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0024 BRIAR PATCH ROAD - Health
24 BRIAR PATCH ROAD, OSTERVH,LE A= 143 029 � a 0 v l � Commonwealth of Massachusetts 43 6D2/ _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 24 Briar Patch Road M yv0y`ey Property Address } Charles Burns Owner Owner's Name 47 information is Osterville V Ma 02655 7/14/2017 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 A. General Information ,s filling out forms v�# � on the computer, T use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection Company Name 74 Beldan Ln. _ 1 Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com S14522 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 7/14/2017 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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. t5ins-3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 h -J I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 24 Briar Patch Road Property Address Charles Burns Owner Owner's Name information is required for every Osterville Ma 02655 7/14/2017 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: ® 1 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: The dwelling located at 24 Briar Patch Rd Osterville is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and a 1000 gallon leach pit. The system was found to be in proper working condition at the time of inspection. 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 f Commonwealth of Massachusetts _ u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Briar Patch Road Property Address Charles Burns Owner . Owner's Name information is required for every Osterville Ma 02655 7/14/2017 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 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 ❑ ND (Explain below): El 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 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Briar Patch Road Property Address Charles Burns Owner Owner's Name information is required for every Osterville Ma 02655 7/14/2017 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. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No 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 ❑ ® 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 1/day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Briar Patch Road Property Address Charles Burns Owner Owner's Name information is required for every Osterville Ma 02655 7/14/2017 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: ❑ ® 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 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design 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 ❑ ❑ 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. 15ins•3/13 Title 5 Official Inspection Form:Subsurface •Sewage Disposal System Page 5 of 17 P Y 9 Commonwealth of Massachusetts w . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Briar Patch Road Property Address Charles Burns Owner Owner's Name information is required for every Osterville Ma 02655 7/14/2017 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 ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered,_opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information 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 gpd 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 24 Briar Patch Road Property Address Charles Burns Owner Owner's Name information is required for every Osterville Ma 02655 7/14/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 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 Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: ` Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 f Commonwealth of Massachusetts H Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 24 Briar Patch Road Property Address Charles Burns Owner Owner's Name information is required for every Osterville Ma 02655 7/14/2017 page. City/Town 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 ❑ 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): t5ins•3/13 Tdle 5 Official Inspection Foam:Subsurface Sewage Disposal System•Page 8 of 17 f Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Briar Patch Road Property Address Charles Burns Owner Owner's Name information is required for every Osterville Ma 02655 7/14/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: original system installed 1984 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: 1 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: 1000 gallons Sludge depth: 6" t5ins•3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 9 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i Patch ~ M •� a 24 Briar atc Road s Property Address Charles Burns Owner Owner's Name information is required for every Osterville Ma 02655 . 7/14/2017 page. Cityrrown 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 3" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers, took measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 24 Briar Patch Road Property Address Charles Burns Owner Owner's Name information is required for every Osterville Ma 02655 7/14/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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.): I - "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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Briar Patch Road Property Address Charles Burns Owner Owner's Name information is required for every Osterville Ma 02655 7/14/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): 0" Depth of liquid level above outlet invert - Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was in good condition, no rot, water level was even with outlet invert. 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): If SAS not located, explain why: I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 24 Briar Patch Road Property Address Charles Burns Owner Owner's Name information is required for every Osterville Ma 02655 7/14/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit was found with 3.5' of standing water and a slight stain line only inches higher. No signs of past hydraulic overloading. 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 24 Briar Patch Road Property Address Charles Burns Owner Owner's Name information is required for every Osterville Ma 02655 7/14/2017 page. City/Town 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.): 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 i Commonwealth of Massachusetts u - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �<0 24 Briar Patch Road Property Address Charles Burns Owner Owner's Name information is required for every Osterville Ma 02655 7/14/2017 page. City/Town 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: 2 hand-sketch in the area below ❑ drawing attached separately l_e�k Sty � o 0 Z T1 13 g ( 2s 30 �J 6z 3° A3 31 D3 30 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GM 24 Briar Patch Road Property Address Charles Burns Owner Owner's Name information is required for every Osterville Ma 02655 7/14/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water El Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health explain: ❑ Checked with local excavators; installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 24 Briar Patch Road Property Address Charles Burns Owner Owner's Name information is required for every Osterville Ma 02655 7/14/2017 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked Z Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 NAME OF OFFENDER � BAR 76670 TOWS OF ADDRESS OFOFFENR �t BARNS`IABLE CITY,STATEnZIP-,DE ,may tl A G 3 Z.' oIFTK MV/MB REGISTRATION NUMBER n, OFFENSE— NAN\\'1'AeIY.. • //yr4-p'� s A- LJ 1IA55. p, 1 Vv' l`Md � �4��„I '4/!�'"'' '"'•ten' `y1 � TIME AND DATE OF VIOLATI 1 (� LjR;ATI OF V1 LATION-. I 1 Z NOTICE OF �'��13�� (.'. P-A-)ON!?f' ? 20 19)yTn.ti�t. t U5 �irtjt� J VIOLATION Slf�y¢T+PPO�F ENFORC1,413 RS% fENFORCING DEPT. BADGE NO. N OF TOWN 0 � � I FBI 413kINCKNOWLEDGE RECEIPT OF CITATION X a ORDINANCE © Unable to obtain signature of offender. THE NONCRIMINAL FINE FOR THIS OFFENSE IS S ItrD J Date mailed 1.1 LU w R YOU HAVE THE FOLLOWING ALTERNATIVES WITH REGARD TO DISPOSITION'OF THIS MATTER.EITHER OPTION(1)OR OPTION(2)WILL OPERATE AS A FINAL a DISPOSITION WITH NO RESULTING CRIMINAL RECORD. w REGULATION a (1)You;:Belect to pay the above fine,either by appearing in person between 8:36 A.M.and 4:00 P.M.,Monday through Friday,legal holidays excepted, y,r before:The rnstable Clerk,200 Main Street,Hyannis,MA 02601,or by mailing a check,money order or postal note to Barnstable Clerk,P. Box 2430, J Hyannis,MA 02601,WITHIN TWENTY-ONE(21)DAYS OF THE DATE OF THIS NOTICE. rl (/i2)If you desire to contest this matter in a noncriminal proceeding,yyou mayy do so by making written request to DISTRICT COURT DEPARTMENT,FIRST tlARNSTABLE DIVISION,COURT COMPOUND,MAIN STREET,BARNSTABLE,MA 02630,Attn:21 D Noncriminal Hearings and enclose a copy of this citation for a hearing. (3),If you fall to pay the above offense or to request a hearing within 21 days,or If you fail to appear for the hearing or to pay any fine determined at the hearing to be due,criminal complaint may be issued against you. 1 HEREBY ELECT the first option above,confess to the offense charged,and enclose payment in the amount of$ Signature Town of Barnstable PyaF sty royti . Regulatory Services RAitIVSTA6t.E.Q# Thomas F. Geiler, Director Y MASS. 0 Public Health Division rEo MAC a Thomas McKean, Director 200 Main Street,Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 May 6, 2008 Barnstable District Court Clerk's Office P.O. Box 427 Barnstable, Ma 02536 Re: Mr. Charles Burns: 508 Cotuit Bay Road Cotuit MA 02635 s a3 A BAR# 76670 ON,\— J To Whom It May Concern: 4 01-1— (o- 6-a'?- On April 8, 2008 I was conducting an investigation pertaining to rental properties which have not registered with Town of Barnstable rental program (Chapter 170). I was searching on Cape Cod Summer Rentals web site and foundf24 Briar,.Patch-Road,_Osterville, MA. This property is being offered for rent but is not registered vith said program. In accordance with what I am told by my superiors, I issued a ticket to ow ier Mr. Charles Burns. (BAR# 76670) Please see attached listing of said property. Sincerely, Timothy B. O'Connell Health Inspector iI Q:Health/Order letters/Housing violations/26 Louis Street vios corrected.doc 24 Briar Patch Road, Barnstable - Osterville, Massachusetts - Google Maps Page 1 of 1 . Address 24 Briar Patch Rd 3 A Osterville, MA 02655 r ✓ 'tF Ji Vw.7, L�'a'Ts fit. y^2 ..- ; �r� ow—"- "A tr F ` ✓ a fJa J {„F• 'S.�a{.t4� '...' m ��. '�`�' �va�f .ssr a. az�� '. {� y: � s• "% T11111- Al s ro i � � � s i-�" -k v t P• � Y } � �� ; N ✓,yam, k � � 9 �° Y 3 I � 3 ©200$C`gg9Jt p�c�ata©2Q08 NAUTEQT"" q rn s € 5 http://www.google.com/maphp?hl=en&tab=wl&q=24+Briar+Patch+Road,+Barnstable+-+O... 5/6/2008 f Cape Cod Summer Rentals - Cape Cod Vacations Homes - Massachusetts Homes for Sale Page 1 of 3 LISTING #YRO10 t r �: x =-•ia s Y 3 • r� t 3 � y rr j y � � e �' GENERAL INFORMATION Location: Barnstable-OsterviIIe I�ap data2aQ08 Tefe Atlas Terms'p#lle Distance To Beach: 2 miles to Gowns Beach Rental Price: $1,800 Rental Rate([Monthly Year Round) Price Description: Monthly Year Round with lease Spring Or Fall: Year Round Max. Occupants: 6 Pet Friendly: Yes/Dods Only Bedrooms: 3 Full Baths: 2 Half Baths: 0 PROPERTY DESCRIPTION Fenced in yard that was professionally landscaped with a`.1?2 foot retaining wall in front of a hill:. Hardwood floors.sY th open;;�athedral ceilings with a l aft in the rn<ain bedraona upstairs that overlooks the living room. Neutral tones throi:ghout. En oy a group gathering on the deck.This has the perfect contemporary open kitchen for chatting and cooking up a storm.A perfect Cape Cod home for someone wishing to live the Crape God way of life.A spacious,2400 sq feet of living space with semi Finished basement.Close to Dowers Beach so"tying lots of beach towels! [.his home has an attached one car garage and a circular driveway. A WORD FROM THE OWNER A perfect hone for Someone who is looking;for a peaceful and a very friendly,neic hborhood to 1:ve in.The elem ntary schorol is across the street!. http://www.capecodusarealestate.com/?pg=listings/details&listings_id=503 5/6/2008 ''ape Cod Summer Rentals - Cape Cod Vacations Homes - Massachusetts Homes for Sale Page 2 of 3 SPECIALS CURRENTLY RENTED UNTIL PARCH 2009..Please see other hares PROPERTY DETAILS Dist.To Beach: 2 miles to Dowes waterfront: Pond Acrross Street Beach Dock. No Water View: Yes, Pond Minimum Stay: One Year Max.Occupants: 6 Max. Cars Allowed: 3 Pets Allowed: Yes/Dogs Only Tub Or Shower: 1. Both/1 Shower BED & BATH DETAILS Sleeper Sofa: No Crib: No Alarm Clock: No • Linens Provided: No Hair Dryer: No Towels Provided No Washer: Yes Dryer: Yes, Laundry Roorn Iron: No . ironing Board: No ENTERTAINMENT TV: N0 Cable: Access Satellite: No VCR: No DVD: No Stereo: No CD Player: No Radio: No Tape Player: No Game Room: No KITCHEN Stove: Gas Stove Type: Gas Dishwasher: Yes Microwave: No Toaster Oven: No Toaster: No Blender: No Coffee Pot: No Lobster Pot: No High Chair: No INTERIOR DETAILS http://www.capecodusarealestate.com/?pg=listings/details&listings_id=503 5/6/2008 Health Master Detail Page 1 of I <<.. i --s '='�¢ _ .z. . t_JcK ed In As. ..t 0W .oconn€--- Health Mas t A!.-�niilario� Centor ? € Y! -W o �i Selection e R Parcel Septic 1 Pere; Well Fuel Tank Parcel: 14 -029 Location:x24` RIAR PATCH ROAD, O T R ILL' Owner: BURNS, CHARLES H &ROBYN T Business name:E, Business phone: I Rental property: FDeed restricted: ? Number of bedrooms Contaminant released: 17' Fuel storage tank permit: Save Parcet1Ghanges Return to Lookup Parcel Info Parcel ID: 1,43-029 Developer lot:I...OT 5 Location: 24 BRIAR PA-1 CH ROAD Primary frontage: 153 Secondary road:BOB WHITE CIRCLE Secondary frontage: 77 Village:OSTERVIL-E Fire district:C-O-MM Sewer acct: Road index:0179 r Interactive map: Town zone of contribution:WP (Wellhead Protection Overlay [district) State zone of contribution:IN Owner Infra Owner: BURNS, CHARL.ES I I £x ROBYN T Co-Owner: Streetl:508 COTIJIT BAY DRIVE Street2: City:COTIJIT State:MA Zip: 02635 Co6nt Deed date: 10/22/1998 Deed reference: 11779/334 s- Land Info Acres: 0.37 Use: Single Earn MDL-01 Zoning:IBC Neighborhood: 010� Topography:Above Street Road:Paved Utilities:Public Water,Gas,Septic Location: Construction Info i3 ilci r? ;r yc""r t33'w F fectiv€ �;re ftoro mis B3 lthrt,c+ry, 1 1984 1498 3 Bedroom 2 Full Buildings value:$151,100.00 Extra features: Q,700.00 Land value: $238,100.00 http://issql/intranet/healthMaster/HealthMasterDetail.aspx?ID=143029 6/6/2008 ✓ 'i OQ y�o BORTOLOTTI CONSTRUCTION, INC. ' 765 WAKEBY ROAD,MARSTONS MILLS, MA'02648 \ i rt 508-771-9399 568428-8926 FAX: 508428-9399 - r SUBSURFACE SEWAGE DISPOSAL SYSTEM 1NSPIECTION FORM PART A CERTIFICATION Property Address: 62V)e2�. 9hz ,4!1a&A.* D Date of Inspection: 7 Inspector's Name: ` ees Name and Address: CERTIFICATION STATEMENT! I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection. The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal s,I/stems. The System: V/ Passes Conditionally Pass Needs Further E atio y e Local Aproving Authority Fails Inspector's Signature: Date: The System Inspector shall sub t a copy of this inspection report to the Approving authority within thir- ty,(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.Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. A)rSY /MP ASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or,repaired. The system,upon comple- tion of the replacement or repair, passes inspection. Indicate yes,'nor,,or not determined(Y,N,OR ND). Describe basis of determinatirn in all instances. If not determined",explain why not. The septic tank is metal,cracked,structurally unsound,shows substantiff infiltration or ieAltration,outank failure is imminent. The system will pass inspection if the existing sep- :tic tank is replaced with a conformitig septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water.level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): - - 1 - r ' i y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System require pumping more than four 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 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 the public health,safety and the environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 vegetate wetland or a salt marsh. `k 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 Feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds.indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm• D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as deflrted in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent to the surface of the ground or surface waters due to an " overloaded or clogged SAS or cesspool. s Static liquid level in the distribution box above outlet invert.duc to an overloaded or clog- ; •• , , . • ; , A.. •, ; .. ged SAS or cesspool. Liquid depth in cesspool is less than G"below invert or.available volume is less than 1/2 day flow. . , • _ Required pumping more titan 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped 2- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continucd) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a;system is 10,000 gpd or greater(Large System)and the system is a significant. threat to public hcaldi and safety and the environment because one or more of the following conditions exist: 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. - .The owner or operator of any such system shall bring the system and facility into full compliance with the. groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: !fYumping information was requested of the owner,occupant,and Board of Health. `✓ None of the system components have been pumped for atleast 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. VII—As-built plans have been obtained and examined. Note if,they are not_available with N/A. 'The facility or dwelling was inspected for signs of sewage back-up. the system does not receive non-sanitary or industrial waste flow. fhe site was inspected for signs of breakout. systeM components,excluding the Soil Absorption System,have been located on site. _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was in- 4 spected fbi condition of baffles or tees,material of construction,dimensions,depth of liquid, Aepth of sludge,depth of scum. V The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) , The facility owner(and occupants, if difl'erent from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL. Design Flow: gallons Number of Bedrooms:_a Nuroer of Current Residents: Garbage Grinder: Laundry Connected'Co System: g Seasonal Use: Water Meter Readings,if ailable: Last Date of Occupancy: o��� 'COMMERCLALJINDUSTRIAL: Ab Type of Establishment: - Design Flow: - gallonstday Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy:_ OTHER: Describe) Last Date of Occupancy: _ r GENERAL INFORMATION x OMPING RECORDS and source of information: a .ds Is ICU System Pumped as part of inspection: If yes,volume pumped"_ Ions Reason for pumping: TYPgO SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool, Overflow Cesspool Privy Shared System(If yes,attach previous inspection records,if any) Other(explain): ROXIMATE A of all components date'nstalle (if known)and source o information: P S ge odors detect when arriving at the site: f�) e -4- r SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: ✓ Depth below.grade: Material of Construction:✓concrete metal FRP_Other (explain) Dimisions: Sludge Depth: Scum Thickness: AQ Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Z Comments:(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid 1 in lion too tlet invert,structural integrity,evide of leakage.etc.) IA .� GREASE TRAP:__Ji Depth Below Grade: Material of Construction`_concrete_metal_FRP_Other (explain) Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or Mille: '.comments:!(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage.etc.) TIGHT OR HOLDING TANK: Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other(explain) ''Dimensions: Capacity: gallons Design Flo%v: gallons/day Alarm Level: Qgnments: (condition,of inlet tee, condition of..alann and.floal:switches, etc.). . DISTRIBUTION BOX: Depth of liquid level above outlet invert: Comments: (note if 1 1 and distribution is equal,eviden a of solids carryover, evidence of 1 ge Into or out o box,etc.) -PUMP CHAMBERS .. ; Pump is in working order: Comments:(note condition of pump chamber,condition of pumps and'appurtenances,etc.) -5- SO SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 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,number:Leaching chambers, number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: Comments: (note condition of soil signs of hydraulic failu level of po in ,condijlon of vegetation., e . .. CESSPOOLS: . • . Number and configuration: Depth-lop of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of Cesspool: Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soilk,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) N i PRIVY: N)laterials Of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.)' _ t -6- r 'SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. i . . r DEPTH TO GROUNDWATER: Depth to groundwater: Feet Methqd of Detbrmination A p��aUon: -7- Commonwealth of Massachusetts ' Executive Office of Environmental Affairs u ACT 2 f0 - Departmenf of 4199 Environmental Protection VAIllam F.Weld `. emma Trudy Coxe EA David B.Struhs commhalorro� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: �j��'�r1QQ j TY'Ca,) Address of Owner: R a. Date of Inspection:/(j./3 jS (If different) Name of InspectoK. �e �, �t> , Company Name,Address and Telephone Number 6gdfr ( zlp1 ,y �Un� L C• 'y(Q 5Cc7Gr�f'�vi 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: ✓_/Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the s,,stem owner and copie, sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C,or D: AJ SYST M PASSES: 7I have not found an information y anon which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. Bj SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/9S) One Wk tir Guest a Boston.IMoomhuseea 02108 a FAX(817)t>i6-1049 a TW"hone P17)Epp - 0 Prinbd on ttecyded Pap.► SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:c:?"V �'r1'C? ^P0k-'11 ppQd Owner. i'jgao6eco %—�Jc Gt fq Date of Inspection: BJ SYSTEM CONDITIONALLY PASSES (continued) _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced �T obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four 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 Cl 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface wales supply ui 166ulary to a surface water supply. _ The system ha, a septic tank and soil absorption system and is within a Zoned of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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 D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or dogged 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. (revised 6/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIF CATION (continued) Prop Address:,pS� �('rl2f' O�f� Property _ 61 Owner: /Ylc� -hew Date of Inspection: D)SYSTEM FAILS(continued): 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 5" below invert or available.volume is less than 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwa ter elevation. _ Any portion of a 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 acesspooI 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic:compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST r�Ile Property Addressc2(// Owner: ma o(-�e 4) 9Q� Date of Inspection: to,/3-95 Check if the following have been done: Zumping information was requested of the owner, occupant, and Board of Health. 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. "he facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow The site was inspected for signs of breakout. vAll system components, excluding the Soil Absorption System, have been located on the site. l/The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. L-�_The facility ov ner (and occupants, if differen! from owner). were provided with information on the proper maintenance of Sub- Surface Disposal System. trevieed 9/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C /,� SYSTEM I ORMATION Property Address:� USG/'�DCt"��, 7G e., o Owner: Date of Inspection: /0 VS FLOW CONDITIONS RESIDENTIAL:ESID : , Design flow: 33�gall ns Number of bedrooms: c Number of current residents: T Garbage grinder(yes or no):—Teg Laundry connected to system yes or no):,Vt Seasonal use (yes or no): Water meter readings, if available: Last date of occupancy: COMMERCIAUINDUSTRIAL• /✓/ Type of establishment: Design flow: gallons/day 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and Source of informatio System pumped as pan of Inspection: (yes or nova If yes, volume pumped: gallon Reason for pumping: t= TYPEOF STEM 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) Other(explain) j APPROXIMATE AGE of all components, date installed (if known)and source of information: Sewage odors detected when arriving at the site: (yes or no) (revised 0/15/95) S n SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C TEM INFO TION (continued) Property Address: 3r�G� � 04 Owner: OctGW�eco Date of Inspection: SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction: concrete _metal _FRP —other(explain) Dimensions: Sludge depth: rI a Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:f6_ Distance from top of scum to top of outlet tee or baffle: Over TD�// Distance from bottom of scum to bottom of outlet tee or baffle: Z Comments: (recommendation for pumping, condition of inlet and outlet tees or b ffles, depth of liquid level in rejatioq_jq outlet invert,.structur . integrity,evidence of leakage,..etc.) //.fQ r - GREASE TRAP:a4 . (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom nt seism t- bottom of.outlet tee or baffle - Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 6/15/95) 6 n _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORRM))ATIO (continued) Property Address; 3^;'- QC% �S Owner: MC-,eJ Q Date of I spe Don: /O /3_ i' TIGHT114- (locate O RH OL DING TAN on site plan) Depth below grade: Material of construction: ct on: concrete metal FRP oth er x_ e lain _ P Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float-switches,,etc.) DISTRIBUTION BOX:_ w - (locate on site plan) Depth of liquid level above outlet invert:_4)64';q Comments: r e if level and distri utio^ is equal, eviden e of soli s car •over evidence of I kage into or out of box, etc. V. PUMP CHAMBER: 14 (locate on site plan) , Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) tzevieed 8115195) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFO TION (cont n gd) t� Property Address- Owner:�Ct d'�,3Fj Date of nl spection: 3 SOIL ABSORPTION SYSTEM (SAS): (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, number.1 leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydr ulic ailure, le el of ponding, co di 'on of vegetation,etc.)2'(S q CESSPOOLS: (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised B/15/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYS EM INF-OJRMA�W,Nj((cconnttinued)) Property Address: ( 6�C% V Q`✓�� v �/i� Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' � % ° C DEPTH TO GROUNDWATER Depth to groundwater:_feet method of d terminat' n or approximation: /`/ !"�ii`'/ � 7�9ryj J� �� ��`. �/�l8e-7 (revised 9/1S/9S) 9 TO OF BARNSTABLE LOCATION SEWAGE # VILLAGE ASSESSOR' MAP & LOT NAME&PHONE NO. SEPTIC TANK CAPAC= LEACHING FACILITY: (type) �t �f� (size) NO.OF BEDROOMS BUILDER O OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet. Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by LC�� I � 711,ei `30 30' 3 f LOCATION �' SEWAGE PERMIT NO. .,E c d 6JII;?�o Lai- 93 VILLAGE OSTE2U rcc �(NSTA LLER'S NAME & ADDRESS �D D U I L D E R OR OWNER DATE PERMIT ISSUED Mt .� 3 DATE COMPLIANCE ISSUED � 1 ���� ov'* r .....,...... �d1w THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH �''r�✓"'" a All = :........ 0-kp lirFa#ion for DwvaaFal Vorkii Towitrurtion Vamit Application is hereby made for a Permit to Construct (✓ ) or Repair ( ) an Individual Sewage Disposal System at: - � 1 ._y✓�1.!.I!�... � �L C_K1L � :...aMA Location-Address or Lot No. ........... ...... � Owner d s a / ��Y.��� � "!,/Y- ---------------------------- Installer Address Type of Building Size Lot..U_�_4�'7�I.....Sq. feet Dwelling—No. of Bedrooms........... ............................Expansion Attic ( ) Garbage Grinder ( ) a Other—Type T e of Building _.._.. No. of _...... Showers ( ) — Cafeteria ( )Pa YP g ------ -- - ---=- persons_.......------------- Q, Other fixtures ..__........ Q ' W Design Flow---------! .!. ...........................gallons per person per day. Total daily flow-------� .......................gallons. WSeptic Tank—Liquid capacity.. AC//_.gallons Length.h-r.17_. Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width...l.____.........._ Total Length........... ._ Seepage Pit No..__....-._ Total leaching area_______....•........sq. ft. l_________ Diameter...._1t__........ Depth below inlet �......_. Total leaching arealftt s8 sq. ft. Z Other Distribution box ( ►/f Dosing'tank ( ) aPercolation Test Results Performed by._-.LO_ J`1_.E (. .......................................... Date....r7_..:.14,:. 7?1�-------.__.. Test Pit No. 1-----P .....minutes per inch Depth of Test Pit...... .......... Depth to ground water_-__--�.--_..._-_-___. 44 Test Pit No. 2......�-----minutes per inch Depth of Test Pit.__...VZ........ Depth to ground water----N, 4.6-___. a' ----•..............•-------••••••••••••••••••••...•--•-•-••••............................•... •............................................................ Description of Soil..................... ' .. . ✓t3.1.afL-t �'� r � G' �0!�l�L�( .FV.>►A�jv x w x -------------------------------------------------------------------•---••-••••••---•-••--••••••••••---••----•••------------•-••---••••••------•••••••----•-••-•••••••-•••••••-••-••............---••-•- U Nature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------------------------- .......................................... ...........................................••-------------------••-•-••----------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary d/— Th ndersigned further agrees not to place the system in operation until a Certificate of Compliance has b oard of health. Signed. .. .................................................... 14".j �i� Date ApplicationApproved By-•--••-•-•••••••-•••-•••-•-••••.....•-•••••••••--•---•-••-••-----•......-•-•--•-•-•••.....•..... ........................................ Date Application Disapproved for the following reasons:---•--------------------------••----------------------------------------------------.-------------------------- •••••••-•-•••-••-•--•---•-•--•-•••-•-•-----•-••••••--•--••••••----•••-•-•....--•--•----------•••-••--•----------•--•--•--•••••••••----------•---••----•---••-••••••••---•••-•••••----•-••-•••--•----•--- Date PermitNo......................................................... Issued....................................................... Date rro._�.3 Sly .. _............ FEs 1 THE COMMONWEALTH OF MASSACHUSETTS / BOARD OF HEALTH I .Ily.1.V.... -----------------OF.............. �. \..C�/J�_4f -�� _ .... Appliration for Dispoii al Works Tnnitrnrtinn ramit Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal System at: %i vr�l �( !tl:.iC.E;MA. ._...._.. ---••• .... Location-Address _ or Lot No. Owner Address W Installer Address d Type of Building Size Lot__I_e i ,7�, Sq. feet Dwelling—No. of Bedrooms____________ ____________________________Expansion Attic ( ) Garbage Grinder ( ) `•4 Other—Type e of Building p,, yp g ....... ........... No. of persons____________________________ Showers ( ) — Cafeteria ( ) a' Other fixtures .----•-----••-- •--------•----- . W Design Flow.........-/.`1�...........................gallons per person per day. Total daily flow-------_��-`�__ ______._.._ ............ WSeptic Tank—Liquid capacity._o V.gallons Length.`J. _Q.:_ Width---------------- Diameter_..-___......... Depth___•-__.-_-_-__. x Disposal Trench—No. .................... Width....;............... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-----------!--------- Diameter.....1�__.__...._ Depth below inlet..... ........... Total leaching area..Z.0'.� sq. ft. Z Other Distribution box ( ✓f Dosing tank ( ) Percolation Test Results Performed .......................................... Date..... _ n��` Test Pit No. 1......k-----minutes per inch Depth of Test Pit--------7. Depth to ground water---------7.............. 44. f `f'-JTest Pit No. 2.........Z.....minutesper inch Depth of Test Pit-------Lz-------- Depth to ground water....N-N_6.... P ----------------------------------------- •------••-------------------....-------•--•---•----•---•---------------....-.....---•-•-----------•-------••-- D Description of Soil--------------------C%_-. .......-1. :._r..�....LL-11,0 5 4' �� - (Z L!�I G-Gsi�V?H�G.T_F_�7�6 t7 "� W UNature of Repairs or Alterations—Answer when applicable.______________........_____________________________............................................ . ----------••-----------••--------•.............•. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT1Z 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed..................................................................................... ................................ Date ApplicationApproved By--•--•----------•---••-•-•--------------•...-•--•------------•-••-•----------------------------•• ........................................ Date Application Disapproved for the following reasons----------------------------••-------•----------------------------------------------------------------......•••-- •................•-•------••-•--•...-••-••------------•---•-•------------.....------......•••----------•-'•----------•-------••-•--------•---•----•-----•--•--------------•----•------------------•------ Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Tler#ifiratr of TnmtrliFanrr THIS IS TO CERTIFY, That th In ividual Sewage Disposal System constructed ( ) or Repaired ( ) by------------------------------------------------ ...................................ZZ............................ ...--•••..............._ Insta has been installed in accordance with the provisions of TITI E ' of The State Sanitary Code as described in the application for Disposal Works Construction Permit No...................'__` .... dated------------------------------------------------ THE ISSUA1 CE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY.DATE............................................... 8 y h Inspector------.... `— ' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......................................OF..................................................................................... No...................•••••• FEE........................ �����i 1 nrk� ��an��rUan rrani� —Be��rm...ission is hereb g ited ---•---------------•------------------------•-----•---•--..._....-••---•---•••-----•-•...•-------....------•-----......••- to�1 7lfstrue�t ( )rid( A a I avid Se* e Disposal S st Y at No.•=................. ------------•--•-•---------•-•�-----------------.-----.-------...----------•----- ��--••-•--•-- t. Street as shown on the,aAplication for Disposal Works Construction Permit No.............. ................................. Board of Health DATE............................................. -----------------------------•---- FORM �5 HOs96S & WARREN. INC.. PUBLISHERS S1 TE PL AN I TYPICAL PROFIL E SCALE — 1 NOT TO SCALE 18 ST©. L T. WG T C.I. MH CO VER ._.-._� c- { --�• 1 4"C!. PIPE ___ __... __ 4"BIT FIBER PIPE TIGHT „,DINTS _ -- --FLOW LINE ._ OUTLET L E VEL7 _---� 77 TO FIRST JOINT } OW�: 77- _L L ING 1 �5. �/0 o o _ _ _j_:_ I - -- C. TEE C.I. TEE `b 1 - STANOARD PRECAST 3 '8 4 — L --,— ( , ( CONCRETEI oe0 GALLON SEPTIC TANK DISTRIBUTION BOX i 8,> TO BE INSTALLED ON J _ LEVEL , STABLE BASE I f f SEPTIC TANK � 1 f TO BE INS TA L L EP ON j LEVEL , STABLE BASE .. ° \ i VL I.4 2"- l/8" TO 1/2" WA SHED PEA STONF t EA CHI,NG PJ T STD, ALL AROUND FREE OF IRONS, FINES BASE TO BE L EVFL fy c lr �A�u 8A,51tJ _ AND DUST IN PLACE 8R!?'K 3 MORTAR COUR£S 3/4" TO /-//2 ` WASHE✓ CRUSHEO r $� A';, REOUIRED TO BRING ✓r �- Ci'> =R TD GRADE 24"C, i. MH COVER STONE ALL AROUND FREE OF "_.___ -- -� AND FRAME !RUNS, FINE., AND ✓DUST IN °LACE — ------ — V. �,� 4" __1 - � _ =_ LEACHING PIT SECTION-- dU `-�T 4 INLilT -- `--_ FLOW L lN£ , , ( _- { '— - - .� ~� 1 I CONCRETE TO BE 4000 PSI 28 DAYS 7 I i -- 6„ 2. REINFORCED WITH 6" x 6" N0. 6 GA. W.W.M. v f 3. 2' AND 4' SECTIONS ARE AVAILABLE FOR GREATER L N nRvp. 09 DYIL . ;_POT 5 ' � ` f i DEPTH REQUIREMENTS. OPENING WITH 4-1/8" ` 4. NUMBER OF PITS REQUIRED vN4 PZoI.} 44 ` ' 0 OUrE.R DIAMETER B Z I-3/4 INSIDE DIAMETER I NOTE 7�'q"EXCAVATE TO ELEVATION _OR LOWER AS �' ''�� " , 36 _' _ 3 _ REQUIRED TO REMOVE ALL LOAM AND CLAY BENEATH PIT. REPLACE EXCAVATED MATERIAL WITH CLEAN GRAVEL TO DESIGNED GRADE a4 �✓ rri- 31 4 MIN EFFFCTIVE DIAMETER c p,� L (NOT TO EXCEED 3 TIMES EFFE-CT/VE DE°TH) I 15,vp' r . WATER TASL E -�.��... SU'L AND F EI-C. 0,4 TA ------ SENERAL NO TES PERC. RATE '. MIN. /IN , i? ZU14 NO HEAVY EQUIPMENT TO RIJN OVER SYSTEM -.J a �{ t l t.l } SEPTIC TANK, DISTRIBUTION BOX , LEACHING PITS TO BE STANDARD TEST BY -� — -- ------- -- --- PRECAST REINFORCED CONCRETE UNITS WITNESSED BY J,_b' e 49 Cr'—1 r> � ' �'_' ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE TO REVISED TITLE 5 OF TKE STATE ENVIRONMENTAL CODE , TES-) PIT GR. EL. _ _ ,o DATE ' G?' i�._ _ MINIMUM REQUIREMENTS FOR THE SUBSUFACE DISPOSAL CF TIST P:T NO. 1 TEST PIT NO SANITARY SEWAGE EFFECTIVE I JULY 1977 0' - -- --, 0" ---- ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE 4 Tv/�:: >',.r,satl.r 3, Tvt°�SU'�hvtL BOARD OF HEALTH. I {�y.�jy AT COMPLETION OF CONSTRUCTION , PRIOR TO BACKFILLING, THE ;\.V7.15AN;i 1 4amFW--fW r-11.tG BOARD OF HEALTH SHALL BE NOTIFIED FOR INSPECTION. -! NA PITCH ALL SEWER LINES 1/4" ;` FT. UNLESS INDICATED J--- OTHERWISE. # N DE,`16N DATA BEDROOMS _____. �} DISPOSAL EST. TOTAL DAILY EFF. GALS. LEGEND FEND -- SEPTIC TANK L�7�.w— GAL . .. SIDEWALL AREA ._._� �_— GAL /SO. FT BOTTOM AREA _________�'.L GAL.ISO. FT r- w5AZ , ,r a x00 EXISTING GRADE LEAcl�ING REuUIREO�? :%1!�°_. sQ FT Sc WAGE D/` JP(�, . c> T� /v! 0 0o FINISHED GRADE LONE ._-_._ �_.__ � ACTUAL LEACHING AREA FT FOR DOMESTIC WATE F SOURCE: T a w N �[ C �' - r�r� INVERT ELEVATION `1' �� - _ _ _ -- -- Wy 1r a-r „ r PROPERTY LINE >,` fly V ! 1�'A >ll � A ►rl A„�<, PLAN REFERENCE_ ' �-�� PGa -4?1 SCALE: '� _ _ 'r L E A S INDICATED t,A �� 1�- � � L MEAN HIGH WATER' - BENCH MARK P NAV Al AA)5'W1CX 9 A 550CIATE S 3 A'TUM: L) !j2 `� _�+�.� � � = - -► MARSH BOX 801 - NL--)q rH FAL 4fOC:'TH t;HOSE T I 0,9 5.56