 plus feetfeet 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: augered a hole to show 4 plus feet of seperation. 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 f Commonwealth of Massachusetts �- 1p Title 5 Official Inspection Form �1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments h � 82 Blanid Rd Property Address Jeffrey and Kathleen Bochman, TTEE Owner Owner's Name information is required for every Osterville MA 02655 09-12-2019 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 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included J'���► a t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 li TOWN OF B TABLE LOCATION AP SEWAGE'# VILLAGE 6�r er �� ASSESSO 'S MAP& ARCEL D INSTALLER'S NAME&PHONE NO. r � _ SEPTIC TANK CAPACITY /"600 . 14 /® , LEACHING FACILITY:(type) C tit A M,�&V S (size) ✓®® � /`� �d NO.OF BEDROOMS_ OWNER -pa,/ e -PA r r e I R PERMIT DATE: -7_,7" (� COMPLIANCE DATE: LN- 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 Li dQ, f-? / Aj�P`S 1 d Y t�S 4- Q� I t v -ate: •. I Y�f R J No. �.S .� I Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS fttlfitation for MisposaY �&pstrm Const rtion jhrmit Application for a Permit to Construct(� Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. /3L.A N>I> )Z D Owner's Name,Address,and Tel.Nof 077V 3 S7F—leVtc.c E_ dyN'rNiq IOAA9 4LN 16o6vx 4R3 Assessor'sMap/Parcel 14.o _. o&g— 4 i✓�S77VaL&_ /Y"4 02690 Installer's Name,Address, nd Tel.No. � ,d/_ Designer's Name,Address,and Tel.No. (�5CS)4q!—1 Z ZY .92/UO3S �L�',' F091,MV7}I 6�/Giv y/Nk lam" DAKADEInY 4,Aj PAL 62s4o Type of Building:5-0� � � 0173 Dwelling No.of Bedrooms 3 Lot Size cSgt7 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) -33V gpd Design flow provided � gpd Plan Date 717 12a/s Number of sheets *2__ Revision Date Title S&PT/C 5YS7Z;_lY1 `(- 00107 oO44a/ Size of Septic Tank / So U Type of S.A.S. C oA,C' F t o 6y N FF Description of Soil Nature of Repairs or Alterations(Answer when applicable) A Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the s stem in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Application Approved by ' Date Application Disapproved by Date for the following reasons Permit No. Date Issued �Q15 O" Fee Ir No. THE COMMONWEALT, ,, OF MASSACHUSETTS Entered;ncomputer: _PUBLIC HEALTH DIVISION - TOWN F BARNSTABLE, MASSACHUSETTS, Yes _..,,� �O , S applicatiodfOr disposal 6pstem CpstrUctl nPermit Application for a Permit to Construct El Repair( ) Upgrade( ) Aliaon d ( ) Complete System El Individual Components Location Address or Lot No. S2 /3LA lv/,�> /2 D Owners Name,Address,and Tel.No. (�s7�,;2V) eYA,-rH;A, 10A44E1Lft p0aa g83 I `=Assessor'sMap/Parcel J•40 _ p(ps . ✓�geN57 k3� /►'1,e� OZ(03a" Installer's Name,Address,.And Tel.No. Designer's Name,Address,and Tel.No, (,r S 1 Z ZS r�A6CA�v-r�1 `.�a w E EA s4o Type of Building: O k-509"„d/1-3 .g 4 m h L j Dwelling No.oaf Bedrooms .3 _ "'Lot Size 6.5 q0 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) '.f gpd Design flow provided 44 gpd Plan Date 7197 1Z0/,5 Number of sheets Revision Date Title S Ei"`T/C -14 00107 P L,4 A/ of Septic Tank /.So O Type of S.A.S. C o/v e Description of Soil. `-� ->Ay_ ✓' f_ Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: i X The undersigned agrees to ensure the construction and maintenance of the afore described on-sitsewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to playhestem in operatofi until a Certificate of X Compliance has been issued by this Board ofJHealth. r' Signed ''� / s f- �_q4te , 7 S Application Approved by j Da e 7 Application Disapproved by V Date for the following reasons f Permit No. ;-d �' Date Issued--------------------------------------------- — -� ------------------------------------------------------------------------------------------ ``., THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Urtificate Of Compliance THIS IS TO.CERTIFY,,t the On-site Sewage Disposal system Constructed(X) Repaired( ) Upgraded( ) Abandoned( )by GL 17 G !, e e f'/110 t S N at RZ /3 L>1 ni)n %2 D d srr has been constructed in accordance _ with the provisions of Title 5 and the for.Disposal System Construction Permit No.o 5'� dated Installer 3,4Iv4 LZJt►"�o i�, Designer L/YIGY- l fN41/NEt,&1A4 r #bedrooms .3 Approved design flow 104+ , gpd The issuance of this permit shall not be cohstrued as a guarantee that the system wil11 u scion as(esigned. r s \ ` Date � I f' Inspector ( / �:�-'�. �. � p JJ c V ------------------------- ------- ------------------ ---------------------Q---------------------------------- ------- No. ' Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal 6pstrm (Construction permit Permission is hereby granted to Construct(k) Repair( ) Upgrade( ) Abandon( ) System located at DS7�r.�VL[ and as described in the above Application for Disposal System Congt Tction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date — roved A b Approved Y - - - og' A - _ &° - vao tiff - sQig m4°oaoeA - - Lxn° R%euU - o� - Gexa� mf• a" - giTxm '^,ua~O - _ uF _ - A �8 " _ ,:o" _ m N m x ___ __- IV z• gna m � 4 an' etiamnK m 'Oie LU a..z I .. I'1 I:I L I� I':I %I oeQ o9 I I.:I I'.1g °om II I'-1 - LIJ g.o I1 r-..: I LJ ICI 4 1 n I o cn _____ a'm9 z I':1 m e PROPOSED TWO STORY CAPE WITH : — M 8hnN RECISION ION eww • BARNSTABLE HARBOR BUILDERS ATTACHED ONE CAR GARAGE - 82 BLANID ROAD mu r o wv. OSTERVILLE•MASSACHUSETTS FOUNDATION PLAN ((��B CPcg PRAWN BY CED DES LN SCALE:AS SHOWN - e/iN+ SECTIONS AND NOTES a�;.c,a -"� pEsaNED er cED DESIGN e vlsis ,• _� CHECKEp Ll �Y OWXER ATEST REV SON,iI5i15 ..® - ------------�a sin In 6 91 n6� i ^ gg DOE ' Ei �m �U F. - 0 EU oA i .��i d — 4 LU — —-—-—-®- --" YSgXo o .. a '• s z a e m k0@0 Y ® c p ' cu D 5 W N D u IF ssc c = D o% r _ u — Y}- - } '.�.: , Y+ R PROPOSED TWO STORY CAPE WITH Rc�uioR o BARNST82B HARBOR BUILDERS ATTACHED ONE CAR GARAGE (� 82 BLANID ROAD I OSTERVILLE,MASSACHUSETTS N FIRST AND SECOND = OR PLANS AND DOOR DRAW%BY,Cm.D Bn SCALE A9 BHDcx FLOOR on N AND WINDOW SCHEDULES I oaicueD Be,Ceo.q=_stcu D-are:lions _ _� cwgc<en.a L '� In 9 0 i L I t 1 t N ---------- i f i i o IN o !. _I { b _ I i c Y;g h s ss ss R PROPOSED TWO STORY CAPE WITH .gym A� NSTABLE HARBOR BUILDERS aEu;teu o BAR ATTACHED ONE CAR GARAGE 1 81 BLAND ROAD OSTERVILLE.MASSACHUSETTS FRONT AND REAR oeF°x ar:cc�-ocsicn' sc�ie es=_roux - wn.. W` ELEVATIONS Town of Barnstable °FT"E'O�ti Regulatory Services M Thomas F. Geiler,Director + aAENSPABLA • MASS. Public Health Division pr 0.19. Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 5087790-6304 Installer & Designer Certification Form Date: Sewage Permit# 9,o/ ,2. Assessor's Map arcel 06 ' � I Designer: 'rl o�'1'k� 11 G�1tv2 _ Installer: L Address: 17 Pc CP} Address: On -� ' was issued a permit to install a (dat installer) . septic system atQ7:W based on a design drawn by (ad ess) �'Ikv C- dated 3`lJN �T ate• (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10 lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State & Local Regulations. Plan revision or as-built designer t foll �A Of M4S ! MICHAELJ. �y BORSELLI 0 IIo Ch '5 rn No.35054 Z In r s e) \ \\\\\\ ( h'O�Fsr'/ST E S�ONAI EN es' er's Signature) (Affix Designer's Stamp Here) 5 PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU, Q:Health/Septic/Designer Certification Form 3-26-04.doc cilia Town of Barnstable >P# FDepartinent of Regulatory services Wit; Public Health Division Date' ' l I� . s'd]P 200 Mein Street,Hyannis MA omol _.,' AEU NlA't� r a . Date Scheduled Time Fee Pd. •� ' Soil Suitability Assessment for Sewsg e Disposal p Performed-By:. Witnessed By: LOCATION& GENERAL INFORMATION 7 74 Sz/-38;Q Location Address 82. [36A/V/0 • � � Owner's Name P�IRR�e.GA D"57FR✓/LG�� M19 02655 Address Po0o> 49s /344-V.5,7 z&cE_ b2630 • Assessor's Map/Parcel:40 —O(O S /)1/kE L3o oe S ErL ``// Enginaer'aName �C-ffL/l�GtrJ�/ ivGin/E�.t2:/ NEW CONSTRUCTION 7- REPAIR >e— _ 4 Telephone# (774) 392 3 -367 Land Use'�1=.�I�1'�.N�` L' 7 Slopes )VA+ a r 5udace5lones .- Distances from: Open Water Body �SVOR _Nossiblc WetArea4��� y 1 ft Drinking Water Well . 10— ft Dralhage Way /{0_f1 Property Line 8~��! ~R Other_�� pt _R I SIC'TCH:(Street name,dimensions of lot,exact ioeatlons of test holes&pare tests,locate wetlands?n proximity to holes) TP 1P . J (3 t->rtt N 1 D R-D � • r.l- Parent material (gaologic)�—_QP&% S� Depth to Bedroek_ Depth toOroundwater. Standing Water In Hole: Weeping 11•01ri Pit lance Estimated Seasonal High Oroundwater T� J L 7DETERMWATTONFOR SEAS NAL' Ri ]HIGH WATER TABLE _ Method Used: cw bw R 1�C,t nN� h PVP Depth Observed standing In obs.hole: Depth to weeping from aide of obs.hole: _. In. Depol 10 soil mottles., bt. ©rotrndwaterAdjustment Index Well l: •Reading Date: Index Well leYul •• 1h• -- AU,factor. _.' Adj.dmundwater Leval Observation PERCOLATION VEST �gte�-7 , rritnri -au_ Hole 0 Time at 4" Depth of Pero Time at 6" Start Pro-soak Time @ Tima(V-15") End Pra-soak O� tom' OV�T,,A -.% Rate Min./Irtch L S _�tN L -'l� SS - ' Site 5ullability Assessment: Site Passed V 'Sine Palled: Additional Testing Needed(YIN) Original: Public Health Division Observation Hole Data To Be Completed on Back— ***If percolation test is to be conducted witiun 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1) week prior to beginning. Q NSEPTICIPERCPORM.DOC ]DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Shcl Color Soil. Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. • r st istcncy.y6'Orevcll O"IS" Am`tl 10 YR q} a DEEP OBSERVATION HOLE LOG Hole#�_ Depth from Soil Horizon. Soil Texture Soil Color Soil Other. Surface(ia) (USDA) (Munsell) Mottling (Structure,Stones,Boulders• Consistency. ra " RIM SVL;T--s DEEP OBSERVATION HOLE LOG Hole# • 3 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Muuscll) Mottling (Structure,Stones,Boulders. Consistancv.%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Solt Color Boll Other Surface(in.) (U$DA) (Munsell) Mottling" (Struetura,Stones;Boulders, Consistency. j l �P�•�H Mgss. Flood Insurance Rate Mapes o�� MICHAEL J. 9�yG Above 500 year flood boundary No_ Yes_ BORSELLI 0 o CIVIL 0 9 No.35054 Within 500 year boundary No 1/ Yes 4 �. . /STEe`��c`�� Within.100 year flood boundary No.-,— Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pery ous material exist in all areas observed thrp hout the area proposed for the soil absorption system? If,not.what is the depth of haturally occurring pervious matorial? �.. Certification" ' I.certjfy=th at' n01ae)I_have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by ma consistent with . the required training,expertise and en a described In 10 CMR 15.017. • Signature &4 Date QAS.EPTIC%PHRCPORM.DOC A m 'o (OFFICIAL USE. M Postage $ --- O y Certified Fee og ark O Return Receipt Fee v y O (Endorsement Required) ^�� Here Restricted Delivery Fee r a (Endorsement Required) M Total Postage&Fees �p�l ,eO o Joaquin Tavares: Estate of 82 Blanid Road Osterville, MA 02655 Certified Mail Provides: o A mailing receipt o A unique identifier for your mailpiece n A record of delivery kept by the Postal Service for two years Important Reminders: o Certified Mail may ONLY be combined with First-Class Mail®or Priority Mailer o Certified Mail is not availablip for any class of international mail. r o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For, valuables,please consider Insured or Registered Mail o For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return. Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for_ a duplicate'return receipt,a USPS®postmark on your Certified Mail receipt is required. • a For an additional fee, delivery may be restricted to the addressee or. addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted-Delivery". a'If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail '.receipt is not needed,detach and affix label with postage and mail— IMPORTANT:Save this.receipt and present it when making an ihidiry. PS Foan 3800,August 2006(Reverse)PSN 7530-02-00D-9047 0 0 0 0 ® Complete items 1;2,and 3.A7desired. A. Signature item 4 if Restricted Delivery isX ❑Agent lnt your name and address ❑Addressee so that we can return the cardB. Received by(Printed Namey C. date Delivery ® Attach this card to the back of the mailpiece, or on the front if space permits. D. Is delivery address different from item V Yes 1. Article Addressed to: If YES,enter delivery address below: ❑No 60/1 +y X / 'Joaquin Tavares: (Estate of 82 Blanid Road Osterville, MA 02655 3. Service Type � [a Certified Mail® 17 Priority Mail Express' � ❑Registered ®Return Receipt for Merchandise ❑Insured Mail ❑Collect on Delivery 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number ^. (Gansfer from service/abed ! t`7 D 1`4 `12 0 '0 �:1' 0 3 5`8 9314 PS Form,3811,July 2013 Domestic Return Receipt 'i IGNITED.STATEq.,§ First-Class Mail Postage&Fees Paid USPS Permit No.G-10 • Sender: lease print your name, address, and ZIP+4®in this box* Town of Barnstable Public Health Division 200 Main Street I Hyannis, MA 02601 I l I a Q P`°Fs�ray Town of Barnstable {BarnMcMble Regulatory Services Department AN-ftericaCity RARwrABLE, • , 9 MASS. $ -w 039. Public Health Division ArfO MAt a' 2007 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL #7014 1200 0001 0358 0314 January 19, 2015 Joaquin Tavares; Estate of 82 Blanid Road Osterville, MA 02655 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 82 Blanid, Osterville, MA was last inspected on 7/28/2014 by James Ford, a certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that the system "Failed" under the „ guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: Single cesspools automatically fail in the Town of Barnstable You are ordered to repair or replace the septic system within two (2) years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE OARD OF HEALTH Thomas McKean, R.S. CHO Agent of the Board of Health i Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\82 Blanid Rd Ost Jan 2015.doc I 1 1 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposaal System Form - Not for Voluntary Assessments 82 Blanid Road Property Address Estate Of Joaquin Tavares s Owner Owners Name i information is required for every Osterville ±; MA 02655 7/28/14 page. City/Town it ! Slate Zip Code Date of Inspection Inspection results must be s'ufamitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A General Information on the computer, /►� n 11, use only the tab key to move your 1. Inspector: v cursor-do not James Ford i use the return Name of Inspector key. (, Company Name �. P.O. Box 49 Company Address e� Osterville MA 02655 Cityrrown State Zip Code 508-862-9400 ) S12482 Telephone Number License Number i 1' B. Certification i x 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 Furth r valuat=on by the Local Approving Authority {' 7/29/14 Insp is Signature s. Date Th sy tem inspector shall submit a copy of this inspection report to the Approving Authority(Board of He th 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 buyar 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. MV t5ins•3/13Tim:Subsurface Sewage Disposal System•Page 1 of 17 I Commonwealth of Massachusetts W Title 5 Official: Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M a 82 Blanid Road t, ` Property Address Estate of Joaquin Tavares Owner Owner's Name information is required for every Osterville MA 02655 7/28/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) F 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: i i B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain.- The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): f; t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Officia1l41nspection Form Subsurface Sewage Disposa(System Form - Not for Voluntary Assessments °A,a 82 Blanid Road ".a Property Address Estate Of Joaquin Tavares ,` a Owner Owner s Name information is required for every Osterville '` MA 02655 7/28/14 page. Cityrrown 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:66ckup 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): II ❑ broken pipe(s)at•e?replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution y:box`is Leveled or replaced- Y p ❑ ❑ N ❑ ND (Explain below is y I! . r' 1� to Il! ❑ 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) el!replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is rdii. ve ',I Qd ❑ Y ❑ N ❑ ND (Explain below):- C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which r�gvire further evaluation by the Board of Health in order to determine if the system is failing to p�otIect public health, safety or the environment. 1. System will pass ur leis 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 $1 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 ii f* ` ac. ; Commonwealth of Massachusetts Title 5 Officia inspection Form Subsurface Sewage Disposal,:System Form - Not for Voluntary Assessments 82 Blanid Road i Property Address Estate Of Joaquin Tavares ; Owner Owners Name information is required for every Osterville 4 MA 02655 7/28/14 page. CityfTown i . State Zip Code Date—of Inspection B. Certification (cont.)- 2. System will fail un[Lass the Board of Health (and Public Water Supplier, if any) determines that the sytem 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. ir. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. i r ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private waterisupply well**. Method used to determine.distance: i **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. i .ki 3. Other: it ;1 ;i D) System Failure Criteria Applicable to All Systems: , 5 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 El ® Static I`.igtid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid 1'0e'pth in cesspool is less than 6" below invert or available volume is less than day flow t5ins•3/13 i Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 fi � i Commonwealth of Massachusetts. w Title 5 Official" Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 82 Blanid Road Property Address Estate of Joaquin Tavares Owner Owner's Name information is Osteryille MA 02655 7/28/14 required for every ` — page. City/Town State Zip Code Date of Inspection B. Certification (cont.) '! ' Yes No Required pumping more than 4 times in the last year NOT due to clogged or ❑ ® obstructed pipe(s). Number of times pumped: I. ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. i�.r El ® 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. i ❑ ® 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 g'ystem is a cesspool serving a facility with a design flow of 2000gpd- 10,00,060. ® ❑ 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 system4wner should contact the Board of Health to determine what will be necessary to correct the failure. to 0 it E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd tp 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 I . • ❑ ❑ the s`y-s,'fem 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 El Elthe system is located in a nitrogen sensitive area (Interim Wellhead Protection Areal;—IMPA) or a mapped Zone II of a public water supply well If you have answered "yesjj 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 with3'10 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts r w Title 5 Officia!I� Inspection Form Subsurface Sewage Disposal!System Form - Not for Voluntary Assessments a 82 Blanid Road Property Address Estate Of Joaquin Tavares Owner Owners Name information is required for every Osterville MA 02655 7/28/14 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have Peen done. You must indicate "yes" or"no" as to each of the following: Yes No ' II ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were 6hyi.of the system components pumped out in the previous two weeks? ❑ ® Has.the system received normal flows in the previous two week period? r, ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspettion? ❑ ® . Were ai 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? r ® ❑ Were all siystem components; excluding the SAS, located on site? ® ❑ Were tke septic tank manholes uncovered, opened, and the interior of the tank inspect d,for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? b El ® Was the facility owner(and occupants if different from owner) provided with informall�op 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: ❑ ® Existinglinformation. For example, a plan at the Board of Health. a ® ❑ Determled 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 Informatioh t Residential Flow Conditions," i; n/a Number of bedrooms (design): 2 Number of bedrooms (actual): DESIGN flow based on 310 MR 15.203 (for example: 110 gpd x#of bedrooms): n/a t, 15ins•3/13 :. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 . s 4 `. r Commonwealth of Mas husetts sac Title 5 Official[Inspection Form Subsurface Sewage Disposal;p,;ystem Form Not for Voluntary Assessments it. . . 82 Blanid Road '4 Property Address Estate Of Joaquin Tavares ' Owner Owner's Name i r information is required for every Osterville i i MA 02655 7/28/14 page. CitylTown I State Zip Code Date of Inspection D. System Informaticin It Description: System is a single cesspooIJ!Single cesspools fail in the town of Barnstable. ------------ I' E; Number of current residents .l none I, Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate se+ivage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected?.,, El Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if ava:iila'ple (last 2 years usage (gpd)): Detail: unavailable t h ' Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Floyv Conditions: 1 Type of Establishment: Design flow(based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seats/p•ersons/sq.ft., etc.): Grease trap present? El Yes ❑ No t. . Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: l5ins-3/13 �,` Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 17 f z Commonwealth of Massachusetts . Title 5 OfficialAnspection Form Subsurface Sewage Disposal;System Form - Not for Voluntary Assessments e 82 Blanid Road " Property Address Estate Of Joaquin Tavares Owner Owners Name information is required for every Osteryille MA 02655 7/28/14 page. City/Town State Zip Code Date of Inspection D. System Informatio'nn(cont.) Last date of occupancy/use; ' Date i . Other(describe below): ii t. General Information Pumping Records: r Source of information: unukown Was system pumped as par`.t,of the inspection? ❑ Yes ® No !, If yes, volume pumped: ' gallons How was quantity pumped determined? t, Reason for pumping: i i, Type of System: l' ❑ Septic tank,,:distribution box, soil absorption system ® Single cesspool ❑ Overflow ce-5spool ❑ 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): I' 15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 r Commonwealth of Massachusetts 1 Title 5 Officia',f inspection Form Subsurface Sewage Disposal;System Form - Not for Voluntary Assessments 82 Blanid Road Property Address Estate Of Joaquin Tavares Owner Owners Name information is required for every Osterville li`�,a MA 02655 7/28/14 page. City/Town i State Zip Code Date of Inspection D. System Information.(cont.) Approximate age of all components;date installed (if known)and source of information: installed on unknown I;' Were sewage odors detectgd`when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): i. Depth below grade: feet i' Material of construction: ❑ cast iron ❑ 40 PVC ® other(explain): orangeburq f Distance from private water,i;gpply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t I+ t i . Septic Tank (locate on site plan): Depth below grade: n/a c? feet l; r Material of construction: ❑ concrete ❑ metal El fiberglass ❑ polyethylene ,, El other(explain) I is sr I_ f If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 3 Dimensions: Sludge depth: l5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal'System Form - Not for Voluntary Assessments • 82 Blanid Road Property Address Estate Of Joaquin Tavares Owner Owner's Name information is E' required for every Osterville MA 02655 .7/28/14 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum,-�o 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.): 4. t1 g' t Grease Trap (locate on site'plan): Depth below grade: ;i feet Material of construction: El concrete a ❑ metal El fiberglass ❑ polyethylene El other(explain): Dimensions: (i k 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 (Sins•3113 } Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts _ Title 5 Officiahnspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 82 Blanid Road Property Address .:r Estate Of Joaquin Tavares +' Owner Owner's Name information is required for every Osterville t MA 02655 7/28/14 page. City/Town State Zip Code p Date of Inspection D. System Information (cont.) it Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to ou;(Iet invert, evidence of leakage, etc.): 1 .r k s Tight or Holding Tank(tangy must be pumped at time of inspection) (locate on site plan): Depth below grade: F+' h Material of construction: ❑ concrete I ❑ metal,' ❑ fiberglass -❑ polyethylene ❑ other(explain): N/a Y i Dimensions: i Capacity: gallons Design Flow: ° gallons per day Alarm present: ❑ Yes ❑ No Alarm level: _ Alarm in working order: ❑ Yes ❑ No. f Date of last pumping: Date Comments (condition of alarm and float switches, etc.): i' II y •ti Attach copy of current pumpltjg contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 j Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 t I l Commonwealth of Mas"Ousetts Title 5 Offici01 ,Inspection Form Subsurface Sewage Disposal`:System Form - Not for Voluntary Assessments 82 Blanid Road Property Address Estate Of Joa uin Tavares ii t Owner Owner's Name information is t required for every Osterville MA 02655 7/28/14 page. Cityrrown State ZipCode Date of Inspection D. System Informatiow(cont.) Distribution Box(if present must be opened)(locate'on site plan): Depth of liquid level above nutlet invert n/a 11 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.): 4 I S i• Pump Chamber(locate on site plan): Pumps in working order: k El Yes ❑ No �.. . Alarms in working order. El Yes ❑ No } Comments (note condition o`f plump chamber, condition of pumps and appurtenances, etc.): i, i ;i I � * 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): If SAS not located, explain why;: M1 15ins•3/13 Title 5 Official Inspection Form P .Subsurface w Se age Disposal System•Page 12 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposai'$ystem Form - Not for Voluntary Assessments c t � 82 Blanid Road f Property Address l . Estate Of Joa uin Tavares Owner Owner's Name information is i required for every Ostervllle MA 02655 7/28/14 page. City/TownState Zi Code P Date of inspection- D. System Information (cont.) Type: ❑ leaching pits.:: number. ❑ leaching chambers number: ❑ leaching gall": ies number: ❑ leaching tre �hes �„ number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: s ; ❑ innovative/alternative system Il a Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): ry r. . Cesspools (cesspool must be'pumped as art of p inspection (locate on site plan): Number and configuration ti 1 -single Depth—top of liquid to inlet invert i, Depth of solids layer 15" Depth of scum layer Dimensions of cesspool 1000 gal. with a 4'shim Materials of construction precast pit Indication of groundwater infjpw ❑ Yes No l5ins•3/13 4' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 t« r f Commonwealth of Massachusetts W Title 5 Officiali -inspection Form Subsurface Sewage Disposal:S.ystem Form - Not for Voluntary Assessments 82 Blanid Road Property Address Estate Of Joaquin Tavares Owner Owner's Name information is required for every Osterville MA _ 02655 7/28/14 page. City/Town ': State Zi Code P Date of Inspection D. System y em Information;(cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): the pit was dry. It is a 1000 gal. pit with a 4' shim the cover was 1' below. the BTG was 10 5 Privy(locate on site plan): Materials of construction: i' Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/a i r: iC 1 of 11 II 1 151ns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 . t • is Commonwealth of Massachusetts u Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 82 Blanid Road Property Address Estate Of Joa uin Tavares r, Owner Owner's Name information is i required for every Osterville MA 02655 7/28/14 page. City/Town State Zi Code i' P 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,betow ❑ drawing attached separately 'Prom' GA(AgL F .aa ` e t • qiq t 4' •G C !Sins•3/13 t Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts v W Title 5 OfficialAnspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,a 82 Blanid Road Property Address ! Estate Of Joaquin Tavares Owner Owner's Name information is required for every Osterville MA 02655 page. City/Town 7/28/14 State Zip Code Date of Inspection ' ' P D. System Information'(cont.) Site Exam: ❑ Check Slope 1 ' ❑ Surface water ❑ Check cellar Ri ❑ Shallow wells k Estimated depth to high ground water: 25' i 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: Using topo and water contours maps ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: i You must describe how you established the high ground water elevation: see above i i.i k Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 f i .. ,�. Commonwealth of Massa9husetts Title 5 Official f Inspection Form Subsurface Sewage Disposal;System Form,-Not for Voluntary Assessments a 82 Blanid Road 4 Property Address Estate Of Joa uin Tavares Owner information is Owner's Name R .: required for every Osterville MA 02655 7/28/14 page. City/Town State ZipCode Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A ,B, C, D, or E checked ® Inspection Summary D4(System Failure Criteria Applicable to All Systems)completed ® System Information— ESt'imated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I is i r. i; It. t' r I. !1 . t5ins•3/13 d Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 17 of 17 a ti mds3performance- - Marvin w.i,ndows & Doors,, MDS Version 17.0, Build 1089 ,4S/31%2 - MDS RB Tabs Version 17.0 BUIid 897 MDS RB Code version 17.0 Build 1051 ' Product Performance Report Unit 1 -------------------------------- ------------------------- Unit ,Name: 01 call Number: WUDH2424 Frame Size: 29 3/8" x 29 3/8 Subtype: No Subtype GlazingTy e: Low E II Argon Glazin Thickness: 11/16" Insulating Glazing Color: Clear Operation: Double Hung --------------- -------------------q-------------------- Daylight opening: 7.31 Sq Ft Ventilation: 4.00 5 Ft Egress Net Clear opening: 4.00 Sq Ft Egress width: 25.86 In Egress Height: 22.25 In Energy Efficiency U value:. 0.31 Energy Efficiency R value: 3 3 ' Solar Heat Gain Coefficients t visible Light Transmittar�[C: it Energy Starr Design Pressure: For STC values click 1 performance values ,b6h S Page 1 I ' i �i rf- 1 ... re•, 1 � P.1'J J• F 0rCyrP 71 .f.. .0 VA to-.%D :7 IL y L a tk � sue± - � r