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HomeMy WebLinkAbout0010 CHINE WAY - Health 10 /0 o. / LOCATION ZSEWAGE PERMIT NO. o t 9- - 70 VILLAc ,M 6� � —ova I N S T A LLER'S NAME i _ ADDRESS l a- &)2,5 S BUILDER OR OWNER DATE . PERMIT ISSUED DATE COMPLIANCE ISSUED��� ��Z r I i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for VoluntaryAssessments ments 10 CHINE WAY Property Address AUSTIN Comer owner's Name information is required for OSTERVILLE MA 6/12/12 every page. Cityrrown State Zi Code P 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 on the computer,use 1. Inspector: JP I only the tab key to move your cursor-do not DOUGLAS A BROWN c use the return Name of Inspector key. DOUGLAS A BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 City/Town State 508-420-4534 Zip Code S 14297 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 6/12/12 Inspect,' 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. t5. / ms 09/08 Title 5 Official I n Form:Subsurface Sewage Disposal System•Page 1 of 17 r Commonwealth of Massachusetts OmEft Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 CHINE WAY Property Address AUSTIN Owner Owner's Name information is required for OSTERVILLE MA 6/12/12 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: PIT HAS 3FT OF USABLE SPACE AT 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-09/p8 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 10 CHINE WAY Property Address AUSTIN Owner information is Owner's Name required for OSTERVILLE MA every page. City/Town 6/12/12 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): ❑ 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. I. 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts AMk Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 CHINE WAY Property Address AUSTIN Owner Owner's Name information is required for OSTERVILLE MA every page. Cityrrown Dat ea12 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 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-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 r` 10 CHINE WAY Property Address AUSTIN Owner Owners Name information is OSTERVILLE required for MA 6/12/12 every page. Cityfrown State Zi Code P 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•09108 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 10 CHINE WAY Property Address AUSTIN Owner Owner's Name information is required for OSTERVILLE MA 6/12/12 every 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 buil t plans of the system obtained ® ❑ p y tamed and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 .DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts ' Title 5 Official 'O ficial Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 10 CHINE WAY Property Address AUSTIN Owner Owner's Name information is required for OSTERVILLE MA 6/12/12 every page. Citylrown State Zip Code Date of.Inspection D. System Information Description: ACCORDING TO AS-BUILT CARD SYSTEM CONSISTS OF A SEPTIC TANK D-BOX AND LEACH PIT Number of current residents: 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)): Detail: 2010---238 2011---241 Sump pump? El Yes ❑ No Last date of occupancy: 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•09/08 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 10 CHINE WAY Property Address AUSTIN Owner Owner's Name information is required for OSTERVILLE MA /12 every page. Cityrrown b State Zip Code Dite te of Inspections . 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•09108 Tide 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 -Y Not for Voluntary Assessments , 10 CHINE WAY Property Address AUSTIN Owner Owner's Name information is required for OSTERVILLE MA every page. City/rown 6/12/12 State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1982 OFF AS-BUILT CARD Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene El 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: 1500/PREVIOUS INSP REPORT Sludge depth: 12" t5ins•09108 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 10 CHINE WAY Property Address AUSTIN Owner Owner's Name information is required for OSTERVILLE MA every page. Cityrrown 6/12/12 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 3211 Scum thickness 6" Distance from top of scum to top of outlet tee or baffle 12 Dist ance from bottom of Scu m to bottom of outlet tee or ba ffle How were dimensions determined? WOODEN POLE Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 CHINE WAY Property Address AUSTIN Owner Owner's Name information is required for OSTERVILLE MA every page. City/Town 6/12/12 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 s Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins-09= Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of !Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 CHINE WAY Property Address AUSTIN Owner owner's Name information is required for OSTERVILLE MA 6/12/12 every page. City/Town 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 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): BOX WAS REPLACED IN 2006 ACCORDING TO PREVIOUS INSP REPORT 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 Forth:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 CHINE WAY Property Address AUSTIN Owner Owner's Name information is required for OSTERVILLE MA every page. City/Town 6/12/12 State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.):` PIT WAS OPENED AND FOUND TO HAVE @ 3 FT OF USABLE SPACE AT TIME OF INSPECTION 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= Title 5 Official fnspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts ugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 CHINE WAY Property Address AUSTIN Owner Owner's Name information is OSTERVILLE required for MA 6/12/12 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privylocate 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.): t51ns•09f08 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 °M 10 CHINE WAY Property Address AUSTIN Owner Owner's Name information is required for OSTERVILLE MA 6/12/12 every 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 s t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 CHINE WAY Property Address AUSTIN Owner Owner's Name information is required for OSTERVILLE MA every page. City/Town 6/12/12State 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: GREATER THAN 5 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: OFF PREVIOUS PASSING INSP REPORT DATED 4/21/2006 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts l Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 CHINE WAY Property Address AUSTIN Owner Owner's Name information is required for OSTERVILLE MA 6/12/12 every page. City/Town 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Assessing As-Built Cards Page 1 of 1 f0 LOCATION SEWAGE PERMIT NO. YILLA ' INSTA LLER'S NAME i ADDRESS f UILDER OR OWNER 14 L6&Q Y2�_ L DATE . PERMIT ISSUED w� ,fie DATE. COMPLIANCE ISSUED_ L/R Af if�X U ttp://www.town.bamstable.ma.us/Assessing/IB4display.asp?mappar=097012&seq=1 6/13/2012 No. 19J Fe$1 0 0 .0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for 33tgpo al �&pgtem Con!Aructton i9ermit Application for a Permit to Construct( ) Repair(4 Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. 4 2 8—3 6 6 6 10 Chine Way, Osterville Joe Hughes Assessor'sMap/Parcel 64 :7 10 Chine Way, Osterville Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. Wm E Robinson ,Sr Septic PO Box '1089 Centerville Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Repair d—box 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 Certificate of Compliance has been issued by this Board of alth c� o� Sign L Date Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. �CD Date Issued !T� NO.. r!- ��P Fee>10 0.0 0 THE COMMONWEALTH'"OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH.DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 21pprication for �Digpo!6ar �&pgtem Con.5truction Permit Application for a Permit to Construct O Repair(0 Upgrade O Abandon O ❑ Complete System ❑Individual Components Location Address or Lot No. +; Owner's Name,Address,and Tel.No. 4 2 8-3 6 6 6 10 Chine Way, Osterville Joe Hughes Assessor'sMap/parcel 10 Chine Way, Osterville Installer's Name,Address,and Tel.No. 7 7 5—8 7 7.6 Designer's Name,Address and Tel.No. Wm E Robinson Sr Septic PO Box 1089 Centerville Type of Building: Dwelling No.of Bedrooms I Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Repair d—box 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 Certificate of Compliance has been issued by this Board.of ealth y a SignQ Date lL � Application Approved by Date 5, Application Disapproved by: Date for the following reasons (, I Permit No. �C�" (O `�. Date Issued ———————— THE COMMONWEALTH OF MASSACHUSETTS 41 BARNSTABLE, MASSACHUSETTS . . t Hughes Certificate of Compliance THIS IS TO CERTIFY,that the On-`site Sewage Disposal System Constructed ( ) Repaired ( X) Upgraded ( ) Abandoned( )by Wm E Robinson Sr Septic Service at 10 Chine Way, Osterville has been constructed in accordance l with the provisions of Title 5 and the for Disposal System Construction Permit No. A?_3 "dated / b Installer P)bi Designer #bedrooms Approved design.#lo. _ gpd The issuance of this pe i shall got be construed as a guarantee that the s s,tem wi4l unc rton as esigned. Date ( 9:th Inspector —————---—---——————————————————— No. Fee • Hughes THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS �Wmigont,*pgtem Construction Permit Permission is hereby granted to Construct ( ) Repair (X�) Upgrade ( ) Abandon ( ) System located at 10 Chine Way, Osterville s 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. Provided: Construction must be completed within three years of the date of h s'pe Date �-s Appro ed b��. ' f rt COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 1./ TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A 6 CERTIFICATION Property Address: 10 Chine way —6sterville Owner's Name: Jna HuQhes; Owner's Address: OS terj t I Lt Date of Inspection: •, �/� Q, f Name of Inspector: (please print)_Sean Jones Company Name: William E. Robinson Septic Service ;. Mailing Address: P 0 Box 1 089 ; Centerville. MA Telephone Number: (5081 775-9776 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported. below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I ant a DEP approved system inspector pursuant to S ction 15.340 of Title 5(310 C1%1R 15.000). The system: Passes Conditionally Passes ' Needs Further Evaluation by the Local Approving Authority Fails r Inspector's Signature: Date: GO The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heanhw 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.'ihe original should be scat to the system owner and copies sent to Qtc buyer,if applicable,and the approving authority. Notes and Comments ""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 uudcr►he same or diftercnt conditions of use., Title 5 Inspection Form 6/15/2000 page 1 r 3 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 10 Chine Way Osterville Owner: Joe Hughes Date of Inspection: Inspection Summary: Check A,B,C,D or E I ALWAYS complete all of Section D A. Sy tem Passes: 5 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: A//A 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 die 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 pipes)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipes)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 tines a year due to broken or obzuctcd pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipes)are replaced obstruction is rcmorcd ND explain: f Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued') Property Address: 10 Chine Way Osterville Owner: _ Tna Hlicthes Dale of Inspection: i C. Further Evaluation is Required by the Board of Health: 4o;• 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. o I. System will pass unlcss.Board of Health determines in accordance with 310 CNIR 15.303(l)(b)that the system is not functioning iu.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 I System will fail unless the Board of Health(and Public Water Supplier,if any)determines that(lie � v system is functioning in a manner(hat 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 I 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 welC _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front a private water supply well•• Method used to determine distance l "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 Gee from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm;provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: t ' 3 : Page 4 of 1 OFFICIAL INSPECTION F01IA1—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 10 Chine Way Osterville Owner. Joe Hughes Dale of Inspection: -;1E c_C� D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes N 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 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 titan 50 f::et from a private watu supply well with no acceptable water quality analysis. (This system passes if the Heil water analysis, performed at a DEf certified laboratory,for coliform bacteria and volatile organic compounds indicates that(lie H•cll is free front pollution front (hat facility and the 1,resence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria arc triggered.A copy of lire analysis must be attached to this form.l /00 (Yes/No)The system fails. I have determined that one or more ofthe 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: A/ �� To be considered a large syslenn (he system must serve a faci!i(y with a design floti,_ of 10,000 gpd to 15,000 gpd• You must indicate either"yes'or"no"to cacti 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 suppl) _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-1WPA)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 tlucal or answered "yes'in Section D above the large system has fiikd.The wwncr ar operator of tray large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CNIR 15.304.The system owner should contact the appropriate regional office of the Department. 4 I _ Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: _ 10 Chine Way Osterville Owner: Joe Hughes Date of Inspection: L/4 / Check if the following have been done.You must indicate'yes"or"no"as to each of the following: . Ycs� No j r _ Pumping information was provided by the owner,occupant,or Board of Health,' Were any of the system components pumped out in the previokus two weeks? Has the system received normal flows in the previous two week period? J 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? w , 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 thhe 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: Yew no i Existing information. For example,a plan at the Board of Health. r/ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance �`- is unacceptable)[310 CMR 15.302(3)(b)j 5 �. f Page G of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 10 Chine Way Osterville `. Owner: Joe Hughes Date or Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN(low based on 310 CMR 15.203 (for example: 110 gpd x M of bedrooms): (p7 F 6P Number of current residents: cP Does residence have a garbage grinder(yes or no). Is laundry on a separate sewage system(yes or no): ,W0 [if yes separate inspection required] Laundry system inspected(yes or no):a,V A Seasonal use:(yes or no): A/0 . Water meter readings, if available(last 2 years usage(gpd)): 2005 - 93, 000 Sump pump(yes or no): AV 2U0 - 115, UOO Last date of occupancy: a V re ^1' COMMERCIAL/INDUSTRIAL A/�A Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION " Pumping Records Source of information: ©t. A#ef- °- a o0y Was system pumped as part of the inspection(yes or no): LVD If yes,volume pumped: gallons-- How was quantity pumped dacimined? 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 contact(to be obtained from system owner) _Tigbt tank Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 6 Viv 7 of I OFFICIAL INSPECTION I"0101 -NOT FOR VOLUNTARY ASSESS111EN-1'S SUBSURFACE SELVAGE DISPOSAL SYSTM INSPECTION F0101 PART C mum INFORMATION(continued) Property Address: 10 Chine Way Os ervi T T e Owncr: Joe Hug es Dalc of Inspecllon: Y, 621 r 0g; BUILDING SE1VEli(locate on site plan) xz 11�% Dcpdt below grade: 5 `f Materials of construction: cast iron ,/d0 PVC_ot)rcr(explaut): F Distance from private svalcr supply well or suction line: Co-Z"Inents(on condition ofjuints,vcIlling,evidence uf.lcakagc,Etc): JUL, L ®8i G N'�j 1 yJ L e$teL3 p�^ SEPTIC TANK: ` (locale on site plait) . Dcpthbelow adc: Br Material of construuion: c�vncrcic rectal fiberglass +- - - - i _othcr(cxplatn) — _1 ) Urylcnc If talk is metal till age: Is age ccrtificatc) coitfuntcd•by a Certificate of Compliance (yes or no): -(attach a copy of Dimensions: 1",c, Sludge depth: Distance from sup of sludge to buttunt of outlet Ice or baffle: , Scum thickness: i OR !+, Distance from top of scum sv top of outlet lee or bafllc: Distance Gom bottom of scum to bottom of out t(cc or w bafllc:. Ilow ere dimensions determined �f'��+cz� rrwt�sr iclulatr. ni gri Comments fun pumping rcevnuneridativrii, inlet and outlet lee or bafllc evnditien, slructwal;tntc6nt}, liyuid,lc�els , •-.{ as related to outlet invert,evidence_ofdcakage, etc.): / doe Cu�:elr�iaL Gr r� �L Sava :( !% does AAz) sVri.'a /a+vr 6C i.r4 Y NO� t°C4 L^s•y ea� _ C G�`n Al/ GREASE TRAP.;14 ale on site plan) a Depth below grade: ' t Material of construction:—concrete tnclal fiberglass pul�•cllr�•Icnc other, (explain): — — — Dirncnsions: Scuts thickncs Distance from top of sewn to lup of outlet Icc or bafllc: Distance from bottom of wont to bolfont of outlet Icc or bafllc: Dale of last pumping: Conuncnts(Oil pumping rcconuncndatiuns, inlcfand uullct (cc ur bafllc cunditio:t, sttuctwal integrity, liquid Icscls as Iclalcd to oullc(invert, ct idcncc of Icakarc, ctc.): 'age 8 of I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSLSSMENTS SUBSURFACE SEIVAGL DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Properly Address: 10 Chine Way s t er i Owner: Joe Hu es Dale of Inspection: TIGHT or HOLDING TANK: r'(ta,tk must be pumped at time of inspection)(Ivcate on site )Ian) Depot below grade: Material of construction:_concrete_Metal _fiberglass_polyethylene other(explaut): Dimensions: Capacity: _ gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alann in wvrking order()•cs or nu): Date of last pumping: — Conuncnts;condition of alarm and float switchcs,ctc.): DISTRIBUTION BOX:/(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: ®% Comments(note if box is level and distribu leakage inry or out of box ctc.): tion to vuticts equal, any evidence of solids carryover, any evidence of , --to... r.�- �► 1nS-a/)e( to te et bplf'e, �f- PUMP CIIAMBLII: Alf-tvcatc on site plan) Pumps in working order ,{ g (yes or nv): Alarms if'working order(),cs or no): __ Cununenis(note condition of pump chamber, cunditivn of pumps and appurtenances, etc.): Page 9 of OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 Chine Way Ostervil e Owner: Joe Hughes Date of �Inspection: � ,t t SOIL ABSORPTION SYSTEM(SAS): .,/(locate on site plan,excavation not required) r If SAS not located explain why: Type . leaching pits,number: leaching chambers,number: leaching galleries,number: - leaching trenches,number, length: leaching Gelds,number,dimensions: overflow cesspool,number:. innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic.failure,level of ponding,damp soil,condition of vegetation,etc.): _ l wG vege ] L -`.rJ L7.PiMC•/ te, a LL r%`i_ 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 or no): Comments(note condition of soil;signs of hydraulic failure, level of ponding,condition of vegetation,etc.): ` PRIM': (locate on site plan) Materials of construction: r Dimensions: Depth of solids: Comments(note condition of soil,.,signs ofhydraulic failure, level of ponding,condition of vegetation, etc.): 9 Page 10 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 Chine Way . Osterville " Owner: Joe Hughes Date of Inspection: o 006 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. 6 rr Of ® ° TNnc Ar- r6P 8- 90- 117f P►•I- e4 10 Page 1101711 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 Chine Way Osterville Owner. Jop- Hu hes Date of Inspection: i SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water ¢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: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: � r�c•. ,r f-i�c Gc f w N'.-h6— r e 11