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0012 COCKACHOISET LANE - Health
12 COCKACHOISET LANE, OSTERVILLE .r r UNITED STATES POSTAL SERVICE First-Class Mail Postage.&Fees Paid LISPS Pbrmit No,rG-10 • Sender. Please print your name, address,and ZIP+4 in this box • I OTown of Barnstable Health Division 200 Main Street Hyannis,MA 02601 I I I , I II�}F!}1�}FilifiilffkFlf i ik 113 1}if3 ! f13 rtt3 ii}i � i SENDER: COMPLET,FTHIS SECTION • •N • • ■ Complete items 1,2,and 3.Also complete A. S' tare Item 4 if Restricted;Delivery is desired. t ❑Agent ■ Print youf name and address on the reverse X ❑Addressee so that we can return the card to you. B. ived by(Printed N C. D to of Delivery ■ Attach this card to the back of the mailpiece, 3 26 or on the front if space permits. ITA D. Is delivery address different from Rem 1 ❑ s 1. Article Addressed to: If YES,enter delivery address below: ❑No 3. Service Type 33Ha 1 ®Certified Mail ❑Express Mail ❑Registered lia Return Receipt for Merchandise V ( ❑Insured Mail ❑C.O.D. N 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number i i 7006' 081�' ��'�0 3r524 i898r1 Vr ' (Transfer from service label) PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 Certified Mail#7006 0810 0000 3524 8981 Town of Barnstable Regulatory Services y f = UARNSPABLE. h 9 Knss Thomas F. Geiler,Director prFa MPS Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 March 20, 2007 William Koch 1601 Forum Place Suite 307 West Palm Beach, FL 33401 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II — MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE CODE CHAPTER 170.' The property owned by you located at 12 Cockachoiset Lane.Osterville, was inspected on March 9, 2007 by Meredith Morgan, Health Inspector for the Town of Barnstable. This inspection was conducted on the basis of the rental registration in accordance with Chapter 170 of the Town of Barnstable Code. The following violations of the State Sanitary Code were observed: 105 CMR 410.300 & 310 CMR 15.00—Title V. Four bedrooms observed, when septic capacity (permit#83-901),is only suitable for a maximum of two bedrooms. The Title V inspection report from James M. Ford dated September 18, 2001 conditionally passed the system on the basis of needing to replace distribution box. No record of installation or replacement of distribution box. 105 CMR 410300—Owner's Responsibility to Maintain Structural Elements. Top level of windows in living room are leaking. You are directed to correct the violations listed above within thirty (30) days of your receipt of this notice by repairing leaking windows in living room; by eliminating 2 bedrooms by removing beds and opening room entrance to five feet. wide or by upgrading or replacing system to accommodate four bedrooms. QAOrder letters\Housing violations\Rental ordinance\12 Cockachoiset Lane.doc You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. Non-compliance will result in a fine of $100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have any questions regarding the above violations, please contact the Town Health Division and ask to speak with the inspector who performed the inspection. ;PER ORDER OF T BOARD OF HEALTH Tho as A. McKean, R.S., HO Director of Public Health Town of Barnstable Cc: Ken, Owner's Representative Cc: Timothy O'Connell &Meredith Morgan, Health Inspectors Q:\Order letters\Housing violations\Rental ordinance\12 Cockachoiset Lane.doc CommoN-IEALTH OF MASSACHUSETTS, _ kf EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAip.s.- 3ERARTME?*TT=OF ENVIR`ONlYIENTAL 'ROTECTION _) M �ITTLE'5 OF'FICLA L INSPECTION FORM-NOT FOR YOLUNTARY-ASSESSMENTS SUBSURFACE SEWA:G'E•DISPOSAL:SY-STEM FORM. PART A OERTIFI CATI ON :Address: f 14. - Owner's I'l'am :� ,�� � �• s Owner's Address: _77- fi -. '.Date'of Inspectio ' Nameof inspect (please Tint Company Nam - 1 iiliha Address: Telephbne Nnmber. a99 : CERTIFICATION :STATEMENT, 1.certify-that I have personally inspected the sewage.disposal system at this address and'that the information.reported below is true,accurate and.conplete as of the time of the,inspection.The inspection was performed based on my training and'e?�perience.in the proper function and maintenance of on;site sewage.disposal systems;..I am a DEP. `approved system inspector pursuant to Section 1.5:340 of'Title5'(310 CMR 15:000) ,The system: . Passes ` Conditionally Passes , Need= Further Evaluation*by the.Local.ApuroingAuthority, F^ s Inspector's Sigh tujr.e : .$' Dine:. 0 The system inspector shall submit a copy of this inspection report to the Approving Authority(B card'of Health or. DEP}within'70 days of con?pletinQ 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 shouid'be sent to:the-systeriv owner and copies sent to the buyer, if applicable;and the approving authority. Notes arid-Comments t ****This report only,describes.conditions at the time ofJnspection_and under.the conditions:of use at that time.jhis:inspection does not nddress`howth<e system will perform in'the future'under'the Same+or differentt ; conditions of use. Title':5 Inspection Form: 6%15l2000 page"1 , Page:2.of 11 T OF IC7A T, INSPECTIO.IY:FORtM:-N.QT FOR VOLUNTARY.ASSESS YIEI`ZTS r` SU SURFA CE SEWAGE;DISPOSA.L SYSTEM IN,SPEC JOIN FORM ,. PART A CERTIFICA..TIO1N (continued)' Property Address: � T Owner.. ��y 0 Date of Inspecti;.on: In . s ection�Summa Check _ P }�� A 'C p ry• ,B,. ,D or B./AT;.WAYS complet�:a11 of Section.D A. ystem Passes I have not found any information which.indicates.that,any of the failure criteria.described in 310;CMR 15.303 or in310 CN1R- 15.304 exist.Any-failure criteria.nbtevaluated are indicatedbelow. Comments: B. .. System Con:ditionalIy Passes: One or more system components.as described in the"Conditional Pass"section nee&to be replaced or ' repaired.The system,upon completion of the replacement or repair;.as approved by the Board of Health-- till"pass: Answer yes,no o not determined(Z',N;�ND)in the for the following statements. If"not determined! please explain. . ; The septic,tank is metal and'over 20,years;olds or the septic.tank(whether metal.or not)is structurally unsound,exhibits substantial.infiltration of exfiltratian or.iank failure is imminenC:System wil}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 taak is less than'20.years old is available:' . ND expIain:: Observation of sewage.backup-or break out.or high static water lever in the distribution box due.to broken or, obstructed pipe('s)yor.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.repladed ND explain: The system required pumping more than'4 times.a year due to broken or obstructed pipe(s).The-systern will pass inspection if(with..approval:of thi..Board of Health): broken pipe(s);are replaced . _77-,obstruction'�i"s:`removed .` ' ND explain: Y ee, _ of1i OFFICIAL INSPECTION FflRi'Y1-NOT FOR`VOLUNTARY ASSESSivIENTS SUBSURP ACF SE �AG .DIPOSAL SI'ST iVI.TNSP'ECTION FORM PARTA . C£+RTIFI C A.TIOYN continued) `Property Address: awner. , Date of Inspection: , C. Further.Evaluation is Required b the Board of Health: q y . 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. X. System will pass unless Board of I-?ealth'determines in accordance with 310 CMR 15:303(1)(b) that the y , s stem is not functioning in a manner which wffprotect:public he'a'1t'h,safety en vironment: Cesspool or pnvy is within 50 feet of a'surface watery'' Cesspool or privy is within�0.feet of a'bordering veoetated`wetland'or'a salt°marsh w. Z: Sys.teiri will fail. finless the Board of Iealth Wid`Public Water Supplier,:if any)determines that the system isTunctioning in 2 manner that,protects the public,h:ealth,.safety:a'nd environment: _ The.system'has a septic tan3c and,s o i I absorption_system (SAS)Viand the SAS is,within'l 00'feet of a. surface water supply or rributary to a surface wateraupply: ' The system has'a septic tank'and SAS;and the SAS is within a.Zone 1--of a public water supply. .. .. .. is The sysfem nas a septic tank and.SAS.and the:SAS is.0 ithin150:feef of.--a private water`supply well. The system.has aseptic 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 i. "Phis system.passes if the well water analysis;perforni.ed at a'DEP certified laboratory,"for eoliform bacteria and volatile organic coinpounds:,irdicates_that the•vwell is:free from:poll"ution frorn'that facility and, the presence of ammonia nitrogen and nitrate nitrogen is equal to or less`t'han 5,ppm, provided that no other failure criteria are'triaeerad.,A copy of the analysis.'Must be.'attached;to this form. 3. 'Other, 3. t Page 4.of. 1 I O.FFIOAL INSPECTIO!t.FORt :IVOT' .O-R VOLI1t dTA t ASSESSMENTS ' SU; SURFACE SEWAGE-I)ISPOSAL SYSTEM INSPEC.TION.FORM PART A CERTIFhCATION(continued): Property. ddress: Own.e J. Date of Inspection D. System Fail'ure-.Criteria applicable to all`systemsc You must indicate"yes" or ,no,,to each-of the•followina for all inspections: Yes N Backup:ofae.vage'into,facilty;or system component due to overloaded.•or clogged SAS or cesspool Discharge or Ponding'of effluent the surface of`the ground.or surface waters due to.an overloaded or. clogged SAS,or cesspool V Static Liquid,2eveI in the distribution•box above..outlet.inverr due to-an.-overloaded-or clogged SAS.or , 7 cesspool iLiquid depth.in cesspool isIess.than 6"'below invert or available volume is.less than %day flow equired'pumping:more.than 4.times in.the last year NOT due to clogged or!obstructed pipe(s).Number. " f or times pumped Any portion of the.SAS,,cesspool or:privy is..below.high ground water elevation. _ Any portion o cesspoof 6*r privy is.within 1 Mfeet of a.surface.water supply or tributaty to:a.surface watersuppLy:j Any portion of a cesspool.or.privy,is within.a Zone 1 of a.publi'c well. Any portion of cesspool..or privy is:within.50-feet of.a.private water supply well: ' Any.' ortion ofa cesspool orprivyis.less.than 1.0'0 feet.but greater than.56feet,from a private water supply well with no acceptable,-water-quality analysis.[.This system passes-if.the.,well water analysis, performed a.t:.a DEP certified laboratory; fo.r colifor.m.ba.cteria and;volatile,organic•cor<tpounds indicates that the-well is free from pollution from that.facility and the.presence:of ammonia nitrogen and,nit.ra:te nitrogen,is:equ'al:to or less than a ppm,pravided�that no:other failure criteria are triggered:.A,-copy-of the analysis:must be attached to this form.] (Yes/No)The system-fails.I have determined•that one or more oftlze above failure criteria exist as. described'in,3.10 CMR 15.303,.tfierefore,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 server facility-with a design ilow of 10,000:gpd to 1.5,000 gPd• You must indicate either"yes" or"no"to each of the following: (Thd following criteria.apply to large systems.in addition to the criteria above) yes n0 — _ the system•is within 4.00 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—1WPA)or a mapped Zone Il,of a pubjlic: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 Iarge system has failed.The owner or operator of any large system considered a significant threatunder 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. • 1 Page 5 of 1.1 OFFCIL I1:SPCTi� 7;FDRi'✓ =i�IOT FO12 'VQI iFiTARY AS'S)�SS:IYIENTS SIJS35TTF 'ACE'S A .E 1?ISFQSAL:SYSTE�YI INSPEC 4 FORM PART B.. CHEC--T IST Property-Address; _ Y OwnerO Date of inspection: 17 Check if the followinz have been done'..You..must indicate"yes"or"no"'as.to each of the-following: Yes. No —sz-_ Pumping:inforn�ation'was.providect by the owner,:occupant, or Board':of Health.;• Were any of the system components pumped out in the previous two weeks v 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'ngt available note as N/A) i/ 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? ' v — Were the septic tank-menholes uncovered, opened,.and the interior•ofthe tank inspected for the condition of the baffles or tees. material of construction, dimensions, depth of liquid,.depth of.sludgeland depth ofscum? . Was the faciIi#y owner,(and occupants if different:from owner)provided with information.on the proper' maintenance-of subsurface sewage disposal systems? t: The size and location of the Soil Absorptlori System-(S.AS) on the-site has been'determined'laseddon: Existins inr rormation. Fo example, a plan at the Board of:Health.. L / Dete--mined in the fleld.(if any of the failure criteria related to Part C is at issue approxiinatidn of distance is unacceptable)[3I0 C_yI1Z 15.302(3)(b)1 - f Pave 6 of 11. OFFICIAL INSPECTION FORM NOT-FORVO,L.UI'v T ARY-ASSESSMENTS SUBSURFACE SEWAGE;DISPOSAL SYS I Ei!rI II°dSPECTION 1 6RM _ PAR:T:C. SYSTEM:11 k RMAT10't Property Address: Owner. _ o.��✓� J Date,of Inspection: j -? FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design).- Number..ofbedrooms.(actual).;. 4. DESIGN flow.based on 310*CMR 15.203 (for example: 11:0 opd x m of bedrooms): Number.of current residents- ' Does residence have a garbage grinder(yes or no):. .. ; . ._ Is laundry on-a'separate!sewage system (y or no).: [if yes:separate inspection required] Laundry. !�system'inspected.ye .or no):L�V Seasonal:use:(yes or na): Water meter-readings. ifa ilable(Iast2 years.usa;e:(gpd)):.D�!%® ®_® Q Z I3,Am Sump-pumpes or no - �" — M (} . ) Last date of occupancy. 1 COMMERCIAL/INDUSTRIAL/�IO Type of establishment:.. Design.flow(based on 310 CM-RA 5.203): -pd' Basis of-design.flow(seats/persons/sq.#t,etc.):. „ Grease trap present(yest 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'vailable: Last date of occupancy/bse: OTHER(describe): GENERAL INFORMATION Pumping Recoi ds ' Source-of information: Was system pumped as part ofth .inspe ti n'(yes or no • ;�(0 If yes,.volume pumped: gallons--How was quantity pumped determined? Reason.for pumping: TYP OF SYSTEM _peptic lank, distribution box,soil.absorption,system _Single cessP ool _Overflow cesspool _Privy - Shared system(yes:or no')(if yes, attach previous inspection _ n records,.if any) _Inno.vative/Alternative technology.Attach a copy of the.current operation and maintenance contract(to be obtained frorh system'owner) Tight tank. _Attach.a copyof the DER approval _.Other.(describe): Ap proximate age of all components, date installed(if known)and source of information: Va:e Were sewage odors.-detected when-.arriving at the site(yes or no):. Page-7 of 17 " OFFICIAL INSPECTION FORM—NOT FOR'VOLUNTAEY ASSESSMENTS 8UBSURF.ACCE SEWAGE DISPOSA.L*-SYSTEM--I3 SSPECTION FORM: PART C a SYSTFM:Ii FORZYI_ATION'(continued) Property Address: �--�-� - A , Owner 40`` Date"of Inspection: - BUILDING SEWER(locate on site a pI n) Depth below grade: Materials of construction:_cast iron 40 PVC other(explain): Distance-from private watersupply well or.suction line:_ Comments (on-condition"off jomts,"vendng, evidence of leakage,etc.): SEPTIC TA'.NK: (/ (Iocate'on site plan w/ Depth below,grad�.,��! Material of-construction:, concrete -metal_fiberillass . .Polyethylene _other(explain)T If tank is metal list age:_ Is aa'?:confirmed by a Certificate of Compliance(yes-or nb)'.;_(attach..a co of -certificate) Dimensions: Sludge depth:Cf/I f� Distance from top of sludge to bottom of outlet"tee or baffle: Scum thickness: Distance from top ofscum to top:of outlet tee or baffle::. Distance from bottom ofscum'.to bottom'"of outlet tee or baffle How were dimensions.deteirtine.d: i� ,t �y� Q ��� Comments(on pumping recommen td i�, i6let and outlet tee or baffle condition, structural integrity, liquid-levels as related to outlet invert,evidence Of leakag , etc:): v � Gj/I gill GREASE TRAP (locate on site.plan} Depth below grade: 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-ofscurn"to bottom of outlet tee or-baffle: Date oflast,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.): p I Page 8 of 1.1 -OFFIC>A.L..INSPECTz:'O.N.'FOItIYI. NOT FOE::. OLUTNTARY ASSESSK NTS SUBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECTION VORVI PART C.. . , S:YSTEII .-JNFORMAT-10I t(continued) Property,Address: �...� Own e Date of Inspection: TIGHT or HOLDING TANK.&(tank must-be pumped at time of inspection)(Iocate,on.site plan)- Depth below grader Material of construction: concrete metal: fiberglass polyethylene. ocher(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: Comm ents:(condition of alarm and float.switches, etc.): DISTRIBUTION BOX: /ofresent must.be opened)(locate n site.plan) Depth of liquid IeveI above outlet invert: Comments (note:if box is:ijevel and distribution-to.outletskgial,-.any evidence of solids carryover,any evidence of akage.into or out of box e ): J 1' PUMP CHAMBER (locate on site plan): Pumps in workirab order(yes'or no): ` Alarms in working:order(yes or no):. Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FO R V OLU3Y •TAR SUBSURFAC V ' `•: P ASS E SE �AGE.DISPOSAL SI'STEiYI INSPECTT Oi�I::F ORl P.ART'C t SYSTEM INFO'RMA-TION(continued) Property Address:,/ Owne 44 Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS.=located explain why: Type leaching pits.,number:._ china'chambers,number: -leaching.galleries, number: leaching trenches,number; length: leaching fields,:number; dimensions: overflow cesspool; number: innovative/aIiernafi.ve system- Type/name of technology: Comments (note condition of soil. signs of hydraulic failure,level of pondinQ, damp soil condition of vegetation, CESSPO LS 1 (cesspool must be pumped as part of inspection)(locate on site plan) Y�-p . Number and,configuration: Depth'—top of liquid to inlet invert: Depth•ofsolids layer: Depth of scum.layer: Dimensions of cesspool: Materials of construction: Indication ofgroundwater inflow..(yes or no): . Comments (note condition-of soil; signs of hydraulic fai lure,:I evel of.ponding, condition of vegetation, etc:): PRIVY (locate on site plan) Materials of construction: Dimensions: Depth of'solids: , Comments (note condition of soil, signs ofhydraulic`fOure,level of ponding, condition of vegetation, etc.): 9 Page I 0 of 1,1:. OFFICIAL-4 NSPEC -..?SOT QR'—V0L�11�iT Y ASSESSMENT.S . SUBSURFACE,SiWA.GE:DWOSAI SYSTEM-1 SPECTIO�i FORIK PART-CC. SYSI'ElMJNFORMATION(continued). Property ddress;. Owners -�'- Date of Inspecti.on::. Q907 i SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the;sewage disposal system includins ties to at least two permanent reference landmarks or a.. benchmarks,Locate all.'wells within 160,feet:'Locate.where public water supply enters the building. Aj A 4 it .. ' ' � . •_ / i . ' J- i Page I 1 of I 1 OFFICIAL INSPEC'TIONI FORM—NOT FOR-VOLUNTARY ASSESS3VIENTS SUBSURFACE SEW, kGE DISPOSAL:SYSTEM.INSPECTIO t FORtYS :PART C SYSTEM (continued) Property Address: &1_.t� .Owne fia 10 A1,11 910111;10010 _Date of nspectionc . 7 ', SITE EXAM SIope Surface water Check cellar Shallow wells Estimated.depti to ground water 10 ' feet r 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(abuttiiia'property/observation.hole within 150 feet of SAS) Checked with Focal Board of Health-explain: Checked with.local excavators, installers-(attach documentation) Accessed USES database-e-plain: You must describe how you established the high groundwater elevation: 11 . Permit.Number: Date: Completed by: SdC� HIGH GROUND-WATER LEVEL COMPUTATION Site Location: 17, �G �dOL510 2__�A Lot No. Owner: Rz) Address: Contractor: Address: !q,5 �-j 7`?, Notes: STEP 1 Measure depth to water table to nearest 1/10 ft. .......... ......................................... Date month/day/Year STEP 2 Using Water-Level Range Zone . and Index Well Map locate site and determine: OAppropriate index well ........ 'l.L�. ...: OB Water-level range zone ....................................................: STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP-2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) determine water-level adjustment .................:......:........................:..................................:..... �. STEP 5 Estimate depth to high water by subtracting the water level adjustment (STEP 4) from measured depth to water level at site (STEP 1) .................... Figure 13.--Reproducible computation form. -4,,�LIM IF 5of tic ay1c, cfa 4, r TOWN OF BARNSTABLE LOCATION 11 � \,%. SEWAGE# 200?-131 VILLAGE ��,\\rt, ASSESSOR'S MAP&PARCEL\V.,/12. INSTALLERS NAME&PHONE NO. �cr�rie,,e�iea� SEPTIC TANK CAPACITY �Gp gai LEACHING FACILITY.(type) - y (size Z9 s 49 ,, �5 ) NO.OF BEDROOMS OWNER PERMIT DATE: - S-Q7 COMPLIANCE DATE: F% 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 A � t y k2 43 2 1A A'.) M "1 No W 7 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zippftcatforl" for ;h6poal *pztem Construction Permit Application for a Permit to Construct( ) Repair(,Ku pgrade( ) Abandon( ) ❑Complete System L Individual Components Location Address or Lot No./, Owner's Name,Address,and Tel.No. AVAC10 104-wc Assesso r's Map/Parcel f� ,�-�3d 11 Installer's Name,Address,and Tel.No. !�!''/@ J��� Designer's Name,Address and Tel.No. Type of Building: p 1�-- Dwelling No.of Bedrooms f v ,"/ 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) 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 i nmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of ealt . Signed - Date Application Approved by ` Mgt Date —7 Application Disapproved by: Date for the following reasons Permit No. Date Issued No. �� �3'� r, Fee _ r Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS .PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 11pplication for Mi5poal *p5tern Construction Permit Application for a Permit to Construct O Repair(`) Upgrade O Abandon O Complete System L Individual Components Location'Address or Lot No.,/-�) G G(,�QChO�>G t,I' ;-e Owner's Name,Address,and Tel.No. 4;�fGuo 731 t✓,T/ 1. 67 "01 Assessor's Map/Parcel � Ste._9 q0-w3d ^'5p Installer's Name,Address,and Tel.No. t 0 Designer's Name,Address,and Tel.No. rj;; Type of Building: R,R, _Dwelling No.of Bedrooms 'v 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 spa- 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) 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 i onmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of .ealt . Signed Date "C)7 " Application Approved by /V,) VC Date - -o - Application Disapproved by: Date ' for the following reasons Permit No. Date Issued _...------------------------------------------------— - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS - Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( N) Upgraded ( ) Abandoned( )by at /a Ay, has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. -)UJ -7 3 dated Installer /3d�r�%�effi �f ,� Designer #bedrooms Approved design flow A gpd The issuance of this 4ermit shall not be construed as a guarantee that the system will'functioh ias desig ed. Date I�n Inspector -------------------------------------- No. e Us - I Fee An/1 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DI''VISION—BARNSTABLE, MASSACHUSETTS - ligoaY 6pgtem Con tructton Vermit Permission is hereby granted to Construct ( ) Re airU Upgrade Abandon p ( ) pg ( ) ( ) System located at 111-114Al and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of�t Its 'pe it. Date L�')�/� Approved by �� TOWN OF BARNSTABLE LOCATION SEWAGE# VU LAGEt4 ASSES OR'S MAP&LOT - D/ � i�t�To s , AME&PHONE NOGO/' , �1 d 1, SEPTIC TANK CAPACITY (Se lG (\ 0d I LEACHING FACILITY: (type) F�0 - i7')ASS d/�s �3 (size) f O.OF BEDROOMS OO ) BUILDER O OIL WNER' ) G�1C�lYJ ��G'PlLZ/0 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) 41 ,14 Feet r Edge of Wetland and Leaching Facility(If any wetlands.exist 1 within 300 feet of leaching faci ' si Feet Furnished by -;Z:A/(f �. .. �. a � . . "' -',�� �. _ � — G T ��z a �� ��� _ . . e , _� � _ r TOWN OF BARNSTABLE ��CCAcION 12 Cockacf oiset .Lane SEWAGE # VILLAGE Osterville ASSESSOR'S MAP & LOT `" INSPECTED BY: 775-3338 &PHONE NO.J.P. Macomber & Son, Inc ,SEPTIC TANK CAPACITY 1 500 gallons D—Box <A "LEACHING FACILITY: (type) flow. diffussors (size) VO.OF BEDROOMS 1}b%&w -OWNER Annette Riley. PERMTIDATE: 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 fe, o e 'ng faci ' )D Feet Furnished 7' 6a(a le X It .000, r � � I TOWN OF BA:FtNSTABLE C C LO�'ATION IQ- CUc U'\O I s� 14�- SEWAGE # O 3" I 01 VILLAGE O ST¢ry L ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY '✓!LEACHING FACILITY: (type` r ry Asr04v -rfkrl (size) ' lNO.OF BEDROOMS S J BUILDER OR OWNER PERMUDATE: 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 ofLleaching facility Feet Furnished by 5&7L -CA.Wu�6n ,I GAS O O O A41- DATE : 5127L98 _ ___ PROPERTY ADDRESS:_12 _Bridget -g�e ------- Osterville,Mass________ 02655 ------------------------ On the above date, I inspected the septic system at the above address. This system consists of the following: 1 . 1 -1500 gallon septic tank. 2. 1 -Distribution box. 3 . 3-Flow Diffussors. Based on my inspection, I certify the following conditions: 4 . This is a title five septic system. ( 78 Code ) 5 . The septic tank was pumped as part of the inspection. 6 : The septic system is in proper working order at the present time. SIGNATURPI - --� l Name,: J . P. _Macomber_Jr . ____ Company: Joseh -P,_ M,,�comter 3 Son, Inc. Address :__Bq _�CZ__-_________ -_G.-enZ.erYiUp-,-Ma--n632-0066 Phone :--508-775- 3338 ------------------- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY �. 3 rEPH P. MACOMBER & SON, INC. Tan ks-Cesspools-Leachflelds Pumped & Installed Town Sewer Connections �F P.O. Box 66 Centerville, MA 02632-0066 � � 775-3338 775-6412 a 1 _ - �� ;{ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS _ DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE HINTER STREET. BOSTON, MA 02108 617.292.5500 WILLIANI F WELD TRUDY COXT Govcmor Sc;rcun ARGEO PAUL CELLUCCI DAVID B STRLHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissions PART A CERTIFICATION Property Address: 12 Bridge Street Osterville,MAkddress of Owner: Date of Inspection:5/27/98 (If different) Name of Inspector: P_Macomber Jr. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: J.P.Macomber & Son Tn(•_ Mailing Address: Box 66 epntprvi 1 1 2'1 ass 02632 Telephone Number: 508-775-3338 CERTIFICATION STATEMENT I cenify that I have personally inspected the sewage disposal system at this address and that the information reposed below is true. accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper iunction and maintenance of on-site se%vage disposal systems. The system: Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority i2hall Fails �40 Inspector's Signatu r Date:The System Inspect submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, Or D: A) SYSTEM PASSES: X •l have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303 Any failure criteria not evaluated are indicated below. COMMENTS: B) SYSTEM CONDITIONALLY PASSES: LOne 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. Indicate yes no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection, or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent: The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revis-d 04/25/91) Pray• 1 of 10 DEP on the World Wide Web: hnpa/www.magnet.state ma usloep j Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 12 Bridge Street Osterville.,Mass. Owner: Claire A. Murray Date of Inspection: 5/2 7/9 8 BJ SYSTEM CONDITIONALLY PASSES (continued) &:�.d Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced AID. The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: 416 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: 4& Cesspool or privy is within 50 feet of a surface water ,(�D Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY.AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. N•� The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance .Urf (approximation not valid). 3) OTHER (revised 04/25/27) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 12 Bridge Street Osterville,Mass. Owner: Claire A. Murray Date of Inspection: 5/2 7/9 8 DI SYSTEM FAILS: You must indicate ei;r.er "Yes" or "No" as to each of the following: &tO I have determined that the system violates one or more of the following failure criteria as defined in 310 Ch1R 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes N / Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. t� 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. �'r{.aW d • / r 144,SaK AAA�47'Off'IPA7-,Ny�Qd re 1Z Liquid depth in below invert or available volume is less than 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). / Number of times pumpedQ. (/ Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 141 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 12 Bridge Street Osterville,Mass. Owner: Claire A. Murray Date of Inspection: 5/2 7/9 8 Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components, *cluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. —The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if djfferent from owner) were provided with information on the proper maintenance of Sub Surface Disposal System. Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)) (revised 04/25/97) 4 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Propeny Address:1 2 Bridge Street Ostervi lle,Mass. Omer: Claire A. Murray Date of Inspection: 5/27/98 FLOW CONDITIONS RESIDENTIAL: Design floM. JWK p. ./bedroom for S.A.S. Number of bedrooms:_ Number of Current residents Carbage grinder (yes or no).A/P Laundry connected 1.0 system (yes or no). Seasonal use Ives or nol.a 1 i1D4jQjs-Jay/•9 v eater meter readings, if available (last two (2) year usage (gpo): _ _ r•• Sump Pump (yes or no):V� j /��� =ttc/✓ �,�� ��or�xa�� s�•Sie�v, :ast date of occupancy 1 4,7 COMM IFRCIAUINDUSTRIAL: Type of establish m nt. ZA4 Design floes �n gallons/day Crease trap present: (yes or no)AL!)- indvstrial Waste Molding Tank present: (yes or no)-A1101 Non•sanitar� haste discharged to the Tale 5 system: (yes or no),4244 Water meter readings, if available. A)19 Last date of occupancy: AW OTHER: :Descnbei Last date or occupancy: GENERAL INFORMATION PUMPING CON S a $ trice o nfor Lion. 5 A O System pumped as pan of inspection: (yes or norL&S li yes, volume pumped: g2Ilons Reason for pumping TYPE OF SYSTEM -1 Septic tank/distribution box/soil absorption system ,jP Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, anach previous inspection records, if any) VA Technology etc. Copy of up to date contract? Other APPROXIMA E AGE of all components, date installed (if known) and source of information: l� Lo jg S-c"age odors detected when arriving at the site: (yes or no) f� Page 5 of 10 � w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 12 Bridge Street Osterville,Mass. Owner: Claire A. Murray Date of inspection:5/27/98 BUILDING SEWER: :ocate on site plan) Depth below grade.material of construQ4�z st iron �/40 PVC _ other (explain) Distance from private water supply well or suction line id t Diameter Comments: tcondition of joints, venting, evidence of leakage, etc.) Joints appear tight, No signs of leakage- SI-1-aw is uQntQd -Enrough the house vent. SEPTIC TANK:/6�4"9114A�r .locate on site plan) Depth below grade.(0 mater,a) of construction: concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age /V Is age confirmed by Certificate of lCompliance t& (Yes/No) Dimensi r6i� s�F� f'7'� ,�T ons Sluage depth. Distance from top of,I dge to bonom of outlet tee or baffler Scum thickness Distance from top of scum to top of outlet tee or baffle: Distance from bosom of scum to bon of outle tee or baffle:_ 1C mow dimensions were determined. Comments trecommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrrtY, evidence of leakage, etc.) Pump tank every 2-3 Years. Inlet & outlet tees are in 121 ace_ Thp sprat 7 r' tank ; G sj-rt7CtyTra 1 1 Ir sound and, shows no signs nf 1pakaga, GREASE TRAP:/��(/e (ioc.ate on site plan) Deptn below grade V14 material of con struajon'(�Zconcrete,( metal VAFiberglasW 4PolyethyleneA) other(explain) AIA Dimensions: V4 Scum thickness: Distance from top of scum to top of outlet tee or baffle:AZ/Y Distance from bosom of scum to bosom of outlet tee or baffle: AV Date of last pumping: AIA fW _ Comments: trecommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, struciurai ,ntegrrty, evidence of leakage, etc.) Grease trap is not present. (r.vi..d 04/25/97) P499 6 of 10 o SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 12 Bridge Street Osterville,Mass. Owner: Claire A. Murray Date of Inspection: 5/2 7/9 8 TIGHT OR HOLDING TANK:NaNG(Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: VA' Material of construction:&A—concreted�metal/�AFiberglassNAPol yet hylene!(other(explain) NR RJI� Dimensions: AM Capacity: 11A gallons Design flow: 04 gallons/day Alarm level: VA Alarm in working orderer Yes;V,4 No Date of previous pumping: _,VA Comments: (condition of inlet tee, condition of alarm and float switches, etc.) Tight or Ho inq Tanks Are Not Present, DISTRIBUTION BOX: (locate on site plan) 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.) Distribution box has one lateral : No evidence of solids carry nypr- No evidence of leakage in or out of t-hp r3i ct-ri hnt-i nn hn, PUMP CHAMBER:/)Gale- (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) Pump Chamber is not present_ (revised 04/25/97) Peg• 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 12 Bridge Street Osterville,Mass. Owner: Claire A. Murray Date of Inspection: 5/2 7/9 8 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: © J leaching chambers, number. F plr�' iSo�S leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, nu ber:O Alternative system: ' Name of Technology: � Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Loamy sand to medium sand:No signs of hydraulic failure or Pondina:All vegetation is normal CESSPOOLS: (locate on site plan) Number and configuration: 0 Depth-top of liquid to inlet invert:_ *)I% Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: N inflow (cesspool must be pumped as part of inspection) Cesspools are not present. Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Cesspools are not present. PRIVY: f�i 1t/li (locate on site plan) Materials of construction: yiQ Dimensions: Depth of solids:_ Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Privy is not present (revised 04/25/97) Page a of 10 SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propeny Address: 12 Bridge Street Osterville,Mass. Owner: Claire A. Murray Date of Inspection: 5/2 7/98 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (locate where public water supply comes into house) qoclr 1. 21 air 15' - O (revisal 04/25/97) Page 9 of 10 SUBSURFACE SENYAGE DISP.. I. SYSTEM INSPECTION FORM t C SYSTEM INFOI: 'ION (continued) Property Address: 12 Bridge Street Osterville,Mass. Owner: Claire A. Murray Date of Inspections,/2 7/9 8 f Depth to Groundwater Y Feet Please indicate all the methods used to determine High Groundwat¢y Elv.ation: Obtained from Design Plans on record Observation of Site (Abusing pwpe observation hole, base iyv-s*s imp etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records k Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwa*crElevation. Must be completed) Used water contours map. Gahrety & MIller Model 12/16/94 (revised 04/25/97) Pic. loot 10 . 1 ya•mnr+r.-n.r�r.•rf 5rnrmr•nmrra'�nse+ris*rr.•r''rrvrrtre*.*mn nsrnv*.a�rnm5ss+ �►ro*sert-m-a.rn-rr-r-nr-:sr--:.....r•- I TOWN OF Barnstable BOARD OF HEALTH � \ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D .- CER'CIFICATION `� �:•••ri•t^T•'.'::5-T.tt�^.T.1TI:Rl:'In'1I.'TSIT'ITATiffT'RT5'r-.5'Ir'11tn1" i1R1�I-T�T5C9�R�1C111t♦T!T'IOTf nnn n:mrr+rrsta-er.-n.rrer.•.+,rrr•r.-�._..� -TYPO OR PRINT CI.EARL1'- PROPERTY INSPECTED STREET ADDRESS 12 Bridge Street Oster/villee,Mass. ' ASSESSORS MAP, BLOCK AND PARCEL OWNER' s NAME Claire A. 'Murray PART U - CERTIFICATION r NAME OF INSPECTOR Joseph P.MAcomber Jr. COMPANY NAME J.P.Macomber & Soot •Inc. COMPANY ADDRESS Box 66 Centerville,Mass. 02632 Street Town or City state Lip COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (790 ) 1 578- 508 R A CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of .inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : -Z yste6 PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have con tcted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303, and as specifically noted on PART C - FAILURE CRITERIA of this inspection f rm . Inspector Signature Date '�y`�6-� One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the DOARD OF 11HAL111, .gyp .. * It the inspection FAILED, the owner or operator shall upgrade ' the aystem within one year of the date of the inspection, unless allowed or required otherwise as provided in 3,10 CHR 16 . 305 , partd .doc ` r w " P ti� b THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE S SYSTEM INSPECTOR as provided in 310 CMR 15 .340 and Section 13 of Chapter 21 A of the General Laws. Issued by The Department of Environmental Protection. Acting Director of die Ll ton off W11cr YUllutiolI Control BORTOLOTTI CONSTRUCTION,INC. - 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 508-771-9399 508-428-8926 FAX: 508-428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: I� �i _e w�✓�� Sl7J���� Dale of Inspection: Inspec(or's Name: ' ).6e ,T Owner's Name and Address: OF CERTIFICATION STATEMENT* f I certify that I have personally inspected the sewage disposal system at this address and that the inforr* !aa' tion reported below is true,accurate and complete as of the time of inspection. The inspection "'4 r- 11�j formed based on my training and experience in the proper,function and maintenance of on-site sew�ge 3 `v disposal sy ems. The System: v Passes 1996 Conditionally Passes �t Needs Further E luation By he ocat Aproving Authority �. Fails - - Inspector's Signature: Date:_ The System Inspector shall submit a opy of this inspection report to the Approving authority within thir- ty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUM A RY• A)SYS PASSES: 7 have not found any informafion which indicates that the system violates any of the failure" criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair, passes inspection.. Indicate yes;nor,or not determined(Y,N,OR ND).Describe basis of 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 obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health); yr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of The Board of Health): Broken pipe(s)are replaced Obstruction is removed C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by'The Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE j PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 Feet of a surface water Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 Feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. _ D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in 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 or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NO'h due to clogged or obstructed pipe(s). Number of times pumped -2- 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. Any portion of a cesspool or privy is within 50 Feet of a private water supply well. 'Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen: E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above` The design flow of a system is 10,000 gpd or greater.(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: The system is within 400 Feet of a surface drinking water supply The system is within 200 Feet of a tributary to a surface drinking water supply The system is located in a nitrogen sensitive area Interim Wellhead Protection Area (IWPA)or a mapped Zone 11 of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and,6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: (/Pumping information was requested of the owner, occupant, and Board of Health. _None of the system components have been pumped for atleast two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ✓As-built plans have been obtained and examined. Note if they are not available with N/A. f The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. _4 All system components,excluding the Soil Absorption System, have been located on site. -The septic tank manholes were uncovered,opened,and the interior of the septic tank was in- spected for condition of baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge,depth of scum. _,fhe size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) y-The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION / FLOW CONDITIONS RESIDENTIAL: Design Flow: 3 g i allons Number of Bedrooms:_ Number of Current Residents: Garbage Grinder:A✓O Laundry Connected To System: Y&,5 Seasonal Use: Water Meter Readings, if available: Last Date of Occupancy: ✓,nren.L COMMERCLAI AINDUSTRI_AL• 4;'^ Type of Establishment: Design Flow: gallons/day Grease Trap Present:(yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings, If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of informa 'on: �i� �7q ' `.S'�G✓ C�/7 IOGc��7 ' System Pumped as part of inspection:/ _ 0 If yes,volume pumped: gallons Reason for pumping: TYPE OF SYSTEM: _�/Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other(explain): APPROXIMATE AGE of all c mponen4,date installed(if known)and source of information: s * Sewage odors detected when arriving at the site: -4- iL x SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grader Material of Construction:_{/Concrete metal FRP Other (explain) Dimisions: Sludge Depth: Scum Thickness: 3 Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.),j"�s Q_ /,5'6 d �n lei 0OU r- 6 1 e- GREASE TRAP: Depth Below Grade: Material of Construction: concrete - metal FRP Other (explain) — Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,evidence of leakage,etc.) TIGHT OR HOLDING TANK: Depth.Below Grade: Material of Construction:_concrete_metal FRP Other(explain) , Dimensions: Capacity: gallons Design Flow gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX:__(, Depth of liquid level above outlet invert:—" kox 49vel Comments: (note if level and distributioiequal,evid ice of solids carryover,eviden a of leakage into or out of box,etc. � y,' o7 e PUMP CHAMBER:i Pump is in working order: . Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) -5- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) S011L ABSORPTION SYSTEM(SAS): l/ (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: �3 Leaching galleries,number: Leaching trenches, number, length: Leaching fields, number,dimensions: Overflow cesspool,number: Comments: (note condition of soil,signs of h draulic failure level of pon mg,condition of vegeta 'on, etc.) �. qlp, 64(l. 75' b CESSPOOLS: Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of Cesspool: Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY: Materials4oconstruction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.) -6 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (conlimic(l) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks: Locate all wells within 100 Feet. tT DEPTH TO GROUNDWATER: j Depth to groundwater; Feet Met d of Determination or Appfroximatioi : i� h��i�l�i%�T / "ii''171 CtI� 1)1,7 _7_ a I RERL E='fH'TE FGi:: 1 g@:_; 4[0 3151 u n 0 3 0 5 / 01 =vS y10:48 JONN P. ALGER PC PAGE 1 • r f • / �7 �V A AORTOLO'r't'I CONSTRUCTION,HVC, 760 WAK99Y ROADS MARSTONS MILIA,MA 07649 "1-7714399 $094*9936 FAX! W419 4M NUSURFACS UWAOIlr DISPOSAL SYMM INSPICTION FOlut PART A MrIFICAnON Property AddresS.W;� s S ��/ Due orl"Muvar In tar''�lamt. eo Name and A dress, ' 1 oe►tia lltttl 1 bAVt1 perroaslly hiapeoted tbo aewp=e dllpotnl system at this sutArm&W that the ieforure• tlon rc rted below Is true,u6om#and""plea v orihs Urns oi'lnsp tI4",rtiu Itupoollort tW per. ?va rotroa WW on my tnlnid;and txpariera 1n Iho propor NnoUon u!d mAlntounee oron.it jp omQe dlspolell pstertu. )rho B»ian: ��1►asses _._y_,,,CtwtUlicmally POkses Needs Fwrlher E ttullon by the Loaf Aproving AuthoMy liuDeoto>+4 Sldrattsta� ,_•_pate' '� 4�""' The System L+r qr @kU WWI to 4opy of this iespeoft report to tho Approvlpg a4o4r wilWa o. b()t)}ds:ye of tx�plellag tills iar on ll the tyttom to R rltarerl ryacm or has h deeitca Qow Qi It1,t)Ot1 10Or Sraeter,thr inspvotor tW We#Mom O"or shw svbmlt the report to the opgrppdall roglu W of the Depanment atls"nvirotuat+,ttel l'rotecUorr The ortgtrttil ob6Wd be Aeot to the yotetn orvntt OW oopiw salt to At buyer,If appilooble mrd the approving auttrorlty. ,1�1g1P�r.Trn�lAJAli<7Ct A)BYST,141 PASSIM l NWO art found arty larormatlon whieh lndieoter Ual the rystem violatee AM of the I>sliwe critvriR W 410"In J to CMR Any Mure odtuim not rvalurtted ue Indift4d below, B)SYMN CONDITIONALLY)PASSE51 ., Ono or man oystero oompenents hoW Ito be nfleced or ropalmd, The system,upon ovn!plt- Uan ortho NtptAsement or ropalr,paws th"Wilon. 10dicote yet,nor,or not delotrNtled(Y,N,'DR ND),4noribs bate ordeleradru!tlon in sd1 molasses, if .fM determined`.exyteln why net. .. Tlw aeplla tuck it raotat,emkod.ttmcnv lty urAound,showj etrbnaatlal infUt"don or VxWtratlory or tank lhUuro U Irtltt!inaft The$Mom milt pw Iaspeedoo Iftbo exleUsg lep- 119 tank tv roplaosd with st oonNsmlag oeprlo tank ar approved by 1U 1!oW orHeNth, �.swore bv'dM?p or breakout Or high 11140 water tevpt observed In the distribution box Is dw to brokeo or obetrt> W plput)or doe to a broke&settled ar vaevon dtetriMoa box, The t 11M%rill pass hOPO Uon It(with ADprovill of The 1100A or Realrb): r r- ATE FA -.: 1 5i_+;. .. iur -11-5r T.ie _ :: 1C+ PAGE: I 10 52 J014N R..A{,QF..R....pC pADE .. .. Was Y1 ma ............. BbRTOLOTTI CAI�'81' 001 IIJIM"ACB IRWA09 g11lPORA16 SYSTSM IN9FRC joN POMP PART C SYST M INY MATIoN(oontlnued) INZTCO AP 119WAGS 1121FOSAL SYATm 'fah*oN tb h'"W hm Prraenent tedsae Does.I�nGlnerka or benohmerks. Loaco�!wells within 100 Feel. U . 1? DIM TO(1RIDVNDWATFl l to FMI Matt►oe o!DetertalnMHO or hgPssoxlmwloil: r'low I IC