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Home My WebLink About0037 CAPTAIN ALDEN'S LANE - Health Captain Alden�s Lane lr[(16.7, Osterville A_ r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form - Not for Voluntary Assessments 37 Captain Alden's Lane Property Address Matthew Peck Owner Owner's Name information is required for every 0 terville Ma. 02655 8/8/2018 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms SI$ I on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection rab Company Name 74 Beldan Lane Company Address ram, Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com S14522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 8/8/2018 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 should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts is Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �o 37 Captain Alden's Lane Property Address Matthew Peck Owner Owner's Name information is required for every Osterville Ma. 02655 8/8/2018 page. City/Town 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: The dwelling located at 37 Captain Alden's Ln Osterville is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and a precast leach pit. The system was found to be in proper working condition at the time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the Conditional Pass section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts` Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 Captain Alden's Lane Property Address Matthew Peck Owner Owner's Name information is required for every Osterville Ma. 02655 8/8/2018 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational.-System will'pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 (I N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M � 37 Captain Alden's Lane Property Address Matthew Peck Owner Owner's Name information is required for every Osterville Ma. 02655 8/8/2018 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 Captain Alden's Lane Property Address Matthew Peck Owner Owner's Name information is required for every Osterville Ma. 02655 8/8/2018 . page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or.privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.) ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered"yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 1 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 Captain Alden's Lane Property Address Matthew Peck Owner Owner's Name information is required for every Osteryille Ma. 02655 8/8/2018 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 gpd t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts x p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 Captain Alden's Lane Property Address Matthew Peck Owner Owner's Name information is required for every Osterville Ma. 02655 8/8/2018 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 Captain Alden's Lane Property Address Matthew Peck Owner Owner's Name information is required for every Osterville Ma. 02655 8/8/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): I General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): 15ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 Captain Alden's Lane Property Address Matthew Peck Owner Owner's Name information is required for every Osterville Ma. 02655 8/8/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: original system 1979 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain)' Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joints ok, no leaks , vented through roof Septic Tank (locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons i Sludge depth: 6 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Captain Alden's Lane Property Address Matthew Peck Owner Owner's Name information is required for every Osterville Ma. 02655 8/8/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Ili Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness 3„ Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers and took measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 Captain Alden's Lane Property Address Matthew Peck Owner Owner's Name information is required for every Osterville Ma. 02655 8/8/2018 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.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 15ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form I� is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 Captain Alden's Lane Property Address Matthew Peck Owner Owner's Name information is required for every Osterville Ma. 02655 8/8/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): 0" Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was in good condition, no rot, water level was even with outlet invert. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts �a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 Captain Alden's Lane Property Address Matthew Peck Owner Owner's Name information is required for every Osterville Ma. 02655 8/8/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1x1000 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit had 1.5' standing water with a stain line 2' higher. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts - = Title 5 Official Inspection Form I� �i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 p Y rY 37 Captain Alden's Lane Property Address Matthew Peck Owner Owner's Name information is required for every Osterville Ma. 02655 8/8/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Captain Alden's Lane Property Address Matthew Peck Owner Owner's Name information is required for every Osterville Ma. 02655 8/8/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately � L I r� 3a A 36 r3i� �S t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form j' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 37 Captain Alden's Lane Property Address Matthew Peck Owner Owner's Name information is required for every Osterville Ma. 02655 8/8/2018 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: 12+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health explain: P ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �., 37 Captain Alden's Lane Property Address Matthew Peck Owner Owner's Name information is required for every Osterville Ma. 02655 8/8/2018 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION 3-4 c"I. 14Ides Ili . SEWAGE# 26/l 30,'' ,VILLAGE ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY.(type) l;l— (size) 1660 qA NO.OF BEDROOMS .mob g0a<P_ � d�1. � OWNER �!�' PERMIT DATE: I COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY C its 9 No. Feel /40 V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pplitatlon for Misposal 6pstem Construction permit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Cz��, l %&r, 110• Owner's Name,Address,and Tel. o. 1 (3k, \ BS�evv►\�� {'aal �w.ev'Soh 3� Ca,�- lA�e)r. �d, Assessor'sMap/Parcel 14(Q &'4 _ Installer's Name,Address and Tel.�o. E(?)'5 - Designer's Name,Address and Tel.No. Ma8�61 %rr►;11 S Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building ReS��.� �� No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) �?j C, gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank /6W �A\- Type of S.A.S. �eaGk n ti V Description of Soil Nature of Repairs or Alterations(Answer when applicable) 1'�,ce -1C �� Date last inspected: ''ZO 1` 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 Certificate of Compliance has been issued by this Board o h. Date Application Approved by Date +' Application Disapproved by Date for the following reasons Permit No. , Date Issued ---- ------------------------- • ..�-r'w +-. r-.qy1. -fsr r,Y-_— ! ^� W" t < _ .. T '°r'-�"-..-,, - - , ®5 ^l No. CJ � �. Fee ��V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: � Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Rpplication for Disposal 6pstrm Construction 3permit Application for a Permit to Construct( ) Repair qr Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 37, C��'c. A iaer` i Aj Owner's Name,Address,and Tel. o. c3slevv�ll� dsl �mearsan 3� C.a�. 0\ err. CVO. a trio\� Assessor'sMap/Parcel to ^-4& O a -Q 1 OZ65S Installer's Name,Address,and Tel.No. 67PNC `SY JF_ J 5 Designer's Name,Address,and Tel.No. fo•?JOY 7 r MarMwr , rn;11 s nnya•ouom Type of Building: ` t Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building Re-5\&V\N No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 33 U gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title } Size of Septic Tank 160 AV Type of S.A.S. 'eaC�i h�� Description of Soil Nature of Repairs or Alterations(Answer when applicable) 12eglzCe--- ti Date last inspected: 2Q 1\ 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 Certificate of Compliance has been issued by this Board o ,. h. Application A S�.n d �. Date � PP Approved by _ Date 41 1 Application Disapproved by + r Date for the following reasons YPermit No. ` ^ Date Issued 91 \ ----------- _ - -- - - - - - - ---- --- _ - F-------------- -- -- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )by C 0 c- sm';QE4)S >;"4 rI at 27 C2dv. vi,g lA. has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No:J D/l^_'�- dated ' /9 11 Installer Ce%t` S"S'rcV>r,U Designer #bedrooms �� Approved design flow bra gpd The issuance of this permit shall not be construed as a guarantee that the system will�l nctio 1i d�e�signe�d. Date ��/y Inspector No. � d Fee f 6- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Disposal �bpstem Constraction prrmlt Permission is hereby granted to Construct( \\) Repair( ) Upgrade( ) Abandon( ) System located at '� A l(k and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be com eted within three years of the date of this Date c� 1 , Approved b f �0*'VKE row Town of Barnstable Barnstable *AmP �°'l Regulatory Services Department �,ca�1 IIAFiN+ STABLE. � a MASS 04Public Health Division �A i63q. �0 m lFb MAMA, 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 �// �� Thomas F.Geiler,Director FAX: 508-790-6304 '/ [� / Thomas A.McKean,CHO CERTIFIED MAIL# 7011 0470 00014525 7598 August 16, 2011 Sovereign Bank 601 Penn Street Reading, PA 19601 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 37 Captain Alden's Lane, Osterville, MA was last inspected on July 30, 2011 by Darren M. Meyer, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Conditionally Passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • D-box is structurally unsound, cover broken, and needs to be replaced. • Piping from tank to d-box and from d-box to leaching pit, needs to be replaced and leveled.. You are ordered to make repairs within two (2) years from the date you receive this notification. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\conditionally passed\254 riverview.doc Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 Captain Alden's Lane Property Address Sovereign Bank, Owner Owner's Name information is Osterville MA 02655 Jul 30 2011 required for y every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms the �� n computer, r,use 1. ,Inspector: only the tab key to move your Darren M. Meyer cursor-do not Name of Inspector use the return key. n/a Company Name y PO Box 981 r `� Company Address East Sandwich MA 02537 3 City/Town State Zip Code77 - -y3 7 1-4 4- 7 8 2 6 48 Sl 3920 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority J � � l Inspector's Signature Date The system inspector shall submit a cop of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of corn ting this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. L ; III t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Dispos System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Captain Alden's Lane Property Address Sovereign Bank, Owner Owner's Name information is Osterville MA 02655 Jul 30, 2011 required for y every page. Cityfrown 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. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 f Commonwealth of Massachusetts l Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 Captain Alden's Lane Property Address Sovereign Bank, Owner Owners Name information is required for Osterville MA 02655 July 30, 2011 every page. Cltyfrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ® Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ® distribution box is leveled or replaced ® Y ❑ N ❑ ND(Explain below): Distribution Box is compromised, deteriorating and needs to be replaced ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑, N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 The 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Fo rm orm- N Y of for Voluntary Assessments 37 Captain Alden's Lane Property Address Sovereign Bank, Owner Owners Name information is required for Osterville MA 02655 every page. CitylTown July 30, 2011State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 ❑ ® 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 Y2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 5 37 Captain Alden's Lane Property Address Sovereign Bank, Owner Owner's Name information is required for Osterville every page. CitylTown Stl a 02655 Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °w. 37 Captain Aden's Lane Property Address Sovereign Bank, Owner Owner's Name information is Y required for Osterville MA 02655 Jul 30, 2011 every page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 37 Captain Alden's Lane Property Address Sovereign Bank, Owner Owner's Name required information isOsterville MA 02655 July 30, 2011 every page. Citylrown State Zip Code Date of Inspection D. System Information Description: 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)): 2009: 093 gpd 2010:. 312 gpd Detail: Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date 1 Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑'Yes ❑ No Water meter readings, if available: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 Captain Alden's Lane Property Address Sovereign Bank, Owner Owner's Name information is required for Ostery Y ille MA 02655 Jul 30, 2011 'i every page. City/town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 3T Captain Alden's Lane Property Address Sovereign Bank, Owner Owners Name information is required for Osterville MA 02655 July 30, 2011 every page. City1rown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: System installation date unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 12"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.): No signs of leakage. Septic Tank(locate on site plan): Depth below grade: 12 inches 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: typical 1,000G tank Sludge depth: 8 inches t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �. 37 Captain Alden's Lane Property Address Sovereign Bank, Owner Owner's Name information is Y required for Osterville MA 02655 Jul 30, 2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 26 inches Scum thickness 2 inches Distance from top of scum to top of outlet tee or baffle 10 inches Distance from bottom of scum to bottom of outlet tee or baffle 8 inches es and rods How were dimensions determined? tapes Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level equal to outlet pipe, structural integrity is sound, no sign of leakage, no sign of hydraulic failure, concrete tees in place. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 Captain Alden's Lane Property Address Sovereign Bank, Owner Owner's Name information required forts Osterville MA 02655 July 30, 2011 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.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 37 Captain Alden's Lane Property Address Sovereign Bank, Owner Owner's Name information required forts Osterville MA 02655 July 30, 2011 every page. City/rown State Zip Code Date of Inspection D. System Information (cont.) 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.): D-box is structurally unsound, cover broken, and needs to be replaced. Piping from tank to d-box and from d-box to leaching pit, need to be replaced and leveled. 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.): Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 f Commonwealth of Massachusetts H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 Captain Alden's Lane Property Address Sovereign Bank, Owner Owners Name information is required for Osterville MA 02655 July 30, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 -6x6 ❑ 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.): 1-6x6 leaching pit, w/approx. 1'stone, pit has 3 inches of standing water. No riser in place, pit is 30" below grade. Vegetation normal, soils normal,no signs of hydraulic failure. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 37 Captain Alden's Lane Property Address Sovereign Bank, Owner Owner's Name required information Osterville MA 02655 July 30, 2011 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts F v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 37 Captain Alden's Lane Property Address Sovereign Bank, Owner Owners Name information is required for Osterville MA 02655 July 30, 2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately �Ror1T � � � o v l � y TtE5 A-I • 3t g-I . I21- 1 2. 313 g-Z: t A- 3, q( A-4 46' t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts . W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 37 Captain Alden's Lane Property Address Sovereign Bank, Owner Owner's Name information is Osterville MA 02655 Jul 30, 2011 required for y every page. Cityfrown 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: 17411+feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Hand augered to 174"and did not observe any groundwater. Bottom of system is 9.5 feet below grade, thus the leaching is not within adjusted groundwater. Before filing this Inspection Report, please see Report Completeness Checklist on next f t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pa, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 37 Captain Alden's Lane Property Address Sovereign Bank, Owner Owners Name information is required for Osterville MA 02655 July 30, 2011 every page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 15ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 5 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments R. 37 Captain Alden lane I O M p Property Address Lucinda Collins Owner Owner's Name information is required for Osterville Ma. 02655 5/29/2007 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 computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name t� P.O.Box 763 Company Address Centerville Ma. 02632 remm City/Town State Zip Code n.Pav (508)428-4028 Telephone Number License Number ts-t —1 cl7 c' B. Certification L_ I c1 ty 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 wasprformed based on my training and experience in the proper function and maintenance of on site sevyge disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5/29/2007 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 :w .0 has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 37 Capt.Alden•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 l Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 37 Captain Alden lane Property Address Lucinda Collins Owner Owner's Name information is Osterville Ma. 02655 5/29/2007 required for every page. City/Town 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: The septic system is in proper working order at the present time.Septic tank should be pumped.Heavy solids in tank. 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 37 Capt.Alden•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 37 Captain Alden lane Property Address Lucinda Collins Owner Owner's Name information is required for osterville Ma. 02655 5/29/2007 every page. City/Town 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. 37 Capt.Alden-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form 551 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Captain Alden lane Property Address Lucinda Collins Owner Owner's Name information is Osterville Ma. 02655 5/29/2007 required for State Zip Code Date of Inspection every page. City/Town 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**. rv.: Method used to determine distance: **This system passes if the well water analysis, perfotmed 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 El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow El ® 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. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 37 Capt.Alden•08/06 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts H . Title 5 Official Inspection Form Subsurface'Sewage Disposal System Form -Not for Voluntary Assessments ^M 37 Captain Alden lane Property Address Lucinda Collins Owner Owner's Name information is required for Osterville Ma. 02655 5/29/2007 a,r_ --- every page. City/Town State Zip Code Date of Inspection r B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. El ® 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- a 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 TM.. system in accordance with 310 CMR 15.304.The system owner should contact the appropriate ---..,.. regional office of the Department. 37 Capt.Alden•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts .::_ . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a _ 9° 37 Captain Alden lane GSM Property Address p Y Lucinda Collins Owner Owner's Name information is Osterville Ma. 02655 5/29/2007 required for 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 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)] 37 Capt.Alden•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 �O Commonwealth of Massachusetts . Title 5 Official Inspection Form _ o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 37 Captain Alden lane Property Address Lucinda Collins Owner Owner's Name information is Osterville Ma. 02655 5/29/2007 required for every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 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 ears usage d Unavailable 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date Commercial/Industrial Flow Conditions: ' Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 37 Capt.Alden•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15—'"lift- Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Captain Alden lane --° Property Address Lucinda Collins Owner Owner's Name information is Osterville Ma. 02655 5/29/2007 required for 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: 7 ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1979 Were sewage odors detected when arriving at the site? ❑ Yes ® No 37 Capt.Alden•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 37 Captain Alden lane Property Address Lucinda Collins Owner Owner's Name information is Osterville Ma. 02655 5/29/2007 required for every page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 21 feet --- Material of construction: _. . ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 1 + fee et Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through house vents.. Septic Tank (locate on site plan): 18" 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: 4'10"x8'6"x57" Sludge depth: 8" it Distance from top of sludge to bottom of outlet tee or baffle 20" II Scum thickness 611 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 8" How were dimensions determined? Measured 37 Capt.Alden•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a'wM 37 Captain Alden lane Property Address Lucinda Collins Owner Owner's Name nz information is Otrville Ma. 02655 5/29/2007 se required for p 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.): Pump tank every 2-3 years.lnlet and outlet tees are in place.Tank appears structurally sound.No evidence of leakage. 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):'.:y ` 37 Capt.Alden-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 37 Captain Alden lane Property Address Lucinda Collins Owner Owner's Name information is required for Osterville Ma. 02655 5/29/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) 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 No 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.): Box is Ievel.Box has one lateral.Nonevidence of solids carryover No evidence of leakage into or out of box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 37 Capt.Alden•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Captain Alden lane M Property Address Lucinda Collins Owner Owner's Name information is Osterville Ma. 02655 5/29/2007 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): M„} Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: i ❑ 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.): Sandy soil.No signs of hydraulic failure or ponding.Leaching pit was dry at time of inspection. 37 Capt.Alden•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 =• • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . 37 Captain Alden lane Property Address Lucinda Collins Owner Owner's Name information is Osterville Ma. 02655 5/29/2007 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 _,KY 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.): 37 Capt.Alden-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts ,Ism. Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments 37 Captain Alden lane Property Address Lucinda Collins Owner Owner's Name information is required for Osterville Ma. 02655 5/29/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. w. Locate where public water supply enters the building. 37 Capt.Alden•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 st Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 37 Captain Alden lane Property Address Lucinda Collins Owner Owner's Name information is required for Osterville Ma. 02655 ^� every page. City/Town 5/29/2007 State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to ground water: 60' feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 1979 e,a„ Date ® Observed site (abutti ng g property/observation hole within 150 feet of SAS) .... ® Checked with local Board of Health -explain: Engineered plans dated 1979 ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used:Gaherty& Miller model 12/16/94 Ground water elevations.Used:USGS observation well data June 1992.Used:Technical bulletin 92-000-01 plate#2 annual ranges of ground water elevations. t 37 Capt.Alden•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 IT 0 AT ION A G E RMIT NO. +ILLAGE pldeAv - INS A LLER76L-C, 'S NAME � ADDRESS aP B U It DE Rom'0� OWN ER Y �/< I DA T E PERMIT ISSUED , 3 , 7Z ii DATE COMPLIANCE ISSUED /� A�� ! i �� , .� � f TOWN`OF.BARNSTABLE !�-"fCATION �� 1J101 �, SEWAGE# IEI AGEor�,Q�11[, ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY ® O LEACHING FACILITY:(type) (size) NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility.(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY Cs_�j• W - -, '�„',1 �> ^��'��3- ��. ill 3//6 - r No...........:�.a. f VS e- -J4- :3 7 FEB....._....................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............OF......NX ...57w.a.�c17 ................. Apptiration for Dispaual Work' Tou.strurtion ramit �I Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: --------Location-Address or.Lot No ................................................. ................................................................................................. 44- wner Address ................................. ......-----------------------...... -----------*----------------------------............... Installer Address Type of Building Size Lot../*S!�!-O.j--!.....Sq. feet Dwelling—No. of Bedrooms...._..._.—7.............................Expansion Attic Garbage Grinder (M� Other—Type of Building ............................ No. of persons............................ Showers Cafeteria Other fixtures .................................... i"�------------- ---------------- pl---------------------------- --------------- Design Flow.-------Ze-."a......................gallons per WIXer ay. Total daily flow..--........K3.e).................gallons. Septic Tank—Liquid capacity/,OAQ.gallons Length..A."_ Width..V-�O.-" Diameter................ Depth..'s-.1'a...-r", Disposal Trench—No. .................... Width.................... Total Length---................. Total leaching area....................sq. ft. Seepage Pit No....-r-"-------;;-,_Diameter 6----- Depth below inlet.....4.....*....... Total leaching area.O.Z . - -sq. ft. Z Other Distribution box Dosing tank Percolation Test Results Performed by.ftqP1t,9eD..A.!'A-140. .....R---T........ Date... Test Pit No. 14.ln-----minutes per inch Depth of Test Pit....#e.l.......... Depth to ground water.W.VAV.16�---- Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ............................................................................................................................................................. 0 Description of Soil............0.n...91—;'r...... .........f JV-b.......... ....................................................... UW0 . '47 W . 'N-D................................................................................ ...........................................k... A....Pzv . ........S.4 ................................................................................. ..................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of I IT LE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i ed Py�tV board of health. ign ................................ ...................................... ................................ '4t�� Date Application Approved By.. --------7.7......... Date Application Disapproved for the following reasons:.............................................................................................................. ......................................................................................................................................................................................................... 4 1,2 , 7,f Date PermitNo.......................................................... Issued.....4�4------------------------------------------ Date ..No.......... �. .. Fps .._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ,Njipliration for Uhiposi al Works TmArartiun Vinmit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal r System at . ........... -------- {........................... Location-Address or Lot No. 1 --••••..•----Owner -•----.-.-.Address W c ---••--••-•................... ------.......--•-------•-............------------ ... Installer Address Type of Building Size Lot./ .....Sq. feet U Dwelling—No. of Bedrooms..... .. . ......... ..........Expansion Attic ( ) Garbage Grinder (V#) Other—Type of Building No. of persons.................. ... Showers — a YP g ------•-•------•------------ . P.. ------- ( ) Cafeteria ( ) Other fixtures ....................... 4............ ;�� W Design Flow..... r ....... gallons per, emon'per' ay. Total dolly flow....... ............gallons. Septic Tank—Liquid* llt?capacity :gallons Length. ..6... " Width.:'! A'" Diameter............... Depth.....'....._.. W Disposal Trench—No..................... Width..................... Total Length___.........._...... Total leaching area....-..............sq. ft. x 4 Seepage Pit No e._.... #............,Diameter.._e.... i...... Depth below nlet.... ............. Total leaching area. . - _sq. ft. Z Other Distribution box ( . Dosing tank ( ) - '-' Percolation Test Results Performed by77.-i2A) 'w./i_.A_.C,:/f`.'>+'A.....R,.5......... Date.._ ,`4a Test Pit No. 141:......minutes per inch Depth of Test Pit...Z`.L`...... Depth to ground water,& 6----__. Test Pit No. 2................minutes per inch Depth of Test- Pit.................... Depth to ground water........................ Ri ------------------•...................-------------------... .....---------------.... -----•------..-......----------... O - Description of Soil s a /�.N-••-. j. ......... v .........-•-•-•-----••. ................... ......... ........ ---- --------------- W UNature of Repairs or Alterations—Answer when applicable................................................................................................ f -----------------------------------•-----...----•--------------•--------------------...-•--•-•--•-•------•-----------------------------•---------------•--•------------•-----•-----------•---.......--•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance 4ith the provisions of TITLE: y g g p y :. S of the State Sanitary Code—The undersigned further agrees not to lace the s . in operation until a Certificate of Compliance has been issued by the board of health. _ )Silo - - -----------=-=----•-•---------- .......--------.........-- ................................ Date Application Approved By.... . . _---------------- �•-------- Date Application Disapproved for the following reasons:........................................................ .................................................. ---------------------------------•----------•-----------..........---------------------......-------••--•.._.........._....------•--•----•-•-•---------------------•-------------------------......._..-- Date PermitNo.------................................................. Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....779 .... ............OF......... ��1.'�..f r!"�..t .iG �........................ uat Entifiratr of Tompliana THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) by---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Installer J► at.... .G7. I!' . ; ....... 0 �"4rl _li� +� ......................................... has been installed in accordance with the provisions of T j of The State Sanitary Code as described in the application for DisposalaWorks Construction Permit �To. .. .- .160!. ............... dated.__.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WNJLL FUNCTION SATISFACTORY. 4 DATE.. L_"'... 7—....ff .................................... > Inspector:... ---• �,. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH. No..99....31R-. ...........OF........ /� ,CUU�.�.�.'i" �!'► .................... ��--• - �i��a��al nrk� �vrn�#r�timrn rrmii Permission is hereby granted.............................................................................................................................................. to Construct (kol�or Rrepair ( )�+jan Individual Sewage Disposal Syy�sjt�e+m�,y+- �r at0a...... 47.7 -�/ ................/�- 1 yF Yf•.........(a� .k.......tree ?J.'.. i4 !1:. .................................... as shown on the application for Disposal Works Construction Per 't7No.___.._ ..... ........ ....... 7- `l-� > Board of Health DATE.--- -------°---------•-[---�••-•----------------------------•-••-----••---. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS TEST H QLE ' - - . AuG.' + ' ,�A UL M UR'RA:y - _N S'P67CT'OR LOT ! 1 . _ T_ " - /9fz o- A4 LoaM. A N 4 'co) F8 a y. . RESERVE woo O . . ; 4 5Ul350/L 4, :EXIST a �� ' oZ6l 144 MEIN/uM sAND L07 TeST . 12- LOB' dBty ro LeACk': PIT ELEV. 6, 5 tu No, CATER E'NCDUIvTERtll 13[J/LD/NG S'ETL3,�1 C� �EJU/,eME•v7i S,e,4 L E �.�� 3V t P120,aO SE-D. . • • , - . � iBEDT2oo,vls.. SE P T l C- 3`YS TLM. COA/S T2[JC T/OiV 5,41A"�L G O�JF.02n%I TO M/q'SS DES/G�l FL Ow. �� GAL,17A Y E^JV/.eOn/MG--NT�L CoDe- T/TLe- Q 1 �9°RNS�A�3 L G A C N 2,1 TE; -- - M/A/. ///VGA/ .�1LT.�/' �GClLA7/DiVS 2EQUIRL--0. LE.�fCIV�AZ?54, l,'.z o, 0� of .ol2O,00S E L E,4Cf-1 .�iae E• _ oo 2 4DF x'E a 57ovE O /Mpc�✓loos co v�,e MAn/HOLE Ca r/E �"o EX TEnID ?O, To ,a2EVeA/T / 'LV/ T�•1/N /" pF � F/n//5/-��c7 GT�.ctD� F2oia-! /A%F/Z T2Q T/N'6 24"c- �c-.zs _ l0.. _ I D/5T. .I �� - I STo.vE i`//A✓11l1(J j . 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TIaE 13;�r`1LDIAt6- GfUaGE SG — SET!QAGK 1?�t�1 /l i?�,NIt�N CST Th�E LOW, JR:. TO LJN OF C3 A 1?N S-TA B L: c j �� ¢ - ---------- sTE a� o '\ 7 tiEQZ-77-1' aG�vT .. i r..