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HomeMy WebLinkAbout0145 CRYSTAL LAKE ROAD - Health .45 RYSTAL LAKE RL-4.OSTERVILLE. A=139.004 r- L ° Town of Barnstable �, « Department of Health, Safety, and Environmental Services sattxsres Public Health Division E0 N1P�p 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean,RS,CHO FAX: 509-790-6304 Director of Public Health TO: ek-Ire- &(Ven', O• DATE: � /, V 2_6 55 ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned b you located at �'I 5�/ fie. �J os S g p y y y v G � was inspected on �an (21 Jei9& by lypa-, zr, Zr. Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: or gz'.Ja , +V o✓ Gv c)_R_A) ILL 4 n oz POEW, c i f or t) i n 7L S'L r g 161 ro,,, or �U f You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office (Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within (14) fourteen days of l receipt of this notice. ou are also directed to bring the septic system into compliance within thirty (30) days of s f x I= eceipt of this order letter. Cabla You are further directed to maintain the system by hiring a licensed septage hauler to avat um the septic stem to prevent discharge of sewage or effluent into the buildings, onto pump P Y p g g g , +^ the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health 9\h W 1h\&fi1c3Wde5i.doc - HM ] 71 H E A L T H M A S T E R ] HELP [ ] R E C O R D ] ACTION I] For Parcel Number 1391 0041 ] ] Rental Property(Y/N) [ ] Owner Name BARVENIK, CLAIRE E ] Zone of Contrib (Y/N) [ ] Location 145 CRYSTAL LAKE RD ] Contaminant Rel (Y/N) [ ] Business Name [ ] Area Number Contact Person [ ] Phone [000] [ ] Fuel Storage Tank Permit [ ] Card on File [ ] Perc Test Well Septic File/Permit No. [ ] [ l [98-75 f] Issuance Date [ ] [020398] Completion Date [ ] [ ] Last Communications [ ] (MMDDYY) Comments [1500 ST DBOX 4-H-20 INFIL W/41STONE SIDES, 14"UNDER] Cancel [ ] NEXT SCREEN [HM ] ACTION [ ] PARCEL NBR [ ] [ ] [ ] TANK NBR [ ] ] [ ] ag � i r TOWN OF BARNSTABLE LOCATION C *, A SEWAGE # = : VII;LAGE 'OJT `" ASSESSOR'S MAP&LOT -3 INSTALLER'S NAME&PHONE NO. :::SEPTIC TANK CAPACITY 15 dt/ o�J$ 1EACHING FACILITY: (type) 7/1t_ti rim}L=' (size) NO,OF BEDROOMS .3 } . B.UILDER OR OWNER �sl��-.• PFRMTTDATE: COMPLIANCE DATE:1_2,(- :$gparation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility' Feet ::.Private Water Supply Well and Leaching Facility (If any wells exist %on site or within 200 feet of leaching facility) Feet `Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i I j t r :r------ --- IT �. � / �. .. ti k . M . i TOWN OF BARNSTABLE � LOCATION /"4 ti X L LAKe ~ SEWAGE # -• VILLAGE ASSESSOR'S MAP& LOT l3 CI• �/ INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY , I LEACHING FACILITY: (type) ► (_ic �L'-" (size) :9X�- `, NO.&BEDROOMS .� r BUILDER OR OWNER 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 leachingfacility) Feet tY) - W d Leaching Facility If an wetlands exist Edge o f Wetland and g tY( Y within 300 feet of leaching facility) Feet Furnished by •s s a / � � 3"' �� i . ►: �� .. ' . . �, � . _ 3 .,�"� .y _ . - ,� � � � �� a�� �� �3�' �� V h �` �.. � `f ` • . �r lt. r— D No. Fe THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pprication for Migpoof 6pgtem Cott5truction Permit Application for a Permit to Construct( )Repair(grade( )Abandon( ) Complete System ❑Individual Components Location Address or Lot No.�y S G�S��Lea Owner's Name,Address and Tel.No. n Assessor's Map/Parcel 13Gc�op\-E t'NAV CC. Installer's Name,Address,and Tel.No. esigner's Name,Address and Tel.No. �g px-c E P. �Lo w c� 'L6 v 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 73 gallons per day. Calculated daily flow 3�5 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1 5,_T\fNrN Y_- Type of S.A.S. Cct dJ6 i� �I Description of Soil 's 14Y� Nature of Repairs or Alterations(Answer when applicable) `"1 t GTU w� 0_10,­ s t o of 61 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 Environmen 1 Code not to place the system in operation until a Certifi- cate of Compliance has been issued by th' QQ Signed — of Date 0 Application Approved by Date Application Disapproved fo the fo owing reasons Permit No. Date Issued No. Feel, THE COMMONWEALTH OF MASSACHUSETTS ^ Entered in computer: Yes PUBLIC HE LTH DIVISION'— TOWN OF BARNSTABLES MASSACHUSETTS t ZlpPf tiou for ;Digpogar *p!5tem Con4ruction Permit Application for a Permit to Construct( )Repair Grade( )Abandon( ) Complete System O Individual Components 04 Location Address or Lot No. ��S Gr�S�'�L-�^�a Owner's Name,Address and Tel.No. r V. Assessor's Map/Parcel S1' i Installer's Name,Address,and Tel.No. esigner's Name,Address and Tel.No. Zo .B�x-c�� ti2uND V 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 3 3 p a gallons per day. Calculated daily flow, 3 y c1 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. 90 f� ` CA PCY-l� Description of Soil Nature of Repairs or Alterations(Answer when applicable) '�y�-ST,EA l� \'S 6V S,T r UY- 4 t rc. Ca k2 V,S "W -1` ST.U'^-e_ 0-0 S 1 h e t-- /4' 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 Environment Code an of to place the system in operation until a Certifi- cate of Compliance has been issued b th' f-la -1 Q Signed d Date a— �g Application Approved by Date Application Disapproved for he fol owing reasons' Permit No. Date Issued t THE COMMONWEALTH OF MASSACHUSETTS N BARNSTABLE, MASSACHUSETTS } Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ),Repaired ( )Upgraded Abandoned( )by \ `'! 1 P S i C, at E�"�S C_`C uv� L.t< rQ ,• ► l by e constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. *" dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed:`'--- ;4 Date Inspector (l ----------------- + Fee—ZE7 I THE COMMONWEALTH OF,M�ASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS =igoar *pztem ConsAructton Permit Permission is hereby granted to Construct( � Repair(�Upgrade( )Abandon( ) System located at \ "' C���C `( S Cti 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 m st b c eted within three years of the date o this'permit./Lj I ,A j Date: _Approved by � Tr L, �� �I 10r9/97 } 1 " F NOTICE: This Form Is To Be Used For the Repair Of Failed Septic'Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) . j i � hereby certify that the application for disposal works construction permit signed by me dated a-a - ; ,concerning the property located at S C r meets all of the 4 following criteria: ! ✓• There are no wetlands located within lo0 feet of the proposed leaching facility 4' V• There are no private wells within 150 feet of the proposed septic system V• There is no increase inflow and/or change in use proposed V. There are no variances requested or needed. + i �/• If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will nM be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. i Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) B)Observed Groundwater Table Elevation(according to Health Division well map) ��-- SIGNE DATE: LICENSED SEPTIC SYSTE ST R IN THE TOWN OF BARNSTABLE NUMBER i • i i [Attach a sketch plan of the proposed system.Also If the licensed Installer posesses a certified plot plan, this plan should be submitted). r i ', q:health folder.ceR �ow� V'� ,� w .r'r. �; w� G e a r D ATE : 1 /12/92, PROPERTY ADDRESS : 145 Crystal Lake .Road Osterville,Mass . 02655 1 On the above date, I Inspected the s-eptic system at the above aCCres6. Thls system con8lats o1 the following: 1 . 2-6 'x8' block cesspools. Based on my Inec)�ectlon, I cerllly the following condltlons: 2 . This is not a title five septic systein. 3 . This is a sewage system. 4 . The sewage system is in failure. Main cesspool for the house was full & overflowing. 5 . The second cesspool that services the lower 1@vel is in operating order. 6 . That sewage system must be upgraded to a title five septiv system. SIGNATURE : Name : J . P . Macomber Jr., r -------,--------------- ' J . P . Macoctber & Son 'Inc . Company---------------- ---- Address b6------a------ ��! �rVF,17 1c,' - BAN __Cen � ervi1Le ,.Mass;-02632 L t 101vNo1 `S 1998 j,q HEq1�8ApNST F TABLE �L Phone :---5�._ZJS—�338------- I G 9 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY SOSEPN P. MACOMBER & SON, INC. T,nk'-': u" I"-Le�thlleld+ PUMP+d L InaUll►4 Town Sower Connocllon; P.O. Box 66 ' Centerville, MA 02632.0066 775-3338 775- 12 t u w tv ur is aluv�t Ats Ll: LOCATION ��otJ' ! .0 l" !'L SEWAGE # I VU LAGS—,L� � � ASSESSOR'S MAP &.LOT t� INSTALLER'S NAME& PHONE NO. SEPTIC TANK CAPACITY `�/L'� LEACHING FACILITY: (type)�^��� �s (size) NO. OF BEDROOMS BUILDER OR OWNER 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) A Feet' Edge of Wetland and Leaching Facility (Lfiny wetlands exist within 300 feet o aching facili,14 Feet Furnished by �'��� 145 �� r f r /r ,per \ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTIO, ONE WINTER STREET, BOSTON, MA 02108 617-292.5500 TRL DY CO\E WILLIANI F WELD ScCre are Go�cmor ARGEO PAUL CELLUCCI DAVID B STRL'HS Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioncr PART A CERTIFICATION Property Address: 1 45 Crystal Lake Road OsterviJ) Wress of Owner: Date of Inspection: 1 /12/g 8 (If different) Name of Inspector: Joseph P.Macomber Jr. I am a DEP appproved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: J.P.Macomber & Son Inc. Mailing Address: OX Centerville,Mass , 02632 Telephone Number: 508-775-3338 CERTIFICATION STATEMENT I cen4 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Deeds Further Evaluation By the Local Approving Authority Fails Inspector's Signature: !'i`� YGf, i Date: 1 The System Inspector shall 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 tine system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, Or D: AJ SYSTEM PASSES: / 6 I 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: —/0 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. Indicate yeas�,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. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:1twww.magnet-state.ma us/dep 0 Printed on RegGed Paper f • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 145 Crystal Lake Road Osterville,Mass . Owner: Claire E. Barvenik Date of InspeCtion:1 /1 2/91 �j B) SYSTEM CONDITIONALLY PASSES (continued) �P.L ©s--e RV,LQ.i-oa- 55 4)0 Sewage backup or breakout or high static water level observed in the distribution box s due to bro�en or oes: _:—.ec pipe(s) or due to a broken, senled or uneven distribution box. The system will pass inspection if (with appro�ai :•�_ Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced �l The system required pumping more than four times a year due to broken or obstructed pipe(s). The system wii: pass inspection if (with approval of the Board of Health): broken pipes) 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 falling :o aro.e(7 public health. safety and the environment. t) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MA.N ,tR WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: it20 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) DETER.,,sI,1,ES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: 42�7 The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface waters pp . o tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supple -el: �1 The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water suaal ^e , The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 ieet or more :rorn a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds nc cafes ln.a: the well is free from pollution from that facility and the presen a of ammonia nitrogen and nitrate nitrogen is e-Q-a to or less than 5 ppm. Method used to determine distance 'U (approximation not valid) 3) OTHER (revised 01/75/97) Page 2 of 10 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 145 Crystal Lake Road Osterville,Mass . Owner: Claire E. Barvenik Date of Inspection: 1 /1 2/98 D) SYSTEM FAILS: You,must indicate ewer "Yes" or "No" as to each of the following: I have determined.that the system violates one or more of the following failure criteria as defined in 310 CN1R 15.303. The bans for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No ✓/ Backup of sewage into facility or system component due to an 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. 4[,4,fl Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped a4k 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. _ 1—� 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 AIA 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 X-0 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) 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) Pegs 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST n Property Address: 145 Crystal Lake Road Osterville,M.ass . Owner: Claire E. Barvenik Date of Inspection: /12/9% 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. Z _ 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 g ins cted for signs of breakout. 4 _ All system components, eluding the Soil Absorption System, have been located on the site. _&O/v,c- 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 different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. _-Z _ 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)) ill (revised 04/25/97) P&go 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 145 Crystal Lake Road Osterville,Mass . Owner: Claire E. Barvenik Date of Inspection:1 /1 2/98 FLOW CONDITIONS RESIDENTIAL: Design flow r . p.d./bedroom for S.A.S. Number of be6roorf5s: Number of current res4dns: Garbage grinder (yes or no):� Laundry connected to system (yes or no).— Seasonal use (yes or no): 40 Water meter readings, if available (last two (2) year usage (gpd): Sump Pump (yes or no):-&?4? Last date of occupancy: /`'4-0 7 COMM ERCIAUINDUSTRIAL: Type of establishment: Design tlow: A1W allons/day Grease trap present: (yes or no)-4)24 industrial Waste Holding Tank present: (yes or no)y� .Non-sanitary waste discharged to the Tale 5 system: (yes or no)IVA/ water meter readings, if available. eLd_ Last date of occupancy: OTHER: (Describe) &4l4 Las( date of occupancy: GENERAL INFORMATION PUMPING ECORDS nd so rce,o information: r A System pumped as pan of inspection: (yes or no) If yes, volume pumped: allons Reason for pumping: 5✓/Gb ll_ _Ju>itC TYPE OF SYSTEM 411) Septic tank/distribution box/soil absorption system _LSD Single cesspool $ ,06 Overflow cesspool /9 Privy / Shared system (yes or no) (if yes, anach previous inspection records, if any) �( I/A Technology etc. Copy of up to date contract( Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) (revltod 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properiv Address: 145 Crystal Lake Road Osterville,Mass . 3hner: Claire E. Barvenik Date of inspection:, /1 2/97 3UILDING SEWER: .Locate on site plan) Depth below grade. �p Material of construction cast on _ 40 PVC — other (explain) Distance from-pr vate water 1upply well or suction line Diameter Comments (condition of)oints, venting, evidence of leakage, etc.) �- SEPTIC TANK:-bvie, !Locate on site plan) Depth below grade:�L� material of con sit vctr 44Aconcrete,C4 metal 1�'4 FibergIass�V,4Polyethylene.Zr other(explain) ti�14 I: tank is metal, list age dL Is age confirmed by Cenificaie of Compliance&1A(Yes/No) Dimensions: A'1;4 Sludge depth: Distance from top of sludge to bosom of outlet tee or baffle: 'e-4 Scum thickness Al 4 Distance from top of scum to top of outlet tee or baffle: A),4 Distance from bonom of scum to bonom of outlet tee or baffle. How dimensions were determined: 1111- Comments recommendaijon for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet inven, nruC. ra ,ntegnry. ev,cence of leakage, etc.) 12 CREASE TRAP:�C,(/� uocate on site plan) Depth below grade:-d,�4 nuter al of con struct son yfconcrete metaI4l FiberglassWW Polyethylene j 4c,ther(explain) .f/lA Dimensions: .Ul� Scum thickness: Distance from top of scum to top of outlet tee or baffle: AI-4 Distance from bonom of scum to bonom of outlet tee or baffle: Cale of last pumping: Comments (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet inverl, strucra niegriry, evidence of leakage, etc.) (r.vi..d 04/25/97) P.9. 6 of 10 I . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 145 Crystal Lake Road Ostervill Y e Mass . r Owner: Claire E. Barvenik Date of inspection:1 /12/98 TIGHT OR HOLDING TANK: y/'(Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: 41A Material of construction: concrete,LA metal.vAFiberglass�vA Polyethylene,LAother(explain) Dimensions: A/A Capaciry: Alh gallons Design flow All- gallons/day Alarm level: ;04 Alarm in working orderA/A Yes:V# Nu Date of previous pumping: A14 Comments (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:/NI/t?. Ilocate on site plan) Depth of !,o.,,d 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.) ;,s 77,e ha7ioiU 7, n tit r_-___ PUMP CHA,ti1BER:Ad I4r— (locate on site plan) Pumps in working order: (Yes or No)_ 1�A Alarms in working order (Yes or No)—,V4 Comments. (note condition of pump chamber, condition of pumps and appunenances, etc.) 04/25/97) P-g. 7 of 10 f • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 145 Crystal Lake Road Osterville,Mass . Owner: Claire E. Barvenik Date Inspection:,ection: p 1 /12/98 SOIL ABSORPTION SYSTEM (SAS)::2-� 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: 61 leaching chambers, number: leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: r{ Comments: (no(e condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) 63 2— CESSPOOLS: tlocate on site plan) 4 jc./4 Number and configuration: r J > Depth-top of liquid to inlet invert: r?r,V'MgQ,�z Depth of solids layer: — A �,ft Depth of scum layer. AE Dimensions of cesspool: Materials of construction: Indi ion of groundwater / inflow (cesspool mu t be pumped as Nil of inspection) 1 Comments: (note conditio of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) - �?A iX/4-441 PRIVY:diL'r� (locate on site plan) Materials of construction: Dimensions: S'/¢ Depth of solids:�/4 Comments: (note condition of soil, signs pf hydraulic failure, level of ponding, condition of vegetation, etc.) (r•v1fed Pag• B of 10 I� i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION lccnlinued) Propen, A:dress: 145 Crystal Lake Road Osterville,Mass. O� Claire E. Barvenik ogle of 1^spert.on1 /1 2/97 SKETCH OF SEWAGE DISPOSAL SYSTEM: in lode ties to at least two permanent references landmarks or benchmarks locale all wells within 100' (locate where public water supply comes into house) SUBSURFACE SEWAGE DISP . :. SYSTEM INSPECTION FORM C SYSTEM INFOI. :iON (continued) Property Address: 145 Crystal Lake Road Osterville,Mass . Owner: Claire E. Barvenik Date of Inspection:( /1 2/98 Depth to Groundwater I P Feet Please indicate all the methods used to determine High GroundwatV EIc a:ion: Obtained from Design Plans on record _Observation of Site (Abuning property, observation hole, baserrw.&s-imp etc.) //Determine it from local conditions ---fff��� Check with local Board of health Check FEMA Maps Check pumping records _Z-Check local excavators, installers use USGS Data Describe n your own words how you established the High Ground ,xurElevation. Must be completed) Used groundwater Contours Map. Gahrety & Miller Model 12/16/94 (z w1��C 01/73/97) Pic, of 10 `-nr.n rv—nrr--�-+err-:rr.•nm ra-r.r.rirrrr�r:-.�.-rran:•nr.n-m err.lzs sas.T.r.m-+ .- .. .rm-rT_r—r-.--.r-. I TOWN OF Barnstable BOARD OF HEALTH 1 SUIISURFACF SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D '- CERTIFICATION ` F•••—•�.T••.-•..t—�.II �.�.T.T.�1•.f.'ITITZir.T.i�TTTT'.r—•.'ie"'IITi+1t T'R1Cr�T'1rterRT-R RTSRRTi'.TTRTi . fTTf Ii TtTIT.TSiT r1Tr+r.:—.r•!••e^-'r•1. .—. -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 145 Crystal Lake Road Osterville,Mass . ASSESSORS MAP , BLOCK AND PARCEL # 139-004 OWNER' s NAME Claire 0. Barvenik PART D - CERTIFICATION r NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Sodf"INc. COMPANY ADDRESS Box 66 Centerville,Mass . 02632 Street Town or City Stat• I I F COMPANY TELEPHONE 1508 ) 775 - 3338 FAX ( 508 1 790 - 1 578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage dieposaj 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 : Systeui PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public healLh or Lhe environment as defined in 310 CMR 15 . 303 , Any fai1�1re criteria not evaluated are as stated in the FAILURE CRITERIA sectioll of t is form . System FAILED* The inspection which I have conducted has found that the system fails to Protect the ilublic health and the environment in accordance with Title 5 , 3.10 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection fo m . Inspector Signature ; Date One copy of this ert.ification must be provided to the OWNER, the BUYER ( where applicable ) and the I30ARD OF HBAL1'H. * If the inspection FAILED , the owner or""operator shall upgrade ' the system within one year of the date of the inspection , unless allowed or required otherwise as provided in 3.10 CPIR 15 . 305 . ' partd . doc cn :v ` fEEi COMMONWEALTH OF MASSACHUSETTS DEPARTMENT ENT OF ENVXRONAENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualificatigns as required and is hereby authorized to use the title CERT i i D TITLE S SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department- of Environmeatal Protection. )„� --- Arun}{ [)11cctor u( the I iicoli U( W21cr Pollution Control r