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HomeMy WebLinkAbout0026 CEDAR LANE - Health ,y. '26 CEDAR LANE, OSTERVILL'E - A=118-055 a iE ii i I I R J 1 i 1 r yiZ��3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 26 Cedar lane Property Address R W Henson Owner Owner's Name information is required for every Osterville MA . 02655 09/04/13 page. CityrFown 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. General Information / n on the computer, use only the tab 1. Inspector. V/ key to move your -- cursor-do not Michael Kellett use the return Name of Inspector key. Aardvark Environmental Inspections Company Name PO Box 896 Company Address East Dennis MA '02641 City/Town State Zip Code 508-385-7608 SI 3742 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address=pd that theme information reported Wow is true,accurate and complete as of the time of the inspecbpn.The ir��ecti6r� was performed based on my training and experience in the proper function and maiixt Nance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.34400 of . Title 5(310 CMR 15.000).The system: r..e7 ® Passes •❑ Conditionally Passes ❑ Fails -t ❑ Needs Further Evaluation by the Local Approving Authority s 09/05/13 Inspictorls Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5lns-11/10 Title 5 Official Insped ion Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Tid 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 26 Cedar lane Property Address R W Henson Owner Owner's Name information is required for every Osterville MA 02655 09/04/13 Page. Citylrown 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•11/10 Title 5Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 26 Cedar lane Property Address R W Henson Owner Owner's Name information is required for every Osterville MA 02655 09/04/13 page. Citylrown state Zip Code Date of Inspection B. Certification (cunt.) > 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 ❑ 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 tarns-11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 26 Cedar lane Property Address R W Henson Owner Owner's Name information is required for every Osterville MA 02655 09/04/13 page. City/rown State Zip Code Date of Inspection B. Certification (cunt.) 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. Y ❑ 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 day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 26 Cedar lane Property Address R W Henson Owner Owners Name information is required for every Osterville MA 02655 09/04/13 page. City/rown State Zip Code Date of Inspection B. Certification (cunt.) 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 11 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Y 26 Cedar lane Property Address R W Henson Owner Owner's Name information is required for every Osterville MA 02655 09/04/13 page. Cityfrown 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 (f any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 I Commonwealth of Massachusetts Title 5 official inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '( 26 Cedar lane Property Address R W Henson Owner Owner's Name information is required for every Osterville MA 02655 09/04/13 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[f 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)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date CommerciaUlndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15203): 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 26 Cedar lane Property Address R W Henson Owner Owner's Name information.is required for every Osterville MA 02655 09/04/13 page. Cityrrown state Zip Code Date of Inspection D. System Information (cunt.) 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)(f yes,attach previous inspection records,if any) ❑ Innovative/Altemative 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 VA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval ❑ Other(describe): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form Not for Voluntary Assessments 26 Cedar lane Property Address R W Henson Owner Owner's Name information is required for every Osterville MA 02655 09/04/13 page. City/Town state Zip Code Date of Inspection D. System Information (cunt:) Approximate age of all components,date installed(d known)and source of information: 06/18/96 per BOH Were sewage odors detected when arriving at the site? El Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.3 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.): e 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: yearn Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) - ❑ Yes ❑ No Dimensions: 1,500 gal Sludge depth: 3" t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form }a Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 26 Cedar lane Property Address R W Henson Owner Owner's Name information is required for every Osterville MA 02655 09/04/13 page. Cltyrrown State Zip Code Date of trspedion _ D. System Information (cunt.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness W. Distance from top of scum to top of outlet tee or baffle . 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.): 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 E;fiberglass Q 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•11110 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 26 Cedar lane Property Address R W Henson Owner Owner's Name information is Osterville MA 02655 09/04/13 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 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•11/10 Title 5 Official Inspection Form:Subsurrace Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System form-Not for Voluntary Assessments ' 26 Cedar lane Property Address R W Henson Owner Owner's Name information is required for every Osterville MA 02655 09/04/13 page. City/Town state Zip Code Date of Inspection D. System Information (font.) 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. 5 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: t5lns•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts INK f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 26 Cedar lane Property Address R W Henson Owner Owner's Name information is Osterville MA 02655 09/04/13 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Type: ❑ leaching pits number: ❑ leaching chambers number: i ❑ leaching galleries number: ® leaching trenches number, length. 1@601i4' ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/aftemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): This system has a 60'long by 4'wide stone trench with the D box in the middle and perforated pipes running the length.There was no sign of ponding or failure in the stones. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 26 Cedar lane Property Address R W Henson Owner Owner's Name information is required for every Osterville MA 02655 09/04/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 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-11/10 Me 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 26 Cedar lane Property Address R W Henson Owner Owner's Name information is Osterville NIA 02655 . 09/04/13 required for every page. Cityrrown state Zip Code Date of Inspection D. System Information (cunt.) 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 garage _rear, 28 46 42 56 t5ins•11/10 Me 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official InspectionForm s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 26 Cedar lane Property Address R W Henson - Owner Owner's Flame information is Osterville MA 02655 09/04/13 required for every page. Cityrrown state Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells 20.0 Estimated depth to high ground water: feet feet Please indicate all methods used to determine the high groundwater elevation: ❑ Obtained from system design plans on record If checked,date of design plan reviewed: pate ❑ 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. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins-11/10 Trde 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 ®fficial Inspection form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 26 Cedar lane Property Address R W Henson Owner Owner's Name information is Osterville MA 02655 09/04/13 required for every 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 t51ns•I M0 Title 6 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17 •' �� TOWN OF BARNSTABLE BOARD OF HEALTH , ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date b /517-0 Time: j In Out Owner Tenant A Address 133 C"0f`ri=/qG(AC (Loc Address (ANL:: M as-s-roil 5 i 11 L'us M A 141-1- Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities .._- 3. Bathroom Facilities �`l 4. Water Supply 5. Hot Water Facilities It 0A)S OT , 6. Heating Facilities �o. 7. Lighting and Electrical Facilities 8. Ventilation / 9. Installation and Maintenance of Facilities ✓ 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17. Temporary Housing 18. Driveway Width 19. Number of Tenants Observed PART 11 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles ed (max Number of Persons Allowed (max) Person(s) Interviewed 0110to Inspector 7 If Public Building such as Store or Hotel/Motel specify here f 1Z 01 COMMOi'1WEALTH,Of MASSACHUSETTS EXEC UT�J.E-,OFFICE:OF ENVIRONMENTAL AFFAIRS DEPARTMENT,OF ENVIRONMENTAL PROTECTION TITLE S OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.FORM PART A CERTIFICATION Property Address:. '26 Cedar Lane Osterville.-MA'02655 Owner's Name: Noreen.Halfard. Owner's Address: Date of Inspection: February 2.7, 2009 Name of Inspector:(Please Print) James M. Ford' Company Name: James M. Ford Mailing Address: P.O.Box 49 Ostecville,MA 02655-0049 Telephone Number: (508):8624400 CERTIFICATION STATEMENT .. I certify that I-have personally-inspected the sewage disposal system at this zddressl and that the information reported below is true,accurate and complete as of Vhe 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 DER approved-system;inspector pursuant to Section 15.34.0 of Title 5(310 CMR 15.000).The system: Passes Con 'tionally Passes Ne ds Further Evaluation by the Local Approving.Authority. Fais Inspector's Signature:. Dater 'March 5.2009 The system.inspector.shall.subt ' .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 10,00.0 gpd or greater,the inspector.and the system owner shall submit the report the appropriate regional office of the' DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,.and the approving authority. . Notes and Cornme*nts ****This report only describes.conditions'at.the'time of inspection and.under the.conditions of use at that tim,e.' This inspection does not address how the system will perform in the.future under the.same or different conditions of use. . I Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEW AGE DISPOSAL.SYS TEM IN SPECTION'FORM PART A . CERTIFICATION (continued), Property Address: 26 Cedar Ldne Osterville. MA Owner's Name: Noreen Halford Date of Inspection: February 27. 2008 Inspection Summary: Check A,B,C,D or E 6ALWAYS 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 CMk 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 riot determined(Y,N,ND)in-the for the following statements. 'If"not detennined",please explain. The.septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration-or exfiltration or tank failure is imminent. System will'pass inspection if the existing tank is replaced with.a complying septic tank as approved by the Board of Health: *A metal septic tank will pass inspection if it is structurally sound,not leaking and.if a Certificate of Compliance indicating that the tank is less than 20 years old is available. .' ND explain: Observation of sewage backup or.break out'or high static water level in the distribution box due to-broken or obstructed pipe(s)or due to'a,broken,settled or uneven distribution:box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed -distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval:of the Board of Health): broken.pipe(s)are replaced obstruction is removed ND explain: Page 3 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: .26 Cedar Lane Osterville. MA Owner's Name: Noreen Halferd Date of Inspection: February 27, 2008 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. • 4 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 coliforn, bacteria and volatile organic compounds'iridicates that the well is free from pollution froin that facility and the presence of ammonia nitrogen and nitrate.nitrogen is equal to or less than 5 ppni,provided that no other failure criteria are triggered. A.copy of the analysis must be attached to this form. 3. Other: 3 Page.4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 26 Cedar Lane : Osterville. M_- . Owner's Name: Noreen Halford ,Date of Inspection: February.271 2008 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following_for all inspections: Yes No ✓ Backup of.sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the.ground or surface waters due town 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 %rday 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,orprivy.is within-a Zone 1 of a public 'Well. ✓ Any portion of a cesspool or privy is within 50,feet of a private water supply well: ✓ Any.portion of a cesspool or privy.is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP.certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free pollution-from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than ppm .provided that no other failure criteria are triggered. A copy of the analysis must be attached to.this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails._The system owner should contact the Board of Health to determine what will be necessary to correct the failure: E: Large:-System: To be considered a-largesystem the`system must serve a facility with a design flow of 105000.gpd to'15,000 gpd. You must indicate either"yes"or"no":to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking:water supply the.system is within 200 feet of a,tributary to a surface drinking water supply: _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area IWPA):or,a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section..E the system is considered a significant threat,'or.answered "yes"in Section D above the large system has failed; The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR - 15.304. The system owner should contact the appropriate regional office of the:Department. 4 r Page 5 of 11 OFFICIAL:INSPECTIONYORM-.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B .CHECKLIST Property Address: 26 Cedar Lane Osterville,MA Owner's Name: Noreen Halfoi^d. Date of Inspection: February 27, 2608 Check if the following•have.been done:.You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information Was provided by the owner,occupant,or Board of Health ✓ Were any of the system-components pumped out in the previous two weeks.? ✓ _ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling-inspected for signs of sewage back up? ' _ Was the site inspected for signs of_break out ✓ Were all system components,excluding the SAS,located on site ✓ "_ Were the septic tank manholes uncovered,opened,and the interior of the tank..inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,:depth of sludge and depth of scum Was the facility owner.(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS)on the site has been.determined based on: Yes No ' ✓ . Existing information. For example,a plan.at the Board of Health. Determined in the.field(ifany of the.:failure criteria related to Part C is at issue approximation of distance is unaccepiable).[310 CMR I5.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM NOT,FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Prop erty - P Y Address: 26 Cedar Lane Ostervdle. MA' Owner's Name: Noreen'Halrord Date of Inspection: February 27, 2008 FLOW CONDITIONS-, RESIDENTIAL Number of.bedrooms(design); 3 Number of bedrooms(actual): 3 ,DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): :330 Number of current residents:: L. Does residence have,a garbage'grinder(yes or no):: n1a" Is laundryon_a separate sewage systeim.(yes or:no): n/a [if yes separate inspection'required] : Laundry system inspected(yes or no): No Seasonal use(yes or no): _No Water meter readings,if available(last 2 year's usage`(gpd)): Unavailable Smnp.Pump(yes orno): No Last date of occupancy: Currently COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based ori310 CMR 15.203): "upd,. Basis of design flow(seats/persons/sgft,etc.):'. Grease trap present(yes or no): Industrial writ e'holding..tankpresent(yes or no) Non-sanitary wastedischarged'to the Title'5 systein(yes or no): " Water meter readings,if available. Last dateof occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping .Records Source of information unavailable Was system pumped as part-of the inspection,(yes or no): No . If yes,volume Pumped: gallons kHow,was quantity"pumped deterinine`d?' Reason.for.pumping: 1 , TYPE,OF SYSTEM ' Y ✓ Septic tank,distribution box;soil absorption systein 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: 6/14/96-as built card Were sewage odors detected when arriving at the site(yes or no): No Page 7 of l 1 g _ I OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE_DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM-INFORMATION.(continued) Property Address: 26 Cedar Lane Osterville, MA Owner's Name: NoreenHalTord Date of Inspection: February 2:7. 2008 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron _40 PVC other(explain):. Distance from private water supply well or suction line Comments(on condition of j o ints,,venting,evidence of leakage,etc.):: - 1 SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 9" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age.confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate Dimensions: 1500 Qal. Sludge depth: 2. Distance from top of'sludge to bottom of outlet tee or baffle:. 30"' Scum thickness: 6„ Distance from to of scum to to of outlet tee r o baffl e: .p 6 p . Distance.from bottom of scum to bottom of outlet tee,or baffle:. 10" How were dimensions determined:- Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels. as related to outlet invert,evidence of leakage;etc.): Tees were present. The liquid level was even with the outlet invert` There did not appear to be any signs of leakd-ae GREASE TRAP: None locate on siteplan) Depth below grade: Material of construction: _concrete —metal'=fiber glass _polyethylene -_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to.bottom of outlet tee or baffle: ..Date of last pumping: Comments(on pumping recommendations,,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.):.= Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 26 Cedar Lane: Osterville, MA Owner's Name: Noreen Halford Date of Inspection: . February 27, 2008 TIGHT or HOLDING_TANK: None (tank.must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of.construction: _concrete_metal _fiberglass _polyethylene _other(explain): - Dimensions: Capacity: gallons. Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:' Even Commnents(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 clean. No solids were present. PUMP CHAMBER: 'None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Coi runen is(note condition of pump:chamber,condition of pumps and appurtenances,etc.), 8 . . Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM PART SYSTEM INFORMATION(continued) Property Address_: 26 Cedar Lane Osterville. MA . Owner's Name:. Noreen Halford Date of Inspection: February 27. 2008 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site.plan,excavation not required) If SAS not located explain why: Type leachingpits,-number: umber: _ leaching chambers,numben leaching galleries;number: ✓ leaching trenches;,number,length: 60'x 4'x 2 Per as-built 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 trench.was drE and clean There did not appear to be any signs offailure A camera was used-for the'insnecti'on CESSPOOLS: None (cesspool must be.pumped:as part.of inspection)(locate on site plan) Number and'configuration: Depth=top of liquid to inlet.invert: Depth of solids layer:. Depth of scum layer: Dimensions of cesspool; Materials of construction: Indication of groundwater inflow(yes.or no): Coinmepts (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.)- PRIVY., None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level ofponding,condition'of vegetation,etc.):'. 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM , PART C SYSTEM INFORMATION(continued) Property.Address: 26 Cedar Lane Osterville MA Owner's Name: Noreen Halford Date of Inspection: February 27 2008 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 a O a.� 3 i a�` yt a m 4q 10 - Page I l of l I OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO N FOR M PART C SYSTEM INFORMATION(continued) Property Address: 26 Cedar Lane Osterville. MA Owner's Name: Noreen Halfor d - Date of Inspection: February 27. 2008 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25+/_ feet Please,indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site,(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board.of Health-explain: Topographic and water contours nuns Checked with.local excavators, installers-(attach documentation) Accessed USGS database=explain; You must describe how,you established the high ground water elevation: _Using Barnstable topographic and,water contours'niaps the inans were showing Qproxhnately 25'+/ to groundwater at this site; This report has been prepared only for the septic.systein and components described herein. This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that theaystem will function properly in the'future.-There-have been no warranties or guarantees, either expressed written or implied, relating to the septic system, the inspection;this report and/or any.components of the septic system which have not been located and inspected. 11 G` a TOWN OF BARNSTABLE LOCATION.�;U SEWAGE # VILLAGE (aS7-L--A! ViLL1' ASSESSOR'S MAP&LOT //a INSTALLER'S NAME&PHONE NO. 1-4 tC.V-fit Ct tZ sT —7 7 I Y l 2-0 SEPTIC TANK CAPACTT`t ��� LEACHING FACILITY: (type)`Tt to C i (size) NO.OF BEDROOMS � BUILDER OK OWNER) PERMTTDATE: J (� 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) Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by A �i u 0 `� a TOWN OF BARNSTABLE / LOCATION a( u.GAr /AAU SEWAGE# 6 �6 VILLAGE 0 S'Ft(-V111Q. ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY r0'Q / LEACHING FACILITY:(type) Tr Co G (size) (o �- NO.OF BEDROOMS J .OWNER. I /JI OrC 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 �X spe!gUon ` �/� A B C* O � a 336 4q 9 � f No. Fee 7 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS 2pprication for nigool *pgtem Cougtruction Permit Application is hereby made for a Permit to Construct or Repair( an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. Oscv-m2v L iJb���-►� o Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 3 i2os lac t..r�a� tad,AA — I Z Type of Building: Dwelling No.of Bedrooms -:3 Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil 0e 2 Q474FI, 2 N4s�,, Sl y Nature of Repairs or Alterations(Answer when applicable) IR kk 1VQ v s7-1v3r. we-Sft t— r­�b ( 1 i Sba a ��` h 6® � � 13Q_� 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- cate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Application Disapproved for the following reasons Permit No. F 9 ' �� / Date Issued Noy Fee Mr A. r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for Pigozar *patent Construction Permit Application is hereby made for a Permit to Construct( ° )or Repair( ✓)an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 0_6 c.e0 Ate. �, pS� �2v .�`L. No���.►� t-v��otz Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 38 tZo�hair .N� tom ►N:S ?'1 —ti17- 8 Type of Building: Dwelling No.-of Bedrooms Garbage Grinder(t Other Type of Building .No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil ©^2 2°— shn& .d Nature of Repairs or Alterations(Answer when applicable) 1�,A .1 .0 L. r!'4` —,- -(4 sc%L., 1, r-. T" 6 0 r,4— S>J0__to Date last inspected: Agreement: s, 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- cate of Compliance has been issued by this Board of Health. Signed y Date. 996- Application Approved by Application Disapproved for the following reasons Permit No.X Date Issued, ,P THE COMMONWEALTH OF MASSACHUSETTS.' PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced( on by µ\Q-- - ,t for r-3000LM l\rya+� a3- ,�L6 CCt;t-Q.. LP.%31Zr E has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 0G .16 dated 6 3 9 6 Use of this system is conditioned on compliance with the provisions set forth below: No. / / Fee y THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mi.5pozaf *pztent Contruction Permit Permission is hereby granted to H (3ANsT1Vve770t✓ to construct( )repair( "l an On-site Sewage System located at C 0 A2 I-AIVV OJr and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. Date: Approved by CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS), hereby certify that the application for disposal works construction permit signed by me dated G y 3 q(o , concerning the property located at 2co Ce?�A,\e— u .- (b meets all of the following criteria: ; • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. i SIGNEDr!L��,_ DATE: /� 996 LICENSED SEPTIC-SYSTEM INSTALLER IN THE TOWN OF BARNSTABL W.MBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. jA- ' � C - - Ci ` -3 1 __ Z 514 8.. 651 .0 311 Receipt for Certified Mail No Insurance Coverage Provided UNITED STATES Do not use for International Mail POSTAL SE-CE (See Reverse) M Sent to 0) Z Street an No. 2 P.O., a an e Postage Go E Certified Tee O LL Special Delivery Fee CL Wes`tFT-t`ecl'YeliG�ry fim- WOU"TWcT,RSfio`0;wo I to Whom,&Date Delivered Return Receipt 'n to Whom, Date,and 's ess TOTA o &Fe Ur � 31 ii STICK POSTAGE STAMPS TO ARTICLE TO COVER FIRST CLASS POSTAGE, CERTIFIED MAIL FEE,AND CHARGES FOR ANY SELECTED OPTIONAL SERVICES(see front). 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address 12 leaving the receipt attached and present the article at a post office service window or hand it to i your rural carrier(no extra charge). I—C 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the return rn address of the article,date,detach and retain the receipt,and mail the article. M 3. If you,want a.returq receipt,write the certified mail number and your name and address on a return ieceryt.card,Form 3811,and attach it to the front of the article by means of the gummed Co ends if space permit's.Otherwise,affix to back of article.Endorse front of article RETURN RECEIPT 'k44 REQUESYED adjaceri}t to the number., 1 Go f ypu�want dehy�rt restricted to the addressee,or to an authorized agent of the addressee, orse:RESTRICTIED DELIVERY on the front of the article. E 5. EN r-fees 'for the services requested in the appropriate spaces on the front of this receipt.If 1i return receipt is requested,check the applicable blocks in item 1 of Form 3811. d 8. Sa.e this receipt and p?ospin it-if you make inquiry. 105603-93-8.0218 �R'// fO �'1Y✓l�� t% 0 Town of Barnstable • F Department of Health, Safety, and Environmental Services MAN M Public Health Division i63q. � 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean FAX: 508-775-3344 Director of Public health January 23, 1996 Mary C. Butler 26 Cedar Lane Osterville, MA 02655 ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at 26 Cedar Lane, Osterville was inspected on December 4, 1995 by Robert Bortolotti a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Discharge or ponding of effluent to the surface of the ground due to overloaded soil absorption system You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office (Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within (14) fourteen days of receipt of this notice. You are also directed to bring the septic system into compliance within thirty (30) days of receipt of this order letter. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH omas McKean, R.S., C.H.O. Agent of the Board of Health `ra r [Installer letter] TO: z p' i��' (Date) ! = Z� 9 ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at was inspected on or 4- a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: 01 You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office (Town Hall, 367 main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within (14) fourteen days of receipt of this notice. You are also directed to bring the septic system into compliance within thirty (30) days of receipt of this order letter. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health Town of Barnstable ASSESSORS MAP M PARCEL NO /g RfCFIV f� DEC 1 1 .19,95 BORTOLOTTI CONSTRUCTION,INC. q : 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 508-771-9399 508428-8926 FAX: 508428-9399 ` .`. 4 SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM ` PART A CERTIFICATION Property Address: ` Date of Inspection:_/,2-9 79,; Inspector' Name: dpol Owner's Name and Address: ,r ' C CERTIFICATION STATEMENT: I certify that I have personally inspected the sewage disposal system at this address and that the informa tion reported below is true,accurate and complete as of the time of inspection..The inspection was per- formed based on my training and experience in the proper function and maintenance of on-'site sewage disposal systems. The System Passes Conditionally-Passes Needs Further Ev uation By the Local Aproving Authority, " Fails Inspector's Signature: , I g ate: lt' The System Inspector hall submit copy of this inspection report to the Approvutg authority.<,within thtr- ty(30)days of complg this inspection: If the system is a shared system or has a design flow of 10,000 or eater,the i gpd gr nspector and the system owner shall submit the to the appropriate regional office of the Department of Environmental Protection. The`original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority, INSPECTION CiTMMARY• { A A)SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure ' y e indicated below.' n failure criteria not evaluated at criteria as defined ui 310 CMR 15.303..A • B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired Thesystem,upon'comple- . tion of the replacement or repair,.passcs inspection. Indicate yes, nor,or not determined(Y,N,OR ND).Describe basis of determination in all instances. If not determined explain why not. The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection.if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water level observed in the distribution box is due. to broken or obstructedpipe(s)or due to.a broken,settled or uneven distribution box. The. . system will pass inspection if(with approval of The Board of Health) -A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A. CERTIFICATION (continued)' Broken i s P Pe()re Placed Obstruction is removed + Distribution Box is levelled or replaced �sF' a : The System required pumping more than four times a year due to broken or obstructed pipe(s): u 3� The system will pass inspection if(with approval of The Board of Health): �x� . Broken pipe(s)are replaced nz 9�H Obstruction is removed `b C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:. g � � Conditions exist which require further evaluation by The Board of Health in order to determine if the system is failing to protect the public health;safety and the environment: t. 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: F�{k r"s Cesspool or privy is within 50 Feet of a surface water ,1 Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh. rz; 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- - ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY,AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 Feet to a surface ;k ' wate }pply or tributary to a surface water supply. it at The system bas a septic tank and soil absorption system and is with.a Zone I of a public water supply well. PP y. The system has a septic tank and soil absorption system and is within_50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well,unless a well water analysis for.COMM bacteria and volatile organic compounds indicates that the well is free from pollution from ' , the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. !71 TEM FAILS:have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health y . should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS r . or cesspool. Discharge or pondingof effluent to the surface of the-ground or surface waters due to an _I� n overloaded or clogged SAS or cesspool. Static liquid level is the distribution box above outlet invert due to an overloaded or clog ged SAS or cesspool. Liquid depth in cesspool is less than G"below invert is less than Li 1/2, p q P P� low it or available v . ' - day flow. r� Required pumping more than 4 times in the last year rLOT due to,clogged or obstructed _ r a nj pipe(s)• Number of times pumped. _2- 'P SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM :PART A . CERTIFICATION(continued) , Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 Feet of a surface water-supply or tributary to a surface water supply: . Any portion of a cesspool or privy is within a Zone I of a public well.` f' An portion of a cesspool or n is within 50 Feet of ' y po � poo privy a private water supply',well. "" r Any portion of a cesspool or privy is less than 100.Feet but greater than 50 Feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria;volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS. The following criteria apply to`a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(]Large System)and die system is a significant > threat to public health and safety and the envirocnnent because one or more of the following conditions exist: The.system is within 400 Feet of a surface drinking water supply The system is within 200 Feet of.a tributary to a surface drinking water supply The system is located in a"nitrogen sensitive area Iciterim Wellhead Protection Area (IWP )or a mapped Zone Il of a public water supply well. ;� The owner or operaW pf iiny such system shall bring the system and facility_into full compliance with the groundwater treatment program requirements of 3.14 CMR 5.00 and 6.00.1,Please consult the local- regional office of the:Department for further information.*' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B 3 � CHECKLIST ` Check ��, the following if have been done. 1Z Pumping information was requested of the owner,occupant,and Board of Health. J,:I�None of the system components,have been pumped for adeast two weeks and the system has r been receiving normal flow rates during that period. Large volumes of water have not been, introduced into the system recently or as part of this inspection. As-built plans have been obtained and examined. "Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up . L The system does not receive non-sanitary or industrial waste now. _ The site was inspected for signs of breakout All system components,excluding the Soil Absorption System,have been located on site. r/The septic tank manholes were uncovered,opened;and the interior of the septic tank was in- spected for condition of;baffles or tees,material,of construction,dimensions,depth of liquid, depth of sludge,depth of.scum. //The size and location of the Soil Absorption System on the site has been determined based on o- existing information or approximated by non-intrusive methods. k _3- a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PARTS CHECKLIST(continued) The facility owner(and occupants, if different from owner)were provided with information on r the proper maintenance of Subsurface Disposal System SUBSURFACE_SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION. FLOW CONDITIONS ti�vr44� RF.SIDENTLAI V Design Flow: allons Number of Bedrooms: Nunioer of.Current Residents: 0001 Garbage Grinder: Laundry Connected To System: r-! Seasonal Use: D s Water Meter Readings, if available: Last Date of Occupancy: IOCeCGv" i c-�eky1� ' CO MERCLAL/INDLJSTRLAL.• Type of Establishment: Design Flow: gallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: r � 1 Non-Sanitary Waste,Pi harged To The Title V System: Water Meter Readings;If"Available: Last Date of Occupancy: , s�z OTHER: Describe) fist. Last Date of Occupancy: GENERAL INFORMATION - PUMPING RECORDS,and source of inform , n: - S""i✓r System Pumped as part of inspection. at If yes,volume pum gallons �{ Reason for pumping: TYPE OF SYSTEM: n4 Septic Tank/Distribution Box/Soil Absorption System Single Cesspool ; Overflow Cesspool ` Privy { Shared System(If yes,attach previous inspection records, if any) Other(explain): r � ROXIMAT AGE of all components,date installed(if known)and s urce of i rmation: Sewage odors detected when arriving at the site: 'a - k H h. - per 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART C. GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: Material of Construction. concrete .metal f . IW Other. (explain) Dimisions: Sludge Depth: Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: A' Comments: (recommendation for pumping,'condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) t GREAS E -• S RAPT De pth tr Below Grade: • Material fCo Construction:oi.• concrete_metal., FRP Other • ..'>y,. •..b•, , (explain) P. Dimensions: Scum Thickness Distance from top of scum to top of outlet tee or baffle: Comments: recommendation for pumping, b ( p p g,condition of inlet and outlet tees or baffles;depth of�hquid level in relation to outlet invert, structural integrity;evidence of leakage,etc.) I F � r t TIGHT OR HOLDING TANK: Depth Below Grade: Material of Construction: concrete metal FRP:,_Other(explain) " Dimensions: Capacity: Qallons Design Flow: �allons/day r Alarm Level:' Comments: (condition of inlet tee,condition of alarm and-float switches.-etc.)- DISTRIBUTION BOX: Depth of liquid level above outlet invert Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) F r - PUMP CHAMBER Pump is in working order: . Comments: (note condition of pump chamber;condition of pumps and appurtenances,etc:) r 5 {. i. T' t j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS): (Locate.on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: Leaching pits,number: Leaching chambers; number:. Leaching galleries,number: Leaching trenches, number, length: ri 1 rdimensions:Leaclun fields, number, g Overflow cesspool,number: Comments: (note condition of soil, signs of hydraulic failure level of ponding,condition of vegetation, etc.) sf CESSPOOLS: Number and configuration: 5 X s Depth-top of liquid to inlet invert: ] Depth of solids layer. /.2 Depth of scum layer:/-Dimensions of Cesspool:. '2Y S'W Ma s of construction:&"U* Z7441ndication of groundwater: Inflow(cesspool muss+bq!pumped as part of inspection) Sri Comments:(note condition of soilk^, signs of hydraulic lure, level of ponding,condition of vegetation etc.) S S' YS 'CJ ' GY� l' ���2YlaG�s L �� / a7 /� DO'S Hof COw y'm 7I1</e 32 E?c=9u. ac r real �e � d4 ov �//°� ar s PRI[VY: / Materials of construction Dimensions: '# Depth of Solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, qx etc.) l j� 1 cn�. xi -G - n SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) , SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references,landinarks.or benchmarks:` Locate all wells within 100.Feet. t4v .. - .. 4 DEPTH TO GROUNDWATER Depth to groundwater. z� Feet Method of Dew . tion-or Approximation: W h'Q G�` X/Ir �i Gr/5 1z� �7C y�// aW 14.313 e .^ 1 W t TOWN OF BARNSTABLE LOCATION SEWAGE# VII,LAGE r,11S krO e Aeo— ASSES77/,W MAP&��L 5 //OT � . S—S— �rS�S'/��7�i�S NAME&PHONE NO.� ,r U�OD�i SEPTIC TANK CAPACITY 1 LEACHING FACILrrY: (type) �S7Xl A� / (size) X S NO'OF BEDR_ CID BUILDER R OWNE r PERMITDATE: 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 :r within 300 FeeLoff leejachin facility J / 4/ZW- Feet Furnished by / */ ��� � ��� I'� {. An my ... ....... ...... "AWIQ�YANWS A Twonn on spy q y �;�I di -:L;.: r HOW x r toot "W"WIN! Minummo Mot A k Zoltan Wm- i p MEMO 4i. �Ii. 100501 A oil J11JAWn Js Y V A N.:0.2.0.Atonal 11�intammwct or Rox-M 1 1: !��l 1 i 7:! : M"i WAS poll lip! 1A Omni VIF ERAK N dr�� AMC RIMS TIME! WMA Oil T A hill BEST WMAN-0 so 1, a�wnsAt 00 c 11........... !!7 SAMOA IOWA& OWN HER.,,. _J:C cu .......... ... ......... Fuel Twass woman 0:5 di 41106" Box! HIM BEEN Timis 1 mays hill .......... it 26— - � �V W elf MAN! IS 1111; KIM,Nlw"_"11_11� a sum 05 Z MARK 1 WINA An,Ty INK am AS". �. .......... . . .... . .... NINE! ........... !its 0ATURsO too: INN lays goo A., gn w WAS_ J,j: plow W Pam - 76' 2'-10" 2'-2". 3' 12• 3.. - .. r _ O 04 .N C U Q a) Lo 0 —• ' ` . .- . - _ _ rvm - 4IrIIIIIIIII t 4 IIII—a—nno B4si„Aew T_•N e I I - III II'IrIIIIu I _aR _iIC 8E/L-4wRII t 0anB_•'s. B- -rz�•e_-ag—t�o_— II IIIII ..i to -c --- - -- - •-/ � J��(C�Z J . 00 �. O«_OQCN s^W `nWJ�NQ C , .. DN MMOV� 5QO 14' 20a 1 L CSET O � O cc O 8'-" 5'11" 4'-2' --6-2 6' /T— 3_3 � co E n ` l4 ------- -- — ------------ R — --- ---'p� tN aaN 21 BED 100M Vaulted Plaster Ceiling ua ___ _ ________________________ _ =EET oem ___ -. ____ ____ as G t 1 ---- ——————————————— �E — --- Cfj a I ------ ------. —————— ------ 5 ., 53 31-6' 5-6'- 2xIO Ceiling Joiis '4——— N -wn ,n 76 Qry t _ ". 76' 2' 4•-7" 15'-5" 36' 18' N (O6 (0D 00 N � O J CVO L t7 ( .B k I I I (O — CU CO I I - • I I I I -. �YQv— �1O —� -- ------------ O O ._ I --' --- ---------- I 36 m M O (� f6 f I I O c- c6 I I U qT M J I I I I I q I 4• "— 2-6"q�4�-4^��z'�" a< I n L---------------- -- -------------- --j -4 N O N -- -- — LO I ----------------------- =----------------j I I J K (O I I �a._,m i i • i ^-- . I 6'-6"--'k 2'-6a s' 1' —ua' 30"x30"x 12" I I I - I -- -- - Thick Footings Typical I g Y a3T-11" _ k 2-6"-1, 4'-e 4'-2• 4'-2• 2'-6• i, 4'-2•�2'-F 44 4•-4• 2'-6•-1,4-4"'k r-6 s - ost From Ridge Above ' - • Post From Ridge Above -------- ---------- I I 14'-8" 24'-e• 14 I x N 1 24'-8 N ——� -— ———————— — I N------------ C/1 ='t rr GARAGE I I i v - , PI) •^, I I 3/4• ' - CZ14 26' 14' - , — w ,n I I v }j ae wn I CAO " 5/8"x 12"Galvanized Anchor Bogs C with 3"x 3^Galvanized Washers I 48"O.C.Typical _ .. I I I I • I I _ — ————————————————— ------------------------ tw 1 @ garage door Kings 22' .. N " LNWG AREA qn STHD14RJ Hold Downs 1 @ garage door Kings - 22' 1 at Corner Studs 79 �u^ k-7'Y'l OSTERVILLE nn � 1' MICAH TAGBOLT '6 I oz POND ON HYD. PARCEL ID: �, � �JOSHUA ELEV.=43.26 I 118/054 POND PARCEL ID: 118/047 N J' LOCUS I �� 26 CEDAR LN. 139.44 IP �" N86°15'10"E � � 36"0 i IP PARCEL ID:CENTER STREET �, 118/055 s^r 10 �'� AREA=14,132t S.F. tip I s o I �' r' 48.0 � ----\ q� 25.9' PROPOSED HOUSE POSED TOF=43.5 N / r , o LOCUS MAP N PRO N o I I CTe DRIVEWAY � I PLAN REF: 97/17 T — W TITLE REF: 23547/37 EXISTING i i CONIC I I D 24"0 O PARCEL ID: MAP 118 LOT 55 DRIVEWAY 14.5' — — 7 5' I N I fr1 ZONING: "RC" WIND EXPOSURE: "B" ZONE 3 J � i� FLOOD ZONE: "C" P ATI O// ' COMMUNITY PANEL: 250012-2F DATED:07/02/92 CATCH ® — I m EXISTING BASIN 0 , i i i i LA 15 SEPTIC EL=40.36 I 2.0 #26 i i O I SYSTEM p PARCEL8/046 Un TOF=43.4 :: 1500 GAL I J CERTIFIED PLOT PLAN rri % N 3—BED. ;; — — O �° _ (FOR NEW HOUSE) I I o DWELL. TANK I I ? , (TO RAZED):/ I ` 61.7 2.0' 14.0 LOCATED AT: M V8// ao L 24"0 26 CEDAR LANE J I O OSTERVILLE, MA. I 40.0 — 0 42 o ao IP PREPARED FOR bo � 111 ° 143.20 R. W. HEN SON & IP S861510 W 30"0 Aft LISA A. KAISER a)I r 30"0 SCALE: 1 =20 UPOLE PARCEL ID: z 118/056 DECEMBER 2, 2013 0I PARCEL ID: r 118/116 ^� MacDougall Surveying & Associates Pam`" OF "Ssq P. O. Box 2428 GRAPHIC SCALE oo��` EDWAARD oyG� Mash pee, Ma. 02649 20 0 10 20 40. 80 STONE ti p NOTE: PH. (508)419-1086 1) SEPTIC LOCATION PER TOWN OF BARNSTABLE L- � ER 0^ fax 508 419-1087 TIE CARD IN FEET ) s /S email: NO2, macdougallsurvey@comcast.net 1 inch = 20 ft. SHEET 1 OF 1 J 1611