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Home My WebLink About0066 CAPTAIN ALDEN'S LANE - Health -66 Captain ; ldes_ Lade Osterville r a I� 0 o t i Commonwealth of Massachusetts Title 5 Official Inspection Form iI; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 66 Captain Aldens Lane Property Address Eric&Joanna Flynn Owner Owner's Name information is required for every Osterville Ma 02655 2-1-2021 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 on the computer, use only the tab Brett Hickey key to move your Name of Inspector cursor-do not B&B Excavation Inc. use the return Company Name key. 374 Route 130 r� Company Address Sandwich Ma 02653 City/Town State Zip Code WSW- 508-477-0653 S113747 Telephone Number License Number I B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 2-1-2021 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 r v , Commonwealth of Massachusetts ....... Title 5 Official Inspection Form -- i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 66 Captain Aldens Lane Property Address Eric&Joanna Flynn Owner Owner's Name information is required for every Osterville Ma 02655 2-1-2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1),,System Passes: ® 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: System was in working order at time of inspection. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5insp.doc-rev.7/25/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts A - Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 66 Captain Aldens Lane Property Address Eric&Joanna Flynn Owner Owner's Name information is required for every Osterville Ma 02655 2-1-2021 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 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): ❑ 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts .- _ 0 Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 66 Captain Aldens Lane Property Address Eric&Joanna Flynn Owner Owner's Name information is required for every Osterville Ma 02655 2-1-2021 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 coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters El ® 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 i Commonwealth of Massachusetts �e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 66 Captain Aldens Lane Property Address Eric&Joanna Flynn Owner Owner's Name information is required for every Osterville Ma 02655 2-1-2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 66 Captain Aldens Lane Property Address Eric&Joanna Flynn Owner Owner's Name information is required for every Osterville Ma 02655 2-1-2021 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? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.726/2018 Title 5 Official Inspection Foam:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 66 Captain Aldens Lane Property Address Eric&Joanna Flynn Owner Owner's Name information is required for every Osterville Ma 02655 2-1-2021 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 441/GPD Description: Number of current residents: 4 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 ears usage e d See below 9 ( Y 9 (gp ))� Detail: 2020-42,000gallons 2019-55,000gallons Sump pump? ❑ Yes ® No Last date of occupancy: CurrentDate t5insp.doc-rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts n - _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 66 Captain Aldens Lane Property Address Eric&Joanna Flynn Owner Owner's Name information is required for every Osterville Ma 02655 2-1-2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: NA 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: Owner-last pumped 4 to 5 years ago 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 Commonwealth of Massachusetts �s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c A, !1 66 Captain Aldens Lane Property Address Eric&Joanna Flynn Owner Owner's Name information is required for every Osterville Ma 02655 2-1-2021 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: New SAS added to existing tank in 2005 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 211" feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: town feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts ��= r Title 5 Official Inspection Form 1 l� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 66 Captain Aldens Lane Property Address Eric&Joanna Flynn Owner Owner's Name information is required for every Osterville Ma 02655 2-1-2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gallon Sludge depth: 10" Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness 2 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 15" 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.): The tank was in working order when viewed. The tank is not in need of pumping at this time but should be pumed every 2 years for maintenance. t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c � 66 Captain Aldens Lane Property Address Eric&Joanna Flynn Owner Owner's Name information is required for every Clsterville Ma 02655 2-1-2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: NAfeet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ® other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle S 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: NA Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts q� == = _- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 66 Captain Aldens Lane Property Address Eric&Joanna Flynn Owner Owner's Name information is required for every Osterville Ma 02655 2-1-2021 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.): The d-box was in working order when viewed. 1 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts d --r Title 5 Official Inspection Form - -- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 66 Captain Aldens Lane Property Address Eric&Joanna Flynn Owner Owner's Name information is required for every Osterville Ma 02655 2-1-2021 page. City/Town 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.): NA * 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) 500 gallon chambers ❑ leaching galleries number: ❑ leaching trenches number, length: I ❑ 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 Commonwealth of Massachusetts =� Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 66 Captain Aldens Lane Property Address Eric&Joanna Flynn Owner Owner's Name information is required for every Osterville Ma 02655 2-1-2021 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.): The SAS was in working order when viewed. Leaching was dry when viewed. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration s NA 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 66 Captain Aldens Lane Property Address Eric&Joanna Flynn Owner Owner's Name information is required for every Osterville Ma 02655 2-1-2021 page. City/Town State Zip Code Date of Inspection 9 P D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form,-Not for Voluntary Assessments u 66 Captain Aldens Lane Property Address Eric&Joanna Flynn Owner Owner's Name information is required for every Osterville Ma 02655 2-1-2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately J� OR' N) 2- a, ry �A k � t Si II y x.mod: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts a - 03 Title 5 Official Inspection Form ~ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 66 Captain Aldens Lane Property Address Eric&Joanna Flynn Owner Owner's Name information is required for every Osterville Ma 02655 2-1-2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar I ® Shallow wells Estimated depth to high ground water: >5' below SASfeet 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: 1/31/2005 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: A plan on file with local Board of Health was used to determine high ground water. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts w� - � Title 5 Official Inspection Form ....... .... I4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 66 Captain Aldens Lane Property Address Eric&Joanna Flynn Owner Owner's Name information is required for every Osterville Ma 02655 2-1-2021 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed& Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1,2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 IC Commonwealth of Massachusetts Title 5 Official Inspection Form reC�� 0��01 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments f&.L �� G M s 66 Captain Aldens Lane Property Address Select Portfolio Services Inc. Owner Owner's Name information is required for Osterville MA 02655 03/25/10 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. Important:When filling out A. General Information forms on the I computer,use 1. Inspector: only the tab key to move your Michael Kellett cursor-do not Name of Inspector use the return key. Aardvark Environmental Inspection Company Name P.O. Box 896 Company Address East Dennis MA 02641 City/Town State Zip Code 508-385-7608 S13742 Telephone Number License Number B. Certification ---4 I certify that I have personally inspected the sewage disposal system at this address and that: he 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-jgf on sfde sewage disposal systems. I am a DEP approved system inspector pursuant to Section 45.3340,, Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails; ❑ Needs Further Evaluation by the Local Approving Authority `w 9-j `"�� G 03/25/10 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. i ****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. f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 66 Captain Aldens Lane Property Address Select Portfolio Services Inc. Owner Owner's Name information is Osterville MA 02655 03/25/10 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND) in the❑for the following statements. If"not determined,"please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced obstruction is removed Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 66 Captain Aldens Lane Property Address Select Portfolio Services Inc. Owner Owner's Name information is required for Osterville MA 02655 03/25/10 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 66 Captain Aldens Lane Property Address Select Portfolio Services Inc. Owner Owner's Name information is required for Osterville MA 02655 03/25/10 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100,feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria 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 ❑ ® 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 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 El ® tributary to a surface water supply. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 66 Captain Aldens Lane Property Address Select Portfolio Services Inc. Owner Owner's Name information is required for Osterville MA 02655 03/25/10 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cunt.): Yes No ❑ ® 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. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s ay'v 66 Captain Aldens Lane Property Address Select Portfolio Services Inc. Owner Owner's Name information is required for Osterville MA 02655 03/25/10 every page. City/Town 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 mote 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)] i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 66 Captain Aldens Lane Property Address Select Portfolio Services Inc. Owner Owner's Name information is required for Osterville MA 02655 03/25/10 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 09/09Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day y(gam) 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: Last date of occupancy/use: Date Other(describe): I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 66 Captain Aldens Lane Property Address Select Portfolio Services Inc. Owner Owner's Name information is required for Osterville MA 02655 03/25/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (f known) and source of information: 2005 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 66 Captain Aldens Lane Property Address Select Portfolio Services Inc. Owner Owner's Name information is required for Osterville MA 02655 03/25/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 1.7 Depth below grade: 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.): Septic Tank(locate on site plan): Depth below grade: 0.9 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 gal Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 27" Scum thickness 3„ Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? measured Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 66 Captain Aldens Lane Property Address Select Portfolio Services Inc. Owner Owner's Name information is required for Osterville MA 02655 03/25/10 every page. City/Town 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.): The tank was sound and tight with tees in place and liquid at outlet invert. 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.): 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): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 66 Captain Aldens Lane Property Address Select Portfolio Services Inc. Owner Owner's Name information is required for Osterville MA 02655 03/25/10 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cunt.) 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.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert even Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The box was level and tight with no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No I , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s 66 Captain Aldens Lane Property Address Select Portfolio Services Inc. Owner Owner's Name information is required for Osterville MA 02655 03/25/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overFlow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): The system has three five hundred gallon drywells in a thirteen by thirty-two foot stone field.There was no sign of ponding or failure in the stones. I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 66 Captain Aldens Lane Property Address Select Portfolio Services Inc. Owner Owner's Name information is required for Osterville MA 02655 03/25/10 every page. CitylTown State Zip Code Date of Inspection D. System Information (cunt.) 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.): 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.): i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fort-Not for Voluntary Assessments M 66 Captain Aldens Lane Property Address Select Portfolio Services Inc. Owner Owner's Name information is Osterville MA 02655 03/25/10 required for state Zip Code Date of Inspection every page. Cityrrown D. System Information (cunt.) Sketch of Sewage Disposal System:Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 66 Captain Aldens Lane Property Address Select Portfolio Services Inc. Owner Owner's Name information is required for Osterville MA 02655 03/25/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 20.0 feet i 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: USGS maps show an elevation of over 20.0 feet. Certified Mail#7006 0810 0000 3525 2940 •° '"�' �. Town of Barnstable a� Regulatory Services MASS, $ Thomas F. Geiler,Director ��f4A�m Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 6W�tT s f 4,f be a rr*4* FMr'( On In A600jP. May 4V4 August 9, 2007 Adalgisa Alvarez ^� A 4 0%00l .vo --4. hO 10Aer oJ►�+. 66 Captain Alden's Lane Dc R,�- (( / � g Osterville, MA 02655 ` l oo"1 a��`f �'�e. r~tc�owM�r• A�os-� r7'41er s� re 44y vv�#%% 7 iJvr* NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II — MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE CODE CHAPTER 170. The property owned by you located at 66 Captain Alden's Lane Osterville, was inspected on August 8, 2007 by Timothy B. O'Connell, Health Inspector for the Town of Barnstable. This inspection was conducted on the basis of a complaint. The following violations of the Town of Barnstable Code were observed: 1& 70-9—Parking Restrictions. Driveway observed to be greater then 25% of front yard. You are directed to correct the violations listed above within thirty (30) days of your receipt of this notice by reducing the driveway size to be no more 25% of the front yard by using timbers, grasses, cinder blocks, fencing, etc. You may request a hearing before the Board of Health if written petition requesting same is received within ten(10) days after the date the order is served. Non-compliance will result in a fine of $100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have any questions regarding the above violations, please contact the Town Health Division and ask to speak with the inspector who performed the inspection. PER ORDER OF THE BOARD OF HEALTH QAOrder letters\Housing violations\Rental ordinance\66 capt alden's.doc Thomas A. McKean, R.S., CHO Directorr of Public Health Town of Barnstable Cc: Timothy B. O'Connell, Health Inspector QAOrder letterMousing violations\Rental ordinance\66 capt alden's.doc TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE I1:MINIMUM STANDARDS FOR HUMAN HABITATION Date o d Owner �1if4 r1 J."e Z-- /I /l Tenant Address �p� Cti �e�! Q� UdYfn.. (P Address Compliance Remarks or Regulation# Yes No Recommendations 2. Kitchen Facilities 3. Bathroom Facilities A. Water Supply 5. Hot Water Facilities 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits Nd (d MA a-P l.dMM 'fj�Pcl/u Pr 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal ��ad►t 2 r 17. Temporary Housing I 0iier Cj^I• yd�.e •�x�' d �r lfS� � I_P � ludo T'M 15s�� a�Pc�r>PSr� o�� PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition F v -. o,J,,4-r. V Person(s) InterviewedPr"ll ,l s Inpec �- If Public Building such as Store or Hotel/Motel specify here J U^ o 1 P- TOWN OF BA(R�NSTABLE LOCATION 1(� lD _�Ct "`"Ci�r� �c�L�N SEWAGE # V ILT AGE `' LeASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY I LEACHING FACILITY: (type) (size) NO.OF BEDROOMS '— BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 � r 3, A 31 � dv� f t, No. 00 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pprication for ;Mi,5poga1 Opotem Construction Permit Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. ��vi ire L� ��Lincc� CflS�Y Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. � r�s Ss�;L S')c• s�� av s�C1. Type of Building: Dwelling No.of Bedrooms Lot Size 13.1, n14 sq.ft. Garbage Grinder( ) Other Type of Building 7-,�OC�IL No.of Persons t2 Showers( ) Cafeteria( ) Other Fixtures L � � —Kac. r \k- \.Ago m_y Design Flow 14 4r) gallons per day. Calculated daily flow 4 41 sz) --gallons. Plan Date ;S\ Number of sheets Revision Date Title Size of Septic Tank Eig zT Ng pe of S.A.S. 41 Q C A Q-� Description of Soil - O 'moo hysfs Nature of Repairs or Alterations(Answer when applicable) `ter C��edl 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 provision of Title 5 of the E ironment 1 Code and not to place the system in operation until a Certifi- cate of Compliance has been issu b t 's Board f e lth. Signed ! Date Application Approved by yW $ Date 3 Application Disapproved for the following reasons Permit No. 2 yd 0 y� Date Issued p Ir ai A kof ,� ( - O�S — O�q �\ � i ;.�,i,�,�q�. Fee ibU - o THE COMMONWEALTH OF MASSACHUSETTS Entered in Yes computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Ofpprication for Mi0po0al bpgtem Construction Permit Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. Owner's-Name,Address and T4.No. Assessor's Map/Parcel i zxo Installer's Name,Add s,and Tel. o_ Designer's Name,Address and Tel o. � L ��c. sHa� �,�v, S�JCSf, ,0 Type of Building: Dwelling No.of Bedrooms Lot Size ` �� sq.ft. Gazbage Grinder( ) Other Type of Building — No.of Persons oZ Showers( ) Cafeteria( ) Other Fixtures Design Flow 440 gallons per day. Calculated daily flow 41 ,sz) gallons. Plan Date 3 Number of sheets Revision Date _ Title f ... Size`of Septic Tank EK t ST Q�00 GC` -tfC�Type of S.A.S. Description of Soil �G . I Nature of Repairs or Alterations(Answer when applicable) 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 system in operation until a Certifi- ca�e of Compliance has been IIYAA �'d by this Boardrofll ealth. Signed Dat Application Approved by 'Vv, _. 5(:�) Date 2- _U Application Disapproved for the following reasons r Permit No. 00 S' yy Date Issued ` 3 5 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CEMI nm he On-site,Se�e Disposal System CJnstructed( )Repaired ( )Upgraded�(V) Abandoned( )b.1 / ��'/ at 1 , m aen lune, t rrV I < < r has been constructed in accordance with the p�ojvisrons of Tit d the for Disposal System Construction Permit No.a G'S;Q y dated Installer_ 1XVU ey Designer t The issuance of this permit shall not be construed as a guarantee that the system Milleton�.as designed.Date Inspector - 1q _ n; No. Fee- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mi$pozal bpgtem Congtruction permit Permission is hereby grant d to C s )R7619- , Hpg (_ Abandon System located �/ ((i )fo v and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title6 and the following local provisions or special conditions. (� Provided:Construction must be completed within three years of the date of th si permit! c Date: - .- 05 Approved by of 41'`.1, v I Town of Barnstable Regulatory Services Thomas F. Geiler, Director + BARNSTABLE, MASS, �0� Public Health Division A'E019. Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: o l Designer: �1G G , Installer: Address: Address: On S- was issued a permit to install a (date) (installer) septic system at U(o o�Vlx � �i^ �, based on a design drawn by �1 (address) Z�l U,c J\ICS , dated (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 certified as=built by designer to follow. sti oI.if MaS staller s Si ur o s�cy. o�: CJ� E iVG� u 4 SHAY Nos 1181 (Designer's Signature) (Affix De v�, ere) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVIS N. 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 w � y "0. 3-0 3' ✓' �9 y/ / ' �dV{./ L�'V'is � �' P 4f» j '` .�tls :: �i� Logged In As: rc Tuesday, August 21 2007 Pa Detail „t� r�k�� ii-p P Parcel Lookup r Parcel Info er Parcel ID 1146-088 Developoot LOT 7 .....__ _..._.,, ..__ - .. _. .. ,. �......._ Location 66 CAPTAIN ALDEN'S LANE Pri Frontage 103 ... ....... ......... ....... ............... ................. Sec. Sec Road Frontage Village OSTERVILLE Fire District jC-O-MM ......., . - -.._ . Sewer Acct? Road Index 0234 Interactive Map3 A �F �s Owner Info r.._........ Owner'ALVAREZ, ADALGISA D Co-Owner Streetl 3 MANCHESTER RD Street2 city YARMOUTHPORT state MA zip 02675 Country USA Land Info __ ..... _ ..............�. ._............ ... _ _..� _ _. ......,,. �,. Acres 10.40 Use jSingle Fa m MDL-01 Zoning SRC Nghbd 0105 ._. _.... Topography Level Road i,Paved ........ .......... ....... ( .......... _ Utilities Public Water,Gas,Septic Location 1 Construction Info ......................................... _.... ................. _ _.. ....... Building I of 1 Year-_. — Roof Ext r ,_......_... �_.. Built 1979 Struct[Gable/Hip wall lWood Shingle EffectRoof Pe 2354 CmpArea Cover T None� mor _ Int Bed .. _..._. style:Cape Cod wail Drywall __ Rooms 4 Bedrooms Int Bath Model .Residential Hardwood 2 Full + 1 H Floor- Rooms - _......,..µ Total Heat... ._.... ... .. _... Q ` Grade;Average TypeI Hot Water Rooms 18 Rooms Stones 1 1/2 Stories Heat Oil Found- Typical Fuel € ation Permit History_,, _ .._........ ......_. _. .. FAILED INSPECTION COMMONWEALTH OF MASSACHUSETTS � �`IVE® EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS N OV 2 9 2004 F DEPARTMENT OF ENVIRONMENTAL PRO TION STABLE - 1'T' twit t > _PT. PARCEL, i a HA, SJev LOT TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 66 CAPTAIN ALDEN OSTERVILLE,MA 02655 Owner's Name: C/O DICK CASEY REALTY EXECUTIVES Owner's Address: 1330 PHINNEYS LANE HYANNIS,MA 02601 Date of Inspection: 11/1/04 Name of Inspector: (please print) JOHN GRACI,INC. Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection..The inspection was performed based on my training and experience in the proper function and maintena e of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of T' 5(310 CMR 15.000). The system: _ Passes _ Conditionally (sses _ Needs Furth, valuation by the Local Approving Authority X Fails Inspector's Signature: / Date: 11/1/04 1 t The system inspector shall submit opy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspect'oj►. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner sh4 1 submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copiA sent to the buyer, if applicable,and the approving authority. Notes and Comments SYSTEM FAILED TITLE V INSPECTION.THE STAIN LINES IN THE LEACH PIT INDICATE THE PIT HAS BEEN FULL OVER THE INLET PIPE-THE PIT HAS BEEN IN HYDRAULIC FAILURE. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Imne..ntinn Fnrm h/i srmi l 1 , Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 66 CAPTAIN ALDEN OSTERVILLE,MA 02655 Owner: C/O DICK CASEY REALTY EXECUTIVES Date of Inspection: 11/1/04 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM FAILED TITLE V INSPECTION.THE STAIN LINES IN THE LEACH PIT INDICATE THE PIT HAS BEEN FULL OVER THE INLET PIPE-THE PIT HAS BEEN IN HYDRAULIC FAILURE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times.a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 66 CAPTAIN ALDEN OSTERVILLE,MA 02655 Owner: C/O DICK CASEY REALTY EXECUTIVES Date of Inspection: 11/1/04 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance n/a "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a 'Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 66 CAPTAIN ALDEN OSTERVILLE,MA 02655 Owner: C/O DICK CASEY REALTY EXECUTIVES Date of Inspection: 11/1/04 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times " pumped n/a. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. _ X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] YES (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large 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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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. A Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 66 CAPTAIN ALDEN OSTERVILLE,MA 02655 Owner: C/O DICK CASEY REALTY EXECUTIVES Date of Inspection: 11/1/04 Check if the following have been done.You must indicate"yes"or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection ? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out'? X _ Were all system components,excluding the SAS,located on site ? X _ 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? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no X _ Existing information.For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] S Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 66 CAPTAIN ALDEN OSTERVILLE,MA 02655 Owner: C/O DICK CASEY REALTY EXECUTIVES Date of Inspection: 11/1/04 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: n/a Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): YES Water meter readings, if available(last 2 years usage(gpd)): n*6- Ce fUJO Sump pump(yes or no): NO Last date of occupancy: n/a v COMMERCIALANDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1979 PER OWNER Were sewage odors detected when arriving at the site(yes or no): NO r Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 66 CAPTAIN ALDEN OSTERVILLE,MA 02655 Owner: C/O DICK CASEY REALTY EXECUTIVES Date of Inspection: 11/1/04 BUILDING SEWER(locate on site plan) Depth below grade: 10" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 4" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: L 8' 6" H 5' 7"W 4' 10"1110" Sludge depth:3" Distance from top of sludge to bottom of outlet tee or baffle:31" 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: 15" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. TANK IS H10 RECOMMEND NOT DRIVING OVER.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 'Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 66 CAPTAIN ALDEN OSTERVILLE,MA 02655 Owner: C/O DICK CASEY REALTY EXECUTIVES Date of Inspection: 11/1/04 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: n/a 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.): NONE LOCATED PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no):NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 66 CAPTAIN ALDEN OSTERVILLE,MA 02655 Owner: C/O DICK CASEY REALTY EXECUTIVES Date of Inspection: 11/1/04 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GALLON 6'X6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): STAIN LINES INDICATE LIQUID LEVEL IN LEACH PIT HAS BEEN FULL OVER PIPE.PIT WAS EMPTY AT TIME OF INSPECTION-DUE TO A LACK OF NORMAL USE-PIT HAS NO EFFECTIVE LEACHING LEFT.. BOTTOM IS AT 10 FT. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a q Page 10of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 66 CAPTAIN ALDEN OSTERVILLE,MA 02655 Owner: C/O DICK CASEY REALTY EXECUTIVES Date of Inspection: 11/1/04 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. i bC 2.1 in Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 66 CAPTAIN ALDEN OSTERVILLE,MA 02655 Owner: C/O DICK CASEY REALTY EXECUTIVES Date of Inspection: 11/1/04 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 10+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: GROUNDWATER DETERMINED BY HAND AUGER-NO WATER AT- 10+FT. BOTTOM OF PIT IS AT 8' 11 f ,t . �fCEIVE COMMONWEALTH OF MASSACHUSETTS' AUc 3 O �000 •� ExECUTIVE OFFICE OF ENVIRONMENTAL AFFAI� �ultyyeF °� DEPARTMENT OF EwnwNMENTAL k ONE WDrMR STREET,BOSTON VA 02108 (617)292-6500 'I'RUW(COXE Sitxrsty ARGEO PAUL CELLUCCI C!All)B.STLAMS Gem raor C.omrt:im;brnet Ul WAFACE'SE'WAGI!010100M SYSM INSFICI M FORM PART A CS81191�`.ATi0111 ' Praparty Addiaee► bb �fft4, n A��a Ms {.a�-e Ma+w.of AMrn.r 5a o 0151 a t� (�f J i�E.1 V'"A. Addi sss of t'errisr:� i k IL Dace+ef - 91� 10 (CO fG �- �S�, C155 . D Marna a6 :(Plaaaa PtUirf! Lod-- a I err► OEP system inyesetar pwowee to Ssecton 16.360 THIS a 9310 CUR 15.000I cilAMly Now: r 0 �t% J �J's►�►d1.<ti�� K J QCti �o t~7 8fa�se Adddaeta: o `jb� - — " &Oa. Tollowarra f+lireriM: SIB 413 5--7 '0 6 I osrtify that I haw personally Inspected the sewage disposal system of this salress and that the information reported below in tm e. acci you end canpieu ss of d»time of inapsctiott. The inspection wee performed based on my training and e=pedance in the proper heivirtic t and meirrtM-artce of on-skip&swap disposal.ii stems. The system: Passes CondHionaMY P64808 Needs Further E!0eluatlon By the Local Approving Authority Fogs e I J bipaatora ti/+Mrra: ., ONW. The llystsm Inspector shall submit a oo6Y Of this Inspection report to the Approving Authority Iaoard of health or DEP)wt Mrt thlrt'r Ill da_VI of aomplating this inspection, if the eyowri Is a shared system or has a design flow of t0,000 gpd or greater,the Inspector grad lis rYslW trlvnor sholi sum the repo"to tho appropmmo moonal oMcs of the Opartmant of Entoolronmental Protection. The original shotild be se•11 to the sysam owner and copies own to the buyer,it applicable,and the approving atrtho►lty. NOTE&AND COMMIENTS 98 Pep t of 1t 0 Pnnted an UvcW P.W► ILFULPIVACE SEMMOE ONPOBAL SYSTEM MIBPECTXM FORM 'ART A CMltf RCATW*toordims" Pr FN" : 6 Co Coo A(&A� LM .O, OwnDolls of �`�� tffif t?CT m BuwmiRy: ChmA A, it, C. or D: A. >!7111BI PAOi6i: _J" I have not found any Informsti-am which indicates that any of the future conditions described in 316 CMft 15.303 imint. ,��ny fo kns erkaria not evokrsted*to WWWW'ed bolow. B. tvBTnil coNanowAur�ABs�fl: One or more system components as described in the"Conditional Paos" 9cdon need to be roplscod w to paired. 1'Psl aid t tom,��pon compiation of the mplooemont ter repair,as approved by the Board '�teaith, wE!pass. Indicets-lee,no,or not determined M 11, or MIDI. Describe bait* mninedon in all instances. If "not datermined",explain v,hy act. The ssptio took is mn:at,Wd"s the owner Or orator has provided the system Inspactor with a copy of a 0in'6 lcsto of ._ Coompilenco(attached:)indicating that the was Installed wtftn twenty(28)years prior to the dote of 1M 1;r,peof1 :cir to*optic tank,whodw or not metal crooked,structurally unsound. shows substantial infiltration or ow;fihrnrt:on, or,lark failure Is imminent. The system pass inspection If the oxioting septic tank is replaced with a complying imp de tank um approved by the Bosrd of M fs�aofio backup nrakout or high static water level observed in the distribution box Is due to broken or ob•m,roatod 1510CM ouo to a br on,um;tdod or uneven disWbution box, The systom will pass inspection If(with approval of tltiu hoard of thD. . be-sken PW*)we replocod obstruction is oetlrovod - �,,., 41atrMution box is 9ewtiod or roomed _ The S"wn nee Iced Iwmping more than four tines a year due to broken or obstructed pipalsl. The system*11 pass inspection if Iwhh ahlrrovel of the board of MeeithD: tr*ken pipolel we replaced pletructlon is removed revised 9/2/98 Prem:*ru IIIJUUMACE IIIE AAOE DISPOSAL SYSTW INSPECTION FORM PART A CM I W ATlOM teonNrr" Fnprt►Addleas: 66 Ca�'E r OWN*: -zacl5ta� Dee.of lne0 .- : 8111-x>`ao c. iuRTH M EVALUATION a REQWKD BY THE BOARD OF HEALTH: Conditions exist which roquka hirther evaluation by the Board of health in order to dat ]no If the system to faB6ng to f!r;rtert thil pubM health,safety and the emMonment. 1'I SYST11d11 VALL MASS UNLESS BOARD OF HEALTH DE1ERMIBt68 IN AMORPANCE WITH 310 CUR 16.3031101 TW1,i1"THE STSTW IS NOT PJWTKWM IN A 11AIMMER WHICH w LL pROTm THE Pt EALTHt AND SAFETY Am Tw BIBMMwIINIY1mT: Cesspool or privy is W tun 60 het of surface water ✓ Cesspool or priW is ivitAin 60 fact of a bordoring wetland or a soft march. 3l SYSTM WLL FAIL UNLOS T SOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERLI Es THAT 1I. :SYCF151 U FWIMP I POMM IN A CHAT PROTI:M THE PUBLIC HSALTII AND SAFETY AND THE 11MVIROMMI®IR: The system a sowdo tank and soil absorption system 19481 end the SAS Is wlftn 100 feet of a surfuae w3ior ieup'tdy or tributary to svrfeea wortar supply. The sy has a seiRde tank end soli absorption system and the SAS is within a Zone I of a public water statga r welt. The sy has a**,ode tank and toll absorption system and the SAS Is withb+ 60 feet of a private wabr eupl:r f wed.. _ The• tem has a wile tank and soil absorption system and t1w SAS Is less then 100 foot but 50 het or amen r from s po a water supply vvell,unless a wall water analysis for collfoPm bacteria and volatile organic comImroC4 Inil1catss-dint the w I is free from poMrrdon from that faculty and the presence of ammonia nitrogen and nitrate nitrogen is,eisj*1 to or leau 5 ppm. Madd-a -used to determine distance M lapproxinnden no.v@M. 31 OTH revised 9/2/98 PW3ottt I biaNSU411#ACE SIEWAGE DISPOSAL SVSTM tit WWTWU PO M PART A COT1fi1CATION fos oll000q •� bU C � Q tkew9 . 01011 Close of bo811sa0W9 9?(;A D. sYrIM PALO: You amiust indicate etper"Yes"or"No" 1:6 each of the following: I he"d#tanflined that one or TWO of the following failure conditions exist as described in 310 CMR 16.301 The husit i or-this; dotarmination Is Identified below. The Board of Health should be contactsd.to determine what will be necessary to aarr,�rt time 11e4ure. Yes No Bockup of sewage Into fecillty at system component duo to overtoaded or clogged SAS or cesspool. Discharge or paneling of offluent to the surface of th round or surface waters due to an overloaded or ca�aliyii,e)SAIS,Dr Cesspool. Static NWW level In the distribution bolt oudst invert due to an overloaded or dogged SAS cc csssi,.:is) . Liquid depth in oaasocbl is less th f1" below invert or available volume is lass than 1 to day flow, Required pumping nta:re th 4 tines In the test year JW due to clogged at obstructed pipelsl. Number of!Imes pumv Any poillon of th uiI Absorption System,easspool or privy Is below the high groundwater elevation. Any portion a assnlmal of privy is within 100 feet of a surface water supply or tributary to a surface arias !1V0jjr. Any on of a cosrifaooi or privy is wltidn•2are I of a public well. portion of a eosalsooi or privy Is within 50 feet of a privatte web►supply wati. Any portion of a a"itimol or privy Is lose-then 100 but greater than 60 feet from a private water w gKrly im!r,ll arith nu acceptable water 4uldtty analysis. If the well h an analysed to be acceptable. attach copy of well wstsr s,islyais f.'r1 colifonn bscterfs, vaim le orgarile cm w un .emmonie nitrogen and Mfrab nitrogan, IL SYSM I;AU: You Blest indkato ettMr "Yee"or"NO" to f the following, The following erkeds apply to tar systems in addition to the orkerla above: /*f serves a feCip I•th a design flow of 10.000 Spiel or greater`large System)and Me system is a stq�ittetiott ;hrs+et ter Ipabk afety and nv ,xvnont because one at more of the following conditions exist: yes stem Is within 400 feel of a surface drinkW*water supply system k within:t00 feet of a trbutary to a aurfaos drinkheg water supply system Is liaMMI In a nkrogmo aenshlive are An atim Wellhead Protection Area-WVPAl ar a mapped Zarva i i of a ituidicter supply weplThe of any such systilm shall upgrade the system in eacordsrnce with 310 CMR 16.304(2). Please consult the iscol rsgkjrxtleRfio1nt for MRher h fo,imatlon. revised 9/2/9.8 t+e®raaflt StlMStAtFACE Stl1NASE DWPOSAL SYSTM Mi P T10M FORM PART a CHRCKLW hopwttr Address: 6 6 C14, AIU W L," Check If the following have boon done,Ifiou must indicat9 either"Yes" or "No"as to oath of the following: Yes me Pumping information ores provided by the owner, occupant.or Board of iieaitl+. None of the system ccirnponents have been pumped for at toast two weeks and the system has been roeliviing tunnel fu:vr rates during that parked, Large volumes of water have not been introduced into the system recently of as furl :of this P � inapsotton. . As built plans have boon obtained and sxam(nad. Note if thsy are not available with N/A. The foalllty or dwelNnnl was inspected for signs of sewage back-up. 4/ — The system does not receive non-sanitary or industrial waste low. — The its was inspoetal for signs of broman. f� AN system cornpaim its,excluding the Sort Absorption Symirn,have been located on the site. fr The septic tank ntanlades were uncovered,opened,and the irtterlor of the soptie tank was inspected for condit w-A of lnrft%w Tf er toss, matomel of construction. dimensions,depth of IgWd,depth of sludge, depth of scum. The site and location of the toil Absorption System an the mite has been determined based on: Erdeting information. for exempie. Plano at B.O.H. Determined In the field (if any of the failure criteria related to part C is at Issue,approximation of distance is un rsceptss+kI) (16.3021�)(b)J The fooSlty owner(arnf occupants,If different from owner)ttrere provided with information an the proper medm:lInance of Subsurface Oisposei lystams. `i revised 9/2/98 Fage�ofi, I :1UNMFACE BEWAME DiPOtAL SYSTEM NSPECT10M FORM PART C SYSTSMl BroRM)ATRON Pmpm*Ar...= 66 AA�A" L Daft Om too ROW CONDffl" Number of bedrooms i Nomber of bedrooms(actusild Teal ON141%sew Nun ff of ourrortt faeidonts Omb+'Ye g+Mda(yes a nOl: LvAv.ky(&swat*system) lye$of no):A92 if yes,$operate Mapectw required Lauetr:ky system inspected_(ems w no) sommonal use)yes er no): 41�( ! va �a Water meter readln",H e pest two year's usag*IgPd): r sum.Nnrtp(yes at no) � Lest<krts of oaeupaney Type of emmahnant: - Design tow: and 1 Based on IS f Basis of design tow Meese trap pry:)yes w nel„•-, MdwWe(Waste NokSf+g Tank pr rnt:(Ns at r+ol` Non-uvnitary waste dischs the Ti+l*B system: (yes or no)_,.,•- Wat*r meter r*edinga,If *bier ------ Lost let*of oo OTIMORk:fosse I --- •.eat date cupar' M9rWRAL M1QRkPf1TfON 5 PMPPpM WOOM end eouroe of Inf:.mnstion: ..-t 4 �4' System pumped as part of inspection; (yes or no)AP if yes, velum*P" P, : _gaMens Reason for pumping: TY�Ii OiT7>�I gapUo --eMoq absorption system _ single cesspool Overtow oosev" Pin► _ shaved system(yes or no) (if pes,attach previous inspection records.,if any) I/A Technology ate,Attach cagy of up to date*peraton and maintenance eonerset Tight Tank Copy of CEP Approval Other - APP11RplfMATE AGE of an cornponorm, me Installed(if known)end source of Infonnatlon: _ 2 0 (�f yo-14-C, SO~oche dstectod when arriving at the sit*: Iris or no w revised 4/2/9.8 Ptiof 11 SLt URFACE SEWAGE DISPOSAL SYs111En WSPECTION PORM PART C SYSTEM IM OfwAUM tc:wdkwsd) N.p.n 6� C A�94,5 Ow W.7 o�a5ta� Dn1e of f>Moeawu: $(DD (cam (Locate on she plan) Dept,bolow ofade: 6 MseafNij of comomotlon:_oast;ron, "A Pvc ot»r(explain) OWWAae fron'`t� ato water Supply wolf or suction NM hn _- T D vW y_ comments:(eonditlon of J Me.venting, vAdente of laakage,ate:.) i—w .TAfNI: (Westo on sits plan) Dept,below gnde:^,.L ma del of constniedon:loonerets entetoi_Nbergloss •_Polvothirlorte,,,,,_other(expiain) If taw.is motel, pet age_ is age confhmed by Certificate of Compliance® (YestNo) Dalof►s: D Sludgn depth: oletence from top of a to bottom of oudat we or be"*-. scum thieknsec c ty Dietwa*from top of scum to top of outlet too or bsMs:.-E _ j� Distaww team be" m of scum to bottom of out of bofflo:�' tow Igmmnsions More doteimlrwd:Joe Comments: ° Irocofnmendatlon for pumping, of Ords;snd outlet toes of befMs.dept:of liquid level in rMs i n to fist Irvert, stnietaxr+i I IMIO N evideno f ) `lac." W _ `E�tk'f cJ o `F- �d.L�� id (iftete on site plan) Depti below We&:�_,. Material of conatructlon:—conoeete_+tvetei_Pdw~loos _P ylene,ctrer(expiain) Dimensions - soon]tMekness: Dtstafte from to of scum to top of MA44 tee 01~4e from bottom of sum to bottent of tse or bells: Date of lest pwnping: Comments: (race 1--nondetion for pumph+g� a�of mist and outlet tees of baMss, depth of liquid level la elation to outlet itvvert,Stnuten ld imMgrl qr oviome of leakage,etc-) revised 9/2/98 ftVIof11 • SUMURFACE tEWAW OMFOiAI sYST®I MIIINSCTION FORM PART C •YKTM N04OFMATIOMI IoaAnwod) &C Cot, EcQtws L4tAA c owner. OMI ofIT as`tj��aa CO TWfT OR HOLOM TANK. (Tans:must be pumped prim to, or at tlme of,inspectionl (locets on am plan) Depth bekw pads:_ Metwlsl of construed":_concrete"meld—M s_Polyr"Orre_,other(oxplain) Cap"Oky: gaNens Design flew: Foonelday Alorm present— Alw9i loud: Alarm wwkinll order;Yes No` Date of previews pu : Comrtronts: (conditlon of Not io* ondlMdonn of Harm and float swltehes,etc.) . Ileotrte an ate plan) .Dspoh of NWW levai above outlet lnvOM!. Co mnvsr�s: (Hoar H level and distribution is oqur6, a+idsn`e�e o/solids esiryovsr,oy4 ee o9 o kago�o J�f box, atc.t PURV CHAMlII:,_,o Porn o on alto plan) Pump In working order:(YOO or Nol_�.— Alon"s In working oidw (Yes or No)_._ Comensnta: (noto eondidon of pump chamber,@andflJon of ps end appurtenanow,ionic.) revised 9/2/98 �elotll f SLIUURFACE$*WAGE falspo"L SYSTEM USPECTIOM FORMA PART C S YSiTM IMFOPOMTI19M iedown om .,.wsw b Cam_A(,LoMS �s►c� co of Ins 20 o (00 sm A11EOFAIMM S1YIIIIII NAMJL llocaa-on she plan.If p meible:saoavaton not required,location may be approxinr:ated by non-Intrusive,methods) M not kmftd. : T„po: Joao"pits nwrtber• t boo"oMmbars.nunbar:,••_• ».-Id dies,numb..:_..._ hraahine wenches,nwnbn,Iana!S!': fk&%.number,dWr#WW1:*G: evvftw eos�poo}. r*._ Moms of Toohl+olesY:., cowanmts: _ r inote condition of soil, sj t hydnuulle I sit a,I"of pondne, damp soil,eons on of vedst ', etc•} �12 — ��!• a;_. �ssPoots: - (locate on sin plan) Mumbon and contwootion: ....-., 7pth.tep of 114W is inlet Im W: Wh of oolkle Iavv, Depth of scum law: Ohnerealons of easspool: Materials of conavue"n:�...�,. hidseation of proundwatar: inflow leosspool must bap paid as part of Inspsetlon} --•- • --•� — Comments. (rW6 Condttlen of soli, of hydreuise IslBuro.Is"of pondln0, eondklon of v,pKation, ate.) POW: flees*on site plan) Matoriota of sonstwstbn: amaralora"_-- ""--r'•- Cape of Oak%:_ Cewonnts: (nett*OWN don of sea, of hydmg Iallwe,,level o*pORdh+p, condition of ve0etetbn, e,ta) —.-- M— revised 9/2/98 pw'of" MUBSURFACE SEWAGE DISPOSAL SYSTEM MBPECTMN FOAM PART C SYSTMIA SMpORMATMN liessavasm ae�o.re„ 66 Copy�(��t� 9^awS Own soft I* SUIk nq Of$MADE DISPOSAL SYSMIi: kwlude dos to at least two porrim"m reference kmMtorks or bomhmwks kmMe eN wells wMMn 100' (La,ot•where pwbNc water supply comes lints house) N revised 9/2/98 ftv Isar ia SLOSURFACE SEWAGE DWOSAL SYSU M NOPECTKIN FORM PAIR C SYSTEM!NFOhhMATM OsmrtlrwdI Dow o:1=� NRCS Aspen ewne -- — Ssp Type— _ _ _-- Tydaal depth to groundwater_ - USGS Do*webelte vWW Observation Wells clacked Groundwater depth: Shallow Moderate SITE EXAM Slaps Surfees water Check Cola Shellow wells Eatimmed Depth to GroundwaterFood: er Piaae,indicate all the meti+ode used to dertsrmine High Groundwst ENv stion: ObWmd from Design Mau on recc,rd Observed Site(Abutting Property,cinarvatlon hois,bsssmsnt sump etc.) ' Daternrined from IecM com"ons r-�— +;hscked wkh kraal$card of health C;hecked FEMA Map decked pumph+g records i;hecked level excavators,instdbn tJeed USGS Data Doseribe h&W you satbblished the High C rowwwater Elevation. (NW be compbnedl "40A(ek S _ revised 9/2/98 revuofIt TOWN OF BARNSTABLEC`�C ] L LOCATION 16 "OL-5 L SEWAGE # LL `Vu.LAGE D&AV�Ue. ASSESSOR'S MAP & LOT ��"® M INSTALLER'S NAME&PHONE NO. Mtn p � � 3gS' 76�Qa `SEPTIC TANK CAPACITY 1 C?C�tcw LEACHING FACILITY: (type) lT (size) I Q00 Q NO.OF BEDROOMS BUILDER OR OWNER ` PERMITDATE: _ COMPLIANCE DATE: �C'�o OD 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 i W7 �r �roW* L0•CATION SEWAGE PERMIT NO. _ LQ--*7 - 1 ,�� - VILLAGE INSTA LER'S NAME i ADDRESS BUILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED _ � �� '� '. �; L �fi�� J / -� /-'�� pp�� V' No. 1. - Fxa.... 's............... THE COMMONWEALTH OF MASSACHUSETTS ' BOARD OF HEALTH .......rD.W..t4.............OF......... Appliration for R-4pasal Marko Tonstrurtiun ramit Application is hereby made for a Permit to Construct (V) or Repair ( ) an Individual Sewage Disposal ®� System at: .fi. .7.� .....L..�r.:.....�.2 1'' j.2 i ILI-L...--•--•-- ev ------•----- ........7--------------------------------•-.---._..------•-----••---- .--Location.A d ess = r Lot No. O ner Address �t ..... -------------------- - ------------. .................... ............... <� Installer Address Type of Building ,— Size Lot�Z..d _-1......Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (A)Z) `4 Other—Type of Building No. of persons............................ Showers — Cafeteria a Other fixtures ---------------------------•--•. •-- - � �-,-�--,-�---,-�------------------------------------------------------------------- -------------------------------- W Design Flow...... ......�d'�?....._..gallons per4KQ FeT'lay. Total daily flow.......... .................gallons. WSeptic Tank—Liquid capacityd2.asagallons Length .'d..". Width.`f.-..2' -_`_'Diameter---------------- Depth..2..�.49 x Disposal Trench•—No. .................... Width.................... Total Length.................... Total leaching area................._..sq. ft. Seepage Pit No.___f....._..._.. Diameter...�..�....... Depth below inlet.__6.......... To leach' g area. .......sq. ft. Z Other Distribution box ( � Dosing tank ( ) � � aPercolation Test Results Performed ..... Date....A).o..V.:...... ?� a Test Pit No. l Z..2_....minutes per inch Depth of Test Pit...4.............. Depth to ground water.j_Pt AeL''....._. f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •----•......---•-- •---• •-•-•-••--------•---•--•.....•-•--------••--..._..•--••---------------------•-••--•-......_..-•--•-...... ... 0 Description of Soil........... "1A....... -.6--------- .. .`P'.l_ `1..`:........ �?tL�a"� ------... rA_W >-------------------------•--•--•--•----------.--------------- U W UNature of Repairs or Alterations—Answer when applicable---------- .a.. ............ ._ ........................... -------•------------------------------- --• ----- --- -- Agreement: The undersigned agrees to install the aforedescr1 ed ividual Sew e Dispo 1 System m n ccoVnce with the provisions of TIT?.�,;. 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. Signe :... ---------------•••-- -••-•••-- ••••.........._.__... 1 �/ Date , Application Approved By........ . ----•{ =y _ Date ADDIlication Disapproved f e f llo in -reason :.....y.�.l C:..�I z c.� . , —� � Permit No................ �,- _.. � '�_ U 1 � � ..............( ' ued. -.... .--- ^ ate-- ----------•------ ------------ Date No......� f;. ........ F:zs.... 5... _ ` THE COMMONWEALTH OF MASSACHUSETTS . BOARD OF HEALTH R �.{rt .f ....... OF......... :)z lv!;7.�� 't. / r.............................. , pphration for Mqpasal Works Tomitrnrtiun rantit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: ��I�' -•-• -- - ............ Location-A dress of Lot No. _Q. 1.._ ? ----., ................................. � .�s Owner Address .._.. ....................................... ................ .um� .c.... 1//6......................... Installer Address Type of Building- Size Lotlf .rf f.....Sq. feet �. 0 s .6,,;,lling—No. of Bedrooms.._.. ...........................Expansion Attic ( ) Garbage Grinder (Mt) a • aOther—Type of Building .................:.......... No. of persons............................ Showers ( ) — Cafeteria ( ) ;.? Other fixtures ---•. --------•--• ----------------• --•---------........------...•-----.•---- W Design Flow...... .......�, Q ,_....gallons per 12"lay. Total daily flow :; 'd� ....gallons. R: ,Septic Tank—Liquid capacity,40. 0gallons Length-��-_'a." Width.. �!.`''Diameter__.:;......... Depth .,5' W "Disposal Trench No. .................. Width... ._........... Total Length......... ........ Total leaching area................. .._ ...._. .sq.fi..`` x Seepage Pit No .. '" '`..:........_ Diameter.. __......... Depth,below inlet .......yof leachi•g area '... ft. Z Other Distribution box ( Dosin tank ( ) ��" ' '` ' '-' Percolation Test Results Performed by- �...t',r_l"ec ,,P&f:?_....&S -.. Date.....Aj o..V ..... tl_ �a Test Pit No. 1_4...Z....minutes per inch Depth of Test Pit...Z.............. Depth to ground water..�N6!1.9....... Test Pit No. 2................minutes per inch Depth of Test Pit-................... Depth to ground water........................ R4 .. .................•---•--•-•-•--------.-- -- -:.:--•---.........................._.. ... ----- DDescription of Soil........... c�•-- 0A.Af-------- N.-f . _ ` 'r ..........................:............ ----------------- W ------•----•------------- --•--•-------•••---••-----•-------•••-•--•---------•-----••-••....-----•----•---------------------•--•----------------------------..._..--.......-- •-••-------•--•---...... U Nature of Repairs or Alterations—Answer when applicable............................................................. ............................... ------------•-----------------------------------------------------------------------•-•-----------------------------------N Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed ---• .---------------------------------------------------------------------------- ------------------------------•- Application Approved B Date PP PP y--------- mow.... .,• � Date � Application Disapproved for the following reasons:. ....................•-----------------------------------------------------------•---------•---•-•...--.-_... ....................................................... -----------------------------------•--------...-----•-----------------------•-----•-----•-•-•----------------------•-••-----•••......-----•----- Date PermitNo..........................=--r.......................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . .....................OF....... .-1167 w......................... Curdifiratr of f amplinna THIS JS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by ' ...... ._.. ----------------------------------------------------------------•----•- ---.......---•----------•-----•-...----._...-----•---•...._ � � Installer ./ at..... ./•.. 'j ..............................................� �-J------. �� .........................................�7 has been installed in accordance with the provisions of T F 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No... _ (s.......... dated_...._ ............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUEDAS A GUARANTEES;T AT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector...................................................................................... THE COMMONWEALTH OF.MASSACHUSETTS BOARD OF HEALTH 77 !. .....OF...............�.... .._jg:A�..... ........._......................... No.... a FEE........................ Disp sal IV rk nn nr#' n pamit Permission is he by granted.....e �... . ---------------------•---••-.....-•------........-----........---------_----- to Con struc ( or.Re ( nd�v'd al w Disposal em at No. r 1 s � reet as shown on the application for Disposal �7orks Construction Pe N :Z Dated_ -•- ..= �_ C� Board of Health v DATE .................,............................................... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 1 ,1 O. i ��-� ;�✓ f i '"� �' "` a _, PAUL. &AR b 41FR SN 5 pE c7OA 7. 30 /44 " rib lbIurs SAND a . a LEACH p IT RES�"R LE /.t7;!; _ 1 ;+ :NpL SFIaTfC m .' l9 z9� 33�R�a� ro 7 h1f< / 7DLcJN. t�1 .T R AVAIL At?-LE "Vts E-J//_�//vG S E7"L3�1CAL 7Z5 - . F�2O�OSEZD ,' • t i SE P T/c 5 ys TEM CON.5 7-12 Uc T/ON SHA:L C7NF02M, TO MA55 DES/G/V 1--L-0w v Q GAL/,p,4 y C1vW/2On/ML-ni7A4- CooE T/TLE le '2 �, P1Z v�o .�t�r/-/ rz��cum A T/O n/5 " .Z?E�J(J/ � t.3 .� � o, of ` 1 P2 0,4 S ZS r-> L-E AC ij /—GiYV. aJ.��:).+ .'C/f�/ ---•••+•..r.v.a<...�Ya�.r•<:{•-...erd.,..e91.-a••..N _ ..... ..e-.i•'i_w-,•-., 1u r •...-, i_ ._v�<- ._ - ..-.4s-v..,rti.n. - �.vr-+ter.. ...,M.<....e.e.s. v.w. �f� w�.q:.q. Ysr....'i s.- �' OF4 ST A i t ' PE, O �. , 5' MAX/ 0LE Ca i/E� 7`O' �X TE!�lZTa TO L�Cl2•✓/OCJS 'GQ t/E/ kV/ w .C20i�1 /A-F/L T2A ate, T/fit/ J /„✓U t /20nf_ I VO/X i !� �.Z/W/DC' Al IA. _A.r 44D 7T4 ia. c 4., /OLCgC4d C Cf 1 4" f407- /D M/ni /4' �4•�FOoT �� Mrni .�irt�r :Pir 3/�,_/, � D/�. - _Y_ MtnJ 5 �4 '�Fdar W<iSNEb. ` 'T ti /�vrr z isTD Av`E ,. _ 4 4. fivl/E27" )C17"/G' y cc C3 OM D� r 6 / LOC:A T/cpilj L3l ST/� L=��l "RYIt Fit' NA'ss . �; EFL 2�n1G� LEI1�+' D7 A ' n A-L, } ANC D/STD/�3C�T/ON �QX NO „ t ' J` �/j� 5 G7UTG ETS'� /.VG m r ,,yam 3 K •� T" t i� f lJNC2E7'E• Sr2-A.107�V. '3600 Psi Y. ` ! /0 L- A'D/nl 4?,CI E VVAy' lk/O T. 710'_B CA / wr *;� �`y�` I��•t..f � �" �' ��. a- 4 4, .avz=-.e sysrEM uA/Z�,--�ss. '�-/=2co C E.F?T f:Fy 'T•1 C�-1-L .14. H.0 aA4 0 '��tIv nE S. vnl L`OA-I�i�iG j AS S'l O, N ,'A'lY -1 T b 04�7 CAM ALY rs A. oe t ?> 7 . /a '�:.? �/�'�+ a,, A p� d V/,4L 4t ra" ALL OUTLET PIPES FROM THE VL 10' min. from *NOTE: ALL PIPES ARE TO BE 4* SCHEDULE 40 P.V.C. VENT PIPE (0 Least 24 inches tall) SFCTrON A -A DtSTRIAUTION BOX SHALL BE tY CONCRETE COVER Schedule 40 PVC w/Charcoal Odor Filter SET LEVU FOR AT LEAST 2 FT. Existing Foundation house to septic tank PROFILE VIEW OF IFACHINC SYSTEM SLpt,c tank Coven must be 3 - 5'OU KNOCKOUTSTLET within 6 in. of finished grade bod e over Septic Tank 98.00 Grade over D-Box 92.00 ode over SAS ELEV- 92.00 314- F I'Z IV-h"CV-#-d St.- F-Ad P.-t- 15.5* 12' INLET t', OU TLET 3 HOLE H-10 W21n JUdevits Lm S 0.02 S-0.10 DIST. BOX 3' Maximum C� Top of SAS-Etev.=89,75 A\ OR GRFATr 26' txl�)T. R S- 0.010* per foot 4' SCH. 40 Tee-/ 1.71 1,000 GAL. 30' 0 C3 LD 1:3 CD - - - I PLAN SECTION CROSS-SECTION C� SEPTIC TANK M r-% CD C�3 E71 11 H-10 K) 20, Effect" Depth >. 0) 0-&W% 0) C3 ; W 3 Unit @ 8.5' = 25.5' FULL FW it. a, 'k-, W -- - 11 3.2, 25.5'- 3.25 3 HOLE H-10 DISTRIBUTION BOX > 00 CO CC) 4' SYSTEM PROFILE 6 in of 3/4*-1 1/2* 4) A co -32 th Le NOT TO SCALE ;> compacted stone a) 11 Effective Not to Scale C >: - ng C Effective width -S -T SOIL ABSORPTION SYSTEM (SAS) GENERAL NOTES 6 in.of 3/4'-1 112" 0 boo C ~1-10 LEACHING UNITS WIGGINS PRECAST 1. Contractor is responsible for Digsafe notification NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6' BELOW GRADE compacted stone CD Not to Scale and protection of all underground utilities and pipes. Bottom of Test Hate I Dev.-82.00 2. The septic tank and distribution box shall be set vObs. Groundwater - Test Hole 1 Elev.= NONE OBSERVED level on 6" of 3/4"-1 112" stone. 3. Backfill should be clean sand or gravel with no stones over 3" in size. 4. This system is subject to inspection during installation by Carmen E. Shay - Environmental Services, Inc. 5. The contractor shall install this system in accordance PERCOLATION TEST with Title V of the Massachusetts state code, the approved plan and Local Regulations. Date of Percolation Test: NOVEMBER 9, 1978 j 6. If, during installation the contractor encounters any Test Performed By. PAUL GARDINER, CROWE & TAYLOR -4 soil conditions or site conditions that are different Results Witnessed By. BARNSTABLE B.O.H. f from those shown on the soil log or in our design Excavated By. UNKNOWN OFr installation must halt & immediate notification be Percolation Rate: Less Than <2 MPI @ 30" cp� made to Carmen E. Shay - Environmental Services, Inc. I' TEST HOLE #1 7. No vehicle or heavy machinery shall drive over the ELEV.= 94.00 septic system unless noted as H-20 septic components. Cc 8. Install Tuf-Tite gas baffles or equals on all outlet tee ends. 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes. Test HoleCA ailed 1 10. All solid piping, tees & fittings shall be 4" diameter No. 1 fO.5' I leach Pit I Schedule 40 NSF PVC pipes with water tight joints. DEPTH SOILS ELEV. 11. Municipal Water is Confected to ALL OF The Residence and Abutting A 0 94.00 1 26' LOT #8 Properties Within 150 Feet. 0 �3\, Sandy Loom 3 NOTE 2' 10 YR 3/2 THE PROPERTY LINES ARE APPROXIMATE AND 0"-9, A, 93.25 % COMPILED FROM THE PLAN BY CROWELL & TALOR, YARMOUTHPORT, MA 00 ENTITLED "CERTIFIED PLOT PLAN OF LOT 7 CAPT ALDEN LANE, Sandy 0 CO Loom 0 OSTERVILLE, MA" DATED APRIL 24, 1979 10 YR 5/6 AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN EXIST. 1000 gal. IT SHOULD BE USED FOR NO PURPOSE OTHER THAN 91.501 Septic Tank 8w THE SEPTIC SYSTEM INSTALLATION. Medium Sand GRAVEL\ EXISTING LEACH PIT TO BE PUMPED OUT AND 10 YR 7/4 C* 4., R�C FILLED IN PLACE OR REMOVED TO FACILITATE INSTALLATION OF NEW SAS. C, 06 DRIVEWA\\� VEI`p PIPE 82.00 CO #66 1 NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE LOT '1#6 \\ FROM THE eXISTING LEACHPIT TO BE DISPOSED EXISTEVC J OF AS PER BOARD OF HEALTH SPECIFICATIONS. 4 BEDROOM NO WETLANDS ARE PRESENT WITHIN 200' OF THE PROPERTY HOUSE CO ASSESSORS MAP 146, PARCEL 088 K PROJECT BENCH MAR TOP OF FOUNDATION LEGEND ELEV. = 100.00 (Assumed) LOT #7 rr Perc #1 DECK 17,614 Square Feet + DENOTES PROPOSED , 0' co PROJECT Top 0 F F ELEV. BE NCH 10 Depth to Perc: 36' to 54" F1 04X 11 Perc Rate= 2 MPI SPOT GRADE C Groundwater Not Observed No Observed ESHWT 104.46 DENOTES EXISTING ADJUSTED H2O Elev. None X SPOT GRADE 225.50 PL PROPERTY LINE PT co All -----T96PI-- PROPOSED CONTOUR o 00 CO co CV CO - - - - - -97 EXISTING CONTOUR 2-18" DIAM. ACCESS MANHOLES 8' DEEP TEST HOLE & NIF CAMBEIDGE PUILDFRS SUPPLY CO. PERCOLATION TEST LOCATION 6 FOOT STOCKADE FENCE INLET OUT ET THE ACCESS COVERS FOR THE SEPTIC TANK, L DISTRIBUTION BOX AND LEACHING COMPONENT SET DEEPER THAN 6 INCHES BELOW FINISHED P L O T P LA N GRADE SHALL BE RAISED TO WITHIN 8" OF STEEL REINFORCED PRECAST CONCRETE FINISHED GRADE. PLAN VIEW INSTALL TUF-TITF GAS BAFFLES OR EQU&S OF PROPOSED SEPTIC SYSTEM UPGRADE 3-24" RrMOV ABLE COVERS-\ PREPARED FOR r NOTE: CONTRACTOR TO NOTIFY DIGSAFE AND R I C H A R D A. CASEY f 3" min. clearance CONTRACTOR TO VERIFY LOCATION OF ALL UTILITIES AT INLET rr�in !-:JX!!!�.E12- min. Inlet to outlet PRIOR TO EXCAVATION. OUTLE tr # 66 CAPTAIN A L D E N LANE I Liquid leve 5 -7' OSTERVILLE, MA 4*-0' min. 0.err Liquid depth Design Calculations Number of Bedrooms: 4 Bedroom EXISTING \��OF 4fl PREPARED BY: Garbage Grinder: No �� R1 E 8'-0' Leaching Capacity Required: 440 Cal./Day (MIN. PER TITLE V) j(j RAM,AT E. SffA Y CROSS SECTION END-SECTION Septic Tank 2 x 440 Col./Day = 880 USE EXIST. 1,000 GAL. Septic Tank. Is H I I I 0 20 40 50: ENVIRONMENTAL SERVICES, INC. SOIL ABSORPTION AREA: Using Percolation rote of <2 min./inch No. III Bottom Area: 0.74 gal/sq. ft. x 416 sq. ft. = 307.84 gallons Q P.O. BOX 627 TYPICAL 1000 GALLON SEPTIC TANK Sidewall Area: 0.74 gal./Sq. ft. x 180 sq. ft. = 133.2 gallons S T 1--?-V NOT TO SCALE Providing: 441.04 gallons \ EAST FALMOUTH, MA 02536 I A P,\l".- Use: (3) PRECAST 500-C UNITS, HAVING A 2' EFFECTIVE DEPTH, SCALE: 1 "=20' TEL/FAX : 508-548-0796 TO BE USED WITH 4' OF WASHED STONE ON THE SIDES AND SCALE: 1 "=20' DRAWN BY: CES ATE: JANUARY 31, 2005 3.25' OF WASHED STONE ON THE ENDS. PROJECT#SD688 FILENAME: SD688PP.DWG SHEET 1 OF 1