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0256 CRYSTAL LAKE ROAD - Health
pr 256 CRYSTAL kk -+RO r Ostervlle A = 140 — 170 r� ti G I -e 9lA4ed 1161 F; 3 � Om a Le Rown i rk J .�'on �� � ,�r`"��i .-.� •� �gala�,6S n '�Y • gg Garage Kitt ,•�•9.}.,erg ,,�,�, •..�.;..., - - C e,tt&T I�� I rc e ca f2�. l�. l C ,.i ; '► . r O '6 2 r\ y t� i IN UJ yT n( 4 Gc1 rck g (f Is ex I ST 2� s� 1ctTio l Cau�`fi�es m1ty cc'R- ' :3 e�- s Lv , w 1 ) ciu�S d.bL 4, 's . , .� as Oko, s k) I N cal eS r t,.lh C,--Ja i,-s - C-x L ST t ►ve �Lcj W 1 W o fall 5 a. CoMig-p-, S7'y1e w +NJ Dam t0 �nou5C- Ut0. reeZ�'vJc� TOWN OF BARNSTABLE L'0CATION oA5& C12--fst*t Llw-c v SEWAGE# .4�13- 16 VILLAGE Ct(^MM L:LCr ASSESSOR'S MAP&PARCEL 149)• F"2'b INSTALLER'S NAME&PHONE NO. it SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) �.��eiC� P NO.OF BEDROOMS OWNER Crt l.s'-tom PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility -+— S 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(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY A✓ i� OO �y O TOWN OF BARNSTABLE C `'I LOCATION �� - SEWAGE # ' VULAGE�t l-U',Uf ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1�t7144 _ i' LEACHING FACILITY: (type) �a�y (size) IM NO.OF BEDROOMS BUILDER OR OWNER/ PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: T 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 Leac 'ng Facility(If any wetlands exist within 300 faooac g ty) Feet Furrushed'by\ w�� \� .. `� - . �'� . .� � � � �° �.� - �` . , ..-- ; e�.. �. ,. C�� TOWN OF BARNSTABLE LOCATION . SEWAGE # / VLv_. /� S ASSESSOR'S MAP & LOT 1. INSTALLER'S NAME&PHONE NO. ,�— SEPTIC TANK CAPACITY -Akin � 1'C 4 C� -rNn al 1.11 A 40-a—h1,05 /rP LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: r 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) I Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by � ��� i s / lop Aeo 14) c� cod - - -/ No. � �� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in co puter: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 9ppYitation for Disposal ftstem Construttiou permit Application for a Permit to Construct 1. ) Repair(k� Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.,°,%�,y5e. Owner's Name,Address,and Tel.No.92/-In Assessor's Map/Parcel t) oo os�exualr AAA (c9ct Installer's Name Ad ress,and Tel.No. 508-0"N-9399 Designer's Name Address,and Tel.No. �s�c_ , r:C �0 e�oe &V s rW_4en°ng, 6 ills va�fE$ nST• 0, Type of-Building: 2 + Dwelling No.of Bedrooms ✓ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 330 gpd Design flow provided 33 Co gpd Plan Date ttp,61 a 4, 24>13 Number of sheets / Revision Date Title ;� i i��e ur �-e �'ci ZT( e7I u Shl,� Size of Septic Tank -Ip l5'j�jn Type of S.A.S.1p Y 3<n I iIpaw 4-661,0— Description of Soil S�pe e1-H-,Q )E Nature of Repairs or Alterations(Answer when applicable)4i�sx�-mQ(Z �psc� (b ���Q _5200 H to .S' 4Q < C j�DA Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental , e and not to lace the system in operation until a Certificate of Compliance has been issued by this Board of Health. tgned Date 3 Application Approved by Date Application Disapproved by Date for the following reasons Permit No. d Date Issued 3 �� • `. No. r Fee ./ THE COMMONW�IEALT.,H OF MASSACHUSETTS Entered in co puler: � -�.. Yes PUBLIC HEALTH DIVISION -TOWN OF-BARNSTABLE, MASSACHUSETTS application for bigpo0a.f.Oy�strm,Construction Permit Application fora Permit to Construct( ) Repair(k� Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.,Z5(,, C r2j5,W CCt&_Fd Owner's Name,Address,and Tel.No. 78/-$g 3 V4 3 D_ _ US1eru��lf'2. �"ccne�- �vu�►9 ���� . Assessor's Map/Parcel /k/0 17U WCL 1 m A go Installer's Namep Address,and Tel.No. $O$- 0 1-9399 Designer's Name,Address,and Tel.No. 5�8"3G�-VS-JYI w �v c o tt i C�ns�rz�c�i can ,o c 490cvn CO-10C &w 5;i (IS v7GYF" �(3q �kti nS{, you nc t1 GaCo7 S Type of-Building: , 'Dwelling No.of Bedrooms Lot Size >f i�, / sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( )- Other Fixtures Design Flow(min.required) gpd Design flow provided 3 gpd Plan Date 4oyI1 34, 1 Number of sheets Revision Date Title e $ rJi tao ok dye, c nu Sew_� t'a-V)e`.& r>;(e le- 1 �� Size of Septic Tank R-10 t5 00 !9,. t• Type of S.A.S.10 1f 3UX a- F. -W ey156re Description of Soil �cke Q n chsnx .'SO i 0 Jn4 1' Nature of Repairs or Alterations( 1iAnswer when applicable) S4-�Q�. ACO tO tj 10 19aY'i 4a-e ,9 n k G IeX w tk o S ��I�{�r�y� Y1D�C cP ` H 11�0' 1�;et�[a 41�'t F I'�c t 1 YP 1?l�Q�i 11 f d!Cl ��1•u r 'X �U+C..�l�raJ ��in� �/Pr� �'•1 ra-St�l� �' � �,� , Date last inspected: Agreement: r The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewa' ge'disp�l system,,in-_., > accordance with the provisions of Title 5 of the Environmental Gone:a;nd t4t place the system in operation until a Certificate of Compliance has been issued by this Board of-Health. -. r3 Signed Date Application Approved by t Date Application Disapproved by Date for the following reasons •o Permit No. Date Issued -------------------------------------------------------------------------------------------------------------------------------------- Th E COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance . THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(JC) Upgraded( ) Abandoned( )by & O j e5riS+(-LSC_41 bY1 C.. at ;;Kh era d rA Jn oe �, C Ui 11,E!- has been constructed in aa�ccordance /� / with the provisions of Title5 and the for Disposal System Construction Permit No.��� �,/y dated / Installer lv IoY�S rY.�`I-f G 1 x� `_ - Designer /1 ev 4_X? Fj-)4 I yw_e_r;M - C_' #bedrooms 3 Approved design flow 3 �0�[ t gpd The issuance of this permit shal not �byco stru d as a guarantee that the system w'lhfunction as designed.,�J' Date :. Inspector \ f ----- t --- No.---------------------------------------------------------------------------------------------------- Fee IGO THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal *pstrm Construction i3Prmit Permission is he-eby granted to Construct( ) tRepa''ir``( ,lUpgrade( ) Abandon � r•U ( ) System located at ?6 c5 (CLVNe d C,7S�_-Y"UI and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completted)within three years of the date of this permit. Date / f / ; Approved by .�: MAY-22-2013 08:02 From:BORTOLOT1iI CON5T 5084289399 To:15087906304 P.1/1 FROM :dawn caPe engineering Inc a F14X NO. :1,5083G29800 Hay. 22 2013 09:09AM P1 -rown of Barnstable e � �� � "�bae►ae iE.Crieilma,�Dlr�tor 71iftram M'cKeenq,D'Ytroctar 20011 mm ter,Hymmub,MA OUDA 016;A" gAB-862 4644 Fm SOS-790.6304 gD0eo� Sewage permitoQ0 Assumoir'a MapW Arcei ?0 J[Des r: 6 w h,. 'Cart lXerc: ✓ (G/��/) (..ptio I�7d ,r�y on 5 r WR9 iWU ad a porMit to insts],i L . a � Septir.s at=at 6 ( �A b-lid, based on a.dasign dxuvm b (1ated T certiT�that SA septic system v6acnced above wm bffWlad ff" Aa3J,XX accardi>ig to the dmn 'wMah nab'iaalWe mkor tip1uoved chanps smh es lotacal relm on of the dlstribtWx hox and/or,scpdc umt Z ca dty that the septio arystmn.r0m maed above was iristkl t4 with met �or ah= s CLe, greater thata la' al rdoed�lion,of the SAS or any m oal toloeatim of any c�oxancnt oftha His elra but aa aeae:ordmce with Scale&Local RagWatiomq. Flan revision or r ,as-bh designer to follow, �N QF ~� DANId� er'B ipature) CIVIL No.4502 +�._4.�✓ +o Nn �a . �1 t �(Dcsigaer,e Stp�aatr�ro� �egiYar'�Stteiu�ete)-- 1��'� .� 1 ^,.w+w°+4., _ • .ram� �' � i Y 4'• w r c �+ w K r "� Lim p .Y gyp,• 4. o r 2• { i i x- �� S, �•.�',� ��' 'n i.rC.. � �{]���'' tq;it y7,1';.k t`# a > 7 § A.�� L }�e"} u '.. :; r ��J r • Town of Barnstable P# � Department of Regulatory Services {ARNWABLE,9*7 Public Health Division Date l ibs� �0 200 Main Street,Hyannis MA 02601 iOTFD MA't A , Date Scheduled-a �P�.J ` Time !_ v Fee Pd. 0/001 y So' 'Suitability Assessment for S . e Disposal • —'��Cd—ice d ;- Performed By: Witnessed By: LOCATION & GENERAL INFORMIO ATN Location Address /� ��(� / Q Owner's Name y 4_ 1� �cf! e% � Q, r Address . Assessor's Map/Parcel: �G f 70 v Engineer's Name NEW CONSTRUCTION REPAIR Telephone# e " Land Use La, W Slopes(%) CiS Surface atones /�Qti e Distances from: Open Water Body 7 to ft Possible Wet Area ft Drinking Water Well 'Drainage Way >(p L✓ ft Property Line �S ft Other ft SKETCH:(Street name,dimensions of lot;exact locations of test holes&perc tests,locate wetlands in proximity to holes)H Od T / _ F. 77 Parent material(geologic) G�aC a, ou-�wa5-'17 Depth to Bedrock 7 GC/ Depth to Groundwater:.Standing Water in Hole: Weeping from Pit Face -/V�,4 Estimated Seasonal High Groundwater 7. DETERMINATION,FOR SEASONAL HIGH WATER TABLE Method Used: „ Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Grbundwater,Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level • PERCOLATION TEST' HateI/�' �3 Tlme ' Observation Hole# Time at 9" � , Depth of Pere Time at 6„ime Start Pre-soak Time @ T (9"-6") End Pre-soak Rate Min./Inch ' L Z Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N), Original: Public Health Division, Observation Hole Data To Be Completed on Back --------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. ' Q:\SEPTIC\PERCFORM.DOC •k , s ,r_DEEP;OBSERVATION HOLE L'OG ,u Hole Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel G L I D yk /1 1 z- 3y Q L S IG yR �/� DEEP OBSERVATION,HOLE�LOG_ Hole# 2 Depth from Soil Horizon Soil Texture Soil Color, Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistence.%Gravely �0-3Z 13 L S to�Rsl� DEEP OBSERVATION HOLE LOG Hole# IUM Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Graven DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Graven Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes Within S00 year boundary No' J Yes - - - Within 100 year flood boundary No V Yes Depth of Naturally OccurrinE Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? e ci If not,what is the depth of naturally occurring pervious material? Certification I certify that on 5-// (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,expertise and experience described in 310 CMR 15.017. Signature DateZ/12310 Q:\SEPTIC\PERCFORM.DOC Commonwealth of Massachusetts Title 5 Official Inspection Form , a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 256 Crystal Lake Road' Property Address Vestry of Saint Peters Church Owner Owner's Name information is required for every Osterville MA 02655 February 20, 2013 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: - key to move your cursor-do not David D. Coughanowr, R.S. use the return Name of Inspector key. Eco-Tech Environmental r� Company Name 43 Triangle Circle _ Company Address Sandwich MA 02563 City/Town State Zip Code 508 364-0894 1328 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance-of onsite sewage disposal systems. I am a DEP approved system inspector pursuant to°Section M340 , Title 5(310 CMR 15.000). The system: CD ; t....»a r '+f..,.�fl ® Passes El'Conditionally Passes ElFafils ❑ Needs Further Evaluation by the Local Approving Authority a C70 5! ems' February 20, 2013 "' � rn Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit theme report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 OfficijInspectiFo Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 256 Crystal Lake Road Property Address Vestry of Saint Peters Church Owner Owner's Name information is Osterville MA 02655 February 20 2013 required for every ry page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Inspector's Note==> The septic system described herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-5. The scope of this inspection is limited to health and environmental compliance and the septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. Removal of grinder is recommended. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. r e The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of ! Health. *A metal septic tank will pass inspection if it is,structurally sound, not leaking.and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 256 Crystal Lake Road Property Address Vestry of Saint Peters Church Owner Owner's Name information is Osterville MA 02655 February 20 2013 required for every ry page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ' ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced, ❑ Y, ❑ N ❑ ND (Explain below):_ ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):. obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):- C) Further Evaluation is Required,by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 256 Crystal Lake Road Property Address Vestry of Saint Peters Church Owner Owner's Name information is Osterville MA 02655 February 20 2013 required for every ry page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: I **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5irs-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 256 Crystal Lake Road Property Address P Y Vestry of Saint Peters Church Owner Owner's Name information is required for every Osterville MA 02655 February 20, 2013 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ z Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® 'Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Z Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. t e For.large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ p ❑ the system is located in a nitrogen sensitive area (InterimWellhead Protection Area-.IWPA) or a mapped Zone ll of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10'. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 256 Crystal Lake Road Property Address Vestry of Saint Peters Church Owner Owner's Name information is Osterville MA 02655 February 20, 2013 requ red for every ry page, Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ❑ ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information.For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): n/a Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a- no plan t5irs-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 r Commonwealth of Massachusetts ti Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 256 Crystal Lake Road Property Address Vestry of Saint Peters Church Owner Owner's Name information is required for every Osterville MA 02655 February 20, 2013 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: System predates Title 5 and no permits or other documentation regarding design flow were found on file at town offices. Assessors records confirm 3 bedroom count. Number of current residents: 0 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 26 gpd 9 ( Y 9 (gpd)): Detail: - 2011 - 19,000 gallons, 2012 - no water used. Sump pump? ❑ Yes ® No Last date of occupancy: over 1 year agoDate Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 256 Crystal Lake Road Property Address Vestry of Saint Peters Church Owner Owner's Name information is Osterville MA 02655 February 20 2013 required for every ry page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: owner's agent Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ® Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ® Other(describe): overflow trench t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts 4 - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 256 Crystal Lake Rcad Property Address Vestry of Saint Peters Church Owner Owner's Name information is Osterville MA 02655 February 20 2013 required for every ry page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Age unknown. Cesspool assumed installed at time of dwelling's construction -trench likely added later. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan):'-, Depth below grade: 2 feet Material of construction: ® cast iron ❑ 40 PVC ❑.other(explain): - Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Sewer line appears structurally sound with no evidence of leakage or backup into dwelling. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is.metal, list age: years Is age confirmed'by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: " Sludge depth: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 256 y Crystal Lake Road M Property Address Vestry of Saint Peters Church Owner Owner's Name information is Osterville MA 02655 February 20 2013 required for every rY page.. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 256 Crystal Lake rys to a e Road Property Address Vestry of Saint Peters Church Owner Owner's Name information is Osterville MA 02655 February 20, 2013 required for every rY page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site*plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of'alarm and float switches, etc.): R u r Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No I t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 256 Crystal Lake Road Property Address Vestry of Saint Peters Church Owner Owner's Name information is Osterville MA 02655 Februa 20 2013 required for every ry page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 256 Crystal Lake Road t Property Address Vestry of Saint Peters Church Owner Owner's Name information is Osterville MA 02655 February required for every 20, 2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 1-30 foot long 0 leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic.failure, level of ponding, damp soil, condition of vegetation, etc.): Soils above leaching trench appear unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. An observation hole was dug into leaching trench stone and no standing effluent or,effluent contact staining was observed in the stone or overlying soils. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 primary Depth—top of liquid to inlet invert n/a-dry Depth of solids layer 4 inches Depth of scum layer n/a Dimensions of cesspool 6 ft x 6 ft approximately Materials of construction Concrete block Indication of groundwater inflow ❑ Yes ® No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 256 Crystal Lake Road Property Address Vestry of Saint Peters Church Owner Owner's Name information is Osterville MA 02655 February 20, 2013 required for every rY page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Cesspool was dry at time of inspection. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 f ._ _ - , ,. I.I—� _.-..1.....,I�..�..-,-,I�.1a�,,I II"'-I-_",1II'."..:-..1i�--'I1,,_A,I1-,_.,—,'..i, . Commonwe-alth of,Massach�I.-,--.-usetts = Title 5 Offi" _,a o.�-.".-�—..-.�--I.:�,,- �'o� .-.._.__..-__.._.-._...,I I...-,�.1... --'`..:.:I-71�I..—.I-_1I--.—!_11..11..-,,,.,.� -.�-1I I-��1 i-�7-_�':---'_1�I.1.--F,.�_I"�..1 IF..I --..' .I. -..� II —..—�I.... � . Subsurface Sewage,.Disposal°System,Form '.Not for'Voluntary Assessmentst-I�-_,.�-._..bI1 I.' I.--I I_� I..I ,��-- I. - -I—.�I1-.. -..I 1 1�. 1. on 2 d'mul.Lake;FRoad' _ - Pro a Adtlress _ . I. P 11 II ,1/,estry':of Saint>Peters,Church Owner OwwsName mformatton is requged,for every Ostervllle` MA 02655 February,20, 201'3 page. C_ttylTowr f : - State `_ Ztp;code Date of Inspection; D. S stem Informat>lon cont i Y:- (. i Sketch Of Sewagel llsposal System Fro�lde afvlew.of the sewage dispo al system, including,ties_to atieast two permanent,"reference landmarks,or benchmarks Locate,all wells within 10Q feet,Locate where public water supply en qP,.,-he t"uil _1 9=Ghee, ne of the boxessbelow . : ® :hand sketch >m - area'belows 0 �drawing�attached separately - .. . - . -- - _ . - - 1. - 1. - ` - _ ,_ l �7 :. .. - n .. - . ...: .. :. 1-.. -.. i, . ,ti.J r ,. 1. 1-1 `;..- . ..- I.1-:.11�,.-11 I I - I I ,� i I: �� " ..I,, , - A' s1. l _ - - .x _ 1. - , 2 } . . - - - . -, - II ;, 1; _ _ .. . . K 1. t t - - -. - E .:. .- v... _. ..: .. :; • _ k ---.,I- ' y ' , - k1' _ �- - �4 � - G - - 1ais „no Tille`S official Irispecbori Form Subsurface sewa©o Dispo`s@,Si em Page 15 of .T Commonwealth of Massachusetts v W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M ° 256 Crystal Lake Road Property Address Vestry of Saint Peters Church Owner Owner's Name information is Osterville MA 02655 February 20 2013 required for every ry page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 25+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers,-(attach documentation) ® Accessed USGS database-explain: Barnstable GIS Department records You must describe how you established the high ground water elevation: Town of Barnstable GIS Department records indicate that the property is over 25 feet above groundwater table. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a) Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 256 Crystal Lake Road Property Address Vestry of Saint Peters Church Owner Owner's Name information is Osterville MA 02655 February 20, 2013 required for every rY page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file f t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 C v DATI'- r6/26J01 --- PROPERTY ADDRESS; 25b� Cstal_ Lake R,gC , Osterville Mass 02655 On the above date, I Instpeoted the 8eptlo ,eyst.e'M at the aboye a d d r a 3 3 This iystem con.slsts of the following: 1 . 1 -6 'X6 ' block cesspool. 2 . 1 -30 ' leaching trench. 30 'X4 'X2 ' I Saved on my Inepecllon, I certify the following oondltlon.7I 3 . This is not a title five septic system. 4 . This is a sewage system that has had a leaching trench' added to the cesspoo.The cesspool now acts as a septic. tank. 5. The sewage system is in proper working order at the present time. S H3 N AT U R E. Name ! l .P ,..K9S9ak9-r- .,Lr----. --- Company; _P _ N•—comb�r b Son , Inc , p -ConceeylIleL He ,-02632-0066 Phone 508- 715;�7 �8 THIS CCRTIFICATION 0OCS NOT CONS TIT VTe A OVARANTY OR WARRANTY JOSEPH P. MA00MBER & SON, INC, T+nki-Q91 ooh-Lor<chflfldl Pump:d 4, In+t0fd 'town Siwir Connµ tl02i6J2-0066 P.O. Box 66 ConlirYlllo, 776:3338 7756<12 • • RECEIVED ,�'U" JUL 3 0 2001 TOWN OF BARNSTABLE HEALTH DEPT. f \ COMMONWEALTH OF MASSACHUSETTS 7 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OFENVIRONMENTAL, PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: ?56 crystal Lake Road Osterville • Owner's Name:Chester Howe Owner's Address: 57 Swan Road wi nnhect�rMa 01 290 Date of Inspection: f/25/01 Name of Inspector: (please print) J.P. Macomber .Tr Company Name:Joseph P. macomber & Son Inc Mailing Address: Box 66 Centarvi 1 1 r- MA 02632 Telephone Number: 508-775-1338- 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 complete as of the time of the inspection.The inspection was performed based on my rraining and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 oJTitle 5(310 CMR 15.000). The system:: �sses Conditionally Passes Needs Further Evaluation by the Local Approving Authority_ ' Fa'Is Inspector's Signature/Ubmit — Date: The system inspector shalla copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authoriry. Notes and Comments , tom**'*This report only describes conditions at the time of inspection and under the conditions of use at that Aime. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 In Form 6/15/2000 page l Page 3 of l I OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 256 Crystal Lake Road Osterville Owner: Chester Howe ` Date of lospection:6 25 0 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Sectlon D A. System Passes: I have not found y information which indicates that any of the failure criteria described in 310 CMR 15.30 or in 310 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This is a sewage system that has had a leaching trnch trench added to It. acts as a The system is in proper wor ing or er a e present: B. System Conditionally Passes: _ ) One or more system components as described in the"Conditional Pass".sectionneed tb be replaced orr ` repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Answer yes,no or not determined (Y,N,ND) in the for the following statements. If"not determined"please explain. df�The septic tank is metal and over 20 years old' or the septic tank(whether metal or not) is structurally . unsound, exhibits substantial infiltration or exftitration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. •A metal sepric tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available.. ND explain: A49&servation of sewage backup or breakout or hig static water level in the istribution box ue to broken or obstructed pipes)or due to a broken, settled or uneve istributionbo System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced., n obstruction is removed distribution.box.is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection,if(with approval of the Board of Health): broken pipe(s)are replaced " obstruction'is removed ,r^ ND explain: 2 Page 3 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 256 Crystal Lake Road Osterville Owner: Chester Howe Date of lospectioo: 6/25/01 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health In order to determine if the system is failing to protect public health,•safety or the environment. I. Svstem will pass unless Board or Health determines In accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: Cesspool or privy is within 50 feet of a surface water LO 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, Irany) determines that the system is functioning in a manner that protects the public health,safety and environment: LOThe system has a septic tank and soil absorption system(SAS)and the SAS is.within 100 feet of a' surface water supply or tributary to a surface water supply. i1JG The system has a septic tank and SAS and the SAS is within a Zone I of a public water supple. • L6 The system has a septic tartk and SAS and the SAS is within 50 feet of a private water supply well. NZ)The system has a septic tank and SAS and the SAS is less than 100 f;et but 0 feet or more from a private water supply\\,ell". Method used to determine distance 'This system passes if the well water analysis; performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is flee from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no ocher failure criteria are rriggered..A copy of the analysis must be attached to this form. 3. Other: , jThe system consists of 1 -6 'X6 ' blockcesspool that as riad a } AiI no s tor Pargrapn Page 4 of 1 1 OFFICIAL INSPECTION FORM — NOT FOP, VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) . Property Address: 256 Crystal Lake Road Osterville OwnerChester Howe Date of Inspection: 6 25 01 D. System Failure Criteria applicable to all systems: You must indicate 'yes"or"no"to each of the following for all inspections:- . Yes 3�Discharge Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ,/B.yrr� Static liquid level in the distribution bo bore outlet invert due to an overloaded or clogged SAS or cesspool iquid depth in cesspool is less than 6"below invert or available volume is less than 'f,day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number /of times pumped Q ��/ y portion of the SAS, cesspool or privy is below high ground water elevation. y,portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface Jaater supply. portion of a cesspool or privy is within;a Zone I of a public well.. y portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory, for collform 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, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) .41b (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303. therefore the system fails,,The system owner should contact the Board of Health to determine what will be.necessary to correct the failure. E. Large Systems: Tc be considered a large system the system most serve a facility with a design now or 10,900 gpd to 15,006 gpd You must indicate either yes".or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no !/ the system is within 400 feet of a surface drinking water supply 11' th 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 —, — Y g (_ ) pP Zone I1 of a public water supply well If you have answered "yes"to.any question in Section E the system is considered a significant threat,ror answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304, The system owner should contact the appropriate regional office of the Department., 4 , Page 5 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 256 Crystal Lake Road Osterville Owner: Chester Howe Date of Inspection:6 25 01 Check if the following have been done. You must indicate"yes or"no"as to each of the following: Yes Tv'o ,(/Pumping information was provided by the owner, occupant, or Board of Health —./Were any of the system components pumped out in the previous two weeks Has the system received normal flows in.the previous two week,period? _ rt/ Have large volumes of water been introduced to the system recently or as pan of this inspection ? _ Were as built plans of the system obtained and examined?(If theywere not available note as N)A) Was the facility or dwelling inspected for signs of sewage back up Was the site inspected for signs,of break out Were all system components,:ecluding the SAS, located on site? F Were the a tic anholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? , Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? , The size arid location of the Soil Absorption System (SAS)on.the site has been determined based on: Yes no ; Existing information. For example,a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is'at issue approximation.of distance is unacceptable) (310 CMR 15.302(3)(b)} . . Page 6 of I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION Property Address:256 crystal Lake Road Ostervi e Owner:Chester Howe Date of Inspection: 6 25 01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): g6rNumber of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):.24C Number of current residents: oZ Does residence have a garbage grinder(yes or'no):yt,5 Is laundry on a separate sewage system yes or no).// (if yes separate inspection required) Laundry system inspected (yes or no):7 ' 4 g Seasonal use: (yes or no):�S /9 y 1 J ltC' )r 4//OI2_5 Water meter readings, if available (last 2 years usage(gpd)): e &6 6-P D, Sump pump(yes or no):�� Last date of occupancy: COMMERCLAL/INDUSTRIAL Type of establishment: ,{]� Design flow(based on 310 CMR 15.203): A)A gpd Basis of design flow(seats/persons/s ft,etc.): A Grease trap present(yes or no): Industrial waste holding tank.present(yes or no): /� Non-sanitary waste discharged to the Title 5 system(yes or no): .6 Water meter readings, if available: Last date of occupancy/use, OTHER(describe): GENERAL INFORMATION Pumping Recordinforms �� � ;?- / Source of information: _ /� _ Was system pumped as pan of the inspection(yes or no): S If yes, volume pumped:-�r gallo s-- How was t��h;;pyymped termined? /yJ Reason for pumping:o� zAj f- �(lelS' ' Yes TYPE OF SYSTEM Septic tank, distribution box,soil absorption system _ Single cesspool Overflow cesspool Pr Sivy hared system(yes or no)(if yes,attach previous inspection records, if any) nnovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be 416 obtained from system owner) 4)eTi t tank A)6 Attach a copy of the DEP approval Other(describe): roxim to ao f al mponents date ' s Iled if kno ra)aource o information: ol Were sewage odors detected when arriving at the site (yes or no) 6, Page 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 256 Crystal_ Lake Road Osterville OwnerChester Howe Date of Inspection: 6 25/01. BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: ast iron A1040 PVC other�(explain): L Distance from private water supply well or suction line: 'yD Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of leakage System is vented through the house vent. SEPTIC TANK4&&&cate on site plan) Depth below grade: 'U14 Material of construction:,V.4 concrete.lJAmetal.t*fiberglass /moo polyethylene ' 4 4other(explain) If tank is metal list age:.�/J Is age confirmed'by a Certificate of Compliance(yes or no):f (attach a copy of certificate) Dimensions: tiR Sludge depth: Distance from top of slud e to bottom of outlet tee or baffle: 64 Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: ,yj¢ Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of.leakage, etc.): Septic tank tat--present - GREASE TRAP6�(i locate on site plan) Depth below grade:��. Material of construction:.UA concrete )Ameta1 44fiberglasw)4 polyethylenejWother (explain): Dimensions: ,t1R Scum thickness:, 1611 Distance from top of scum to top of outlet tee or baffle: ,(>� Distance from bottom of scum to bottom of outlet tee or baffle: XJ Date`of last pumping: N4 Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): . Grease Trap not present Page 8 of 1 1 t OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL°SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 256 Crystal Lake 'Road ' Osteryille Owner:Chester Howe Date of Inspection:6/2 5/01 TIGHT or HOLDING TANK4"(tank must be pumped at time of inspection)(locate on site plan) ` Depth below grade: 40 Material of construction: concrete metal All?fiberglass,gg Polyethylene,4�Lother(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: _ 2A Comments(condition of alarm and float switches,etc.): Tight or holding tank not Present DISTRIBUTION BOX (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: •IJ�9 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box,etc.): Distrihuti nn hnx nni- nreGent PUMP CHAMBER (locate on site plan) Pumps in working order'(yes'or no): Alarms in working order(yes or no): + Comments(note condition of pumpchamber,condition of pumps and appurtenances,etc.): Pump chamber not present !. v r w ` Page 9 of I I OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 256 Crystal Lake Road Osterville Owner: Chester Howe. Date of Inspection: 6/2 5/01 SOIL ABSORPTION SYSTEM (SAS) (locate on site plan,excavation not required) If SAS not located explain why: Located_ See page # 10 Type 4)0 leaching pits,.number: O JZ leaching chambers,number: a A leaching galleries,number: leaching trenches,number, length: ' jil leaching fields,number, dimensions: overflow cesspool,number: D VO innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level o ponding, damp soil,condition of vegetation, etc.): Loamy boney sand to medium fine sand. No signs of hydraulic- failure or .ponding-Soi 1 G are dry VegPtati on is normal. esspool must be pumped as art�of inspection)(locate on site plan) CESSPOOLt-c . J I Number and configuration: Tiie� x Depth—top of liquid to inlet invert: Depth of solids layer: /D Depth of scum layer: i Dimensions of cesspool: f Materials of construction: e/E Indication of groundwater inflow(yes or no): Comments (note condition of soil, signs of.hydraulic'failure, level of ponding,condition of vegetation, etc.): Same as above. PRIVY(locate on site plan) , u Materials of construction: .�.� . Dimensions: �rQ Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation;etc.): privTnot: present 9 Page I I of 1 1 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 256 Crystal Lake Road Osterville Owner: Chester Howe ` Date of Inspection: 6/2 5/01 SITE EXAM Slope Surface water Check cellar Shallow wells h Estimated depth to ground water ( feet Please indicate (check) all methods used to determine the high ground water elevation: tained from s stem design plans on record- If checked,date of design plan reviewed: Observe site( uttinpro a observation hole within 150 feet of SAS) hecked with local Board of Health-explain: hecked with local excavators,.installers- (attach documentation) Accessed USGS database-explain: h You.trust describe how you established the high ground water elevation: A — Used; Gahrety & Miller. ModPl 12116/94 `, L t.•rmr..-n•r�*-.-r�- rnramv.mrnr•�+n rnrrerarn�•r�►r�nn TtRR,s+*s�►��rtwn .rn-e-r-r-anr-.-..-•,r . 'I'OWN OF BARNSTABLE HOARD OF HEALTH SWISURFACE SEWAGR DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I .•.Try.T••••.' -�.1,1.�.�TTS.TT.11•R.7TI!'gRlf'{9f1111TrT-t•I r'{VTR'�7R�7'�TwR��1 i�111 •.•nf•TT'T•�• �..^ -TYPE OA PRINT CI.EARLY- PI?OPERTY INSPECTED STREET ADDRESS 256 Crystal Lake Road Osterville ASSESSORS MAP , BLOCK AND PARCEL # OWNER' s NAME Chester H6we PART D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr., COMPANY NAME Joseph P. Macomber &won Inc COMPANY ADDRESS Box 66 Centerville Ma 02632 . Stet Tovn or City State E I P COMPANY TELEPHONE (508 ) 775 3338 FAX ( 508 790 -1578 et w CCRTIfICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and omplete 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 . Chec one ; System 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 161303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . B 4 System FAILED* The inspection - which I have con.\_d-trct has found that the system fails to Protect. the E,)iIblic health and te environment in accordance with Title 5 , 3.10 CMR 15 , 303 , and as specifically noted on. PART C - FAILURE CRITERIA of this inspection, form . - Inspector Signature Date ne copy of this certification must be provided to the OWNER, ' the BUYER ( where applicable ) and the DOARD OF HEAL'I'll, If the 'inspection FAILED, the owner or o.perator 'ehall upgrade ' t.he system within one year of the date of the inspection, unless allowed or, required otherwise as provided in 3.10 CMR 16 . 306 . purtd . doc Page 10 of I I +. . OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:256 Crystal Lake Road' Osterville Owner: Chester Howe Date of Inspection: 6/25/01 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feel. Locate where public water supply enters the building. LA iD 10 1 . COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON, MA 02108 617.292.5500 WILL.)ASt F.WELD TRUD1'COX Govcmor SCCfCta ARGEO PAUL CELLUCCI WNVID B STRL'F Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commission t a PART A CERTIFICATION Property Address: 250 Crystal Lake Road Ost. Address of Owner: Date of Inspection: 2/2 3/9 8 (If different) Name of Inspector: J.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 Inc. Mailing Address: BOX 66 Centerville,Mass. 02632 Telephone Number: C;()R_7 7 S_-1 3-1 a CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site selvage disposal systems. The system: asses Conditionally Passes Needs Further Evaluation By the local Approving Authority _ Fails /J Inspector's Signature: Oate: Oc"� The System Inspector all 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 god 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 tfie system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: AI SYSTEM PASSES: 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: BI SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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 ex-filtration, 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) Paq• 1 of 10 DEP on the World Wide Web: http:lhvww.mapnet.state.ma.usidep Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 250 Crystal Lake Road Osterville,Mass. Owner: Chester Howe Date of Inspection: 2/2 3/9 8 BJ SYSTEM CONDITIONALLY PASSES (continued) � 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 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 Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: A,�'V_ 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: QL� 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 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. ND 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. A 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 (approximation not valid). 3) OTHER i (revised 04/25/97) Page 2 of 10 . 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D) SYSTEM FAILS: You must indicate ei;•.er "Yes" or "No" as to each of the following: —,00 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. 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. NON 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 of i-�7 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. EJ 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: /Up 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 safery and the environment because one or more of the following conditions exist: Yes No A [1err the system is within 400 feet of a surface drinking water supply �IQ the system is within 200 feet of a tributary to a surface drinking water supply AA 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) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 250 Crystal Lake Road Osterville,Mass . Owner: Chester Howe Date of Inspection: 2/2 3/9 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. ZThe system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. 1 All system components,. cluding the Soil Absorption System, have been located on the site. 22dA/L_ 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. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance 15 unacceptable) (15.302(3)lbl) (revised 04/25/97) ?&g• 4 o1 20 r �l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.-INFORMATION Property Address: 250 Crystal Lake Road Osterville,Mass . Owner: Chester Howe Date of Inspection:2/2 3/9 8 FLOW CONDITIONS RESIDENTIAL: Design flow: ` g.p.d./bedroom for S.A.S. Number of bedrooms:_V�At 7— v2 a,&, Number of current residents: 0 Garbage grinder (yes or no): 4 0 Laundry connected to system (yes or no):.ZeC1 Seasonal use (yes or no): Ye.S Water meter readings, if available (last two (2) year usage (gpd): Sump Pump (yes or no): NU Last date of occupancy: �/f( COMMERCIAUINDUSTRIAL• Type of establishment: .Ur� Design flow: ,0,4 allons/day Grease trap present: (yes or no)V4 Industrial Waste Holding Tank present: (yes or no) Vi4 Non-sanitary waste discharged to the Title 5 system: (yes or no) L4 Water meter readings, if available: .Ulf Last date of occupancy: IVA OTHER: (Describe) 14 Last dare of occupancy: GENERAL INFORMATION PUMPING RE/CO 3�9 7 sou, /11�f information: System pumped as part of inspection: (yes or no)_4p If yes, volume pumped: t44 gallons Reason for pumping: TYPE OF SYSTEM Aln Septic tank/distribution box/soil absorption system , r r �r Single cesspool u/1'1Li tPi9c�n�%vq T. em. tb Overflow cesspool 'W Privy L O Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APL"ROXIMAT AGE of all components, date installed (if known) and source of information: /th Sewage odors detected when arriving at the site: (yes or no) (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 250 Crystal Lake Road Osterville,Mass . Owner: Chester Howe Date of Inspection: 2/2 3/9 8 BUILDING SEWER: (Locate on site plan) I Depth below grade: Material of construction: cast iron _40 PVC_ other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, v nting, evidence of leakage, etc.) l�r9 12wv 'e)', ywi2kmx4e ? Jc SEPTIC TANK:&awe (locate on site plan) Depth.below grade: Material of constructionA44 concrete.l�ymetaWA Fiberglass/w4 Polyethylene VAother(explain) xl�v If tank is metal, list age _&`A Is age confirmed by Certificate of Compliance 414(Yes/No) Dimensions: .UXI Sludge depth: W Distance from top of sludge to bottom of outlet tee or baffle:•�JQ Scum thickness:,_ Distance from top of scum to top of outlet tee or baffle: NA Distance from bottom of scum to bottom of outlet tee or baffler How dimensions were determined: A21Q Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) t l , GREASE TRAP: /& (locate on site plan) Depth below grade: Material of construction:A//koncrete&,' netaWhFiberglass.vAPolyethylene4Lother(explain) ,vA Dimensions: /1/A Scum thickness:_W Distance from top of scum to top of outlet tee or baffler Distance from bottom of scum to bottom of outlet tee or baffle: . 09 Date of last pumping: AM 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.) (revised 04/25/97) Pag• 6 of 10 , I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 250 Crystal Lake Road Osterville,Mass. Owner: Chester Howe Date of Inspection: 2/2 3/9 8 TIGHT OR HOLDING TANK:A/QyCGTank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade:-A--119 Material of cons ruction:4.oconcreteq[Bmetal f iberglass v gPolyethylene,pAother(explain) r � Dimensions: Capacity: gallons Design flow: gallons/day Alarm level:/ Alarm in working order 4lAYes;� No Date of previous pumping: _ Comments (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX;d-12;IVi�- (locate on site plan) Depth o' liquid level above outlet invert: Commen:s (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) 7;/ ul )S tier 421VS PUMP CHAh1BER:A-�u� (locate on site plan) Pumps in working order: (Yes or No) tiD Alarms in „orking order (Yes or No) 4/0 Comments. (note condition of pump chamber, condition of pumps and appunenances, etc.) ttH2/l M A.2j 7 Dl&,e.2 ir>T. tr•vii•d 0t/25/97) 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 250 Crystal Lake Road Osterville,Mass. Owner: Chester Howe Date of Inspeclion:2/2 3/9 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: leaching chambers, number: leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: '1 Name of Technology: Comments: ( ote condition of soil, signs of hydraulic failure, level of pondin condition of vegietatiin, etc.) CESSPOOL_ (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: ifJjly{/tQ� inflow (cesspool must be pumped as part of inspection) L /mil J l. Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) i9yl�l PRIVY: �.�l�i (locate on site plan) Materials of construction: �� Dimensions: Depth of solids: 26 ' Comments: (note condition of soil, signs of-hydraulic failure, level of ponding, condition of vegetation, etc.) (zwim.d 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 250 Crystal Lake Road Osterville,Mass . Owner: Chester Howe Date of Inspection: 2/2 3/98 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) / r � i p 1. (revised 01/25/97) �190 P�gi 9 �' *Pof 1 0S ` 111 SUBSURFACE SEWAGE DISP L SYSTEM INSPECTION FORM v I . C SYSTEM INFOI: .. !ION (continued) Property Address: 250 Crystal Lake Road Osterville,Mass . Owner: Chester Howe Date of Inspection:2/2 3/98 Depth to Groundwater IZ Feet Please indicate all the methods used to determine High Groundwater Ele aiion: Obtained from Design Plans on record Observation of Site (Abutting property, bservation hole, baserntnrsimp etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records _zcheck local excavators, installers Use USGS Data Describe in your own words how you established the High Grouncl�vaur'Elevation. Must be completed) Used water contours map. Based on gahrety & Miller Model 12/16/94 (rw1zed 04/25/97) Pac of 10 rrnr+.-n.ra—•rrrnrmr•nos*rrrrtn+sn.rr•.r.::r+:rmrr'n�mnermv*.urrv:mc: -. **-a.rn-.-*ra-a.rrr-�-r—.-..- r 1 TOWN OF Barnstable BOARD OF HEALTH S(II)SURFACE SFWACE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION ` F.•••—.••1.T••.-•.'i-�..I �.�TT1.'n.�r.nnrrrrrrrrri-r-!.'t*-nrrn-.anrrrr-`.�+rnc.r+r art . RTII TSTTT[TT!TTr�T.•.�.�!'T'P-•1• �. -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 250 Crystal Lake Road Osterville,Mass ASSESSORS MAP , BLOCK AND PARCEL # OWNER' s NAME Chester Howe PART' D - CERTIFICATION I NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Son Ine." COMPANY ADDRESS Box 66 Centerville,mass. Street Town or Clty Stat• LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (508 1 790 - 1 578 CER'1IFICATION STATEMENT I certify that I have personally inspected the sewage disposal system n'te- this address and that the inforration 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 : Y S Y stem PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or Lhe 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 cona'ticted has found that the system fails to Protect the j)ublic 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 f rm . Inspector Signature Date l One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the DOARD OF HEAL'11I. * If the inspection FAILED, the owner or" 'Perator shall upgrade the system within one ,year of the date of the inspection , unless allowed or required otherwise as provided in 3.10 ChIR 15 . 305 . partd . doc L 1 -1 /< lt1 7 r1, ti THE CONMONWEALTH OF M_A.SS.A,CHUSETTS DEPARTNI ENT OF ENVEZONNEENTAL 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 .. CERTE M D TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15 _340 and Section 13 of Chapter 21A of the General Laws _ Issued by Tile Department of Environmental Protection- - r --- Ar un}{ [).hector of the 51 '()n of W2tcr Pollution Control (zit r ALL SYSTEM COMPONENTS SHALL BE SYSTEM PROFILE MARKED WITH MAGNETIC TAPE OR South � �e< (NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. NOTESC. PROVIDE WATERTIGHT MIN. 20" DIAM. �, Moin ACCESS COVERS TO WITHIN 6" OF FIN. GRADE CONCRETE COVERS TO WITHIN 3" GRADE 1. DATUM IS APPROX. NGVD N t TOP FOUND. EL. 31.7' 2" PEASTONE OR GEOTEXTILE \ FILTER FABRIC OVER STONE 2. MUNICIPAL WATER IS EXISTING G 31 .0' MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM 31 .0 " e5t ° �e5 3. MINIMUM PIPE PITCH TO BE 1/8 PER FOOT. PRECAST H-10` BLOCKS OR RISERS (TYP.) 4. DESIGN LOADING FOR ALL PROPOSED PRECAST 2'0 4"OSCH40 PVC MORTAR ALL PRECAST RISERS UNITS TO BE AASHO H-10 o��o t; PIPES LEVEL 1S 2' COMPONENTS H-10 y (TYP,) INV'S EL. 28.3' 1 5. PIPE JOINTS TO BE MADE WATERTIGHT. :. *29.5 10" 1500 GAL H-10 14" 29.1 O vo�o�'0 'a ° 28 98' TEE SEPTIC TANK TEE ° ° P ° ° ° 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE a 8.73' ®®®® ��®� o00000000° �� =Jaya >00000000 , o 0 0 0 ° > o ° ° ° ° ° ° ° ° ° °°°°°°°° ��®®®��0�®® o°o°o°o°°° ® ®��®���� °°°°°° WITH 310 CMR 15.000 (TITLE 5.) O O O O O O o 0 0 o n n n a o 0 0 0 l °o°o°o°o°o°o - 'o°o°o°o° O O O 0 °o°o°o°Oo° O O O O O O O �o°o°o°o° GAS BAFFLE::' �_o0o�o °,°_ °o°o°°°° �Q��®Q®Q®�Q °°o°°°°°°° ® a®a®oaaoo °°°°°o°0 7, THIS PLAN IS FOR PROPOSED WORK ONLY AND n N >°000°o°o ®®®®®®®oo�� ono°o°oo°o ® ®®®®®®®®a ;°°0000°o o��SV 28.54' 28.37 '°O°°°°°° °°°°°°°°°° °°°°°°° 26 3' NOT TO BE USED FOR LOT LINE STAKING OR ANY ° o 0 0 ° ° ° ° ' o 0 0 ° 7 4 LIQ. LEVEL (ACME OR EQUAL) . ° ° ° ° ° ° ° ° ° ,.., +; .,.r. .• :.:,:•;... :. :r:• 6" MIN SUMP OTHER PURPOSE. o°°o°°o°°o°°o°°o°°o°°o°°o°°o°°o°°o°°o°°o°°o°o°O°o°o°°o°o°°o°o°0 12" MIN. INT. DIM » ,° o°o°ono°o o�o�o°o°o°o°o°o�o�o�o„o�o°o°o°o. 7H-1 0 500 GAL.'LEACHING CHAMBER BY ACME PRECAST OR EQUAL. 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4 PVC. 3/4"-1-1/2" DOUBLE WASHED STONE (2) UNITS REQUIRED 6" CRUSHED STONE OR MECHANICAL OVERALL DIMENSIONS TO OUTSIDE OF STONE: 30.0' X 9.83' I 9. COMPONENTS NOT TO BE BACKFILLED OR Nantucket COMPACTION. (15.221 [21) CONCEALED WITHOUT INSPECTION BY BOARD OF S(� o HEALTH AND PERMISSION OBTAINED FROM BOARD Ound ( 2+ % SLOPE) LO( % SLOPE) ( 1 % SLOPE) OF HEALTH. FOUNDATION 22' SEPTIC TANK 19' D' BOX 9° LEACHING 10. CONTRACTOR SHALL BE RESPONSIBLE FOR LOCUS MAP FACILITY CALLING DIGSAFE (1-888-344-7233) AND 21.3' BOTTOM TH-1 & 2 VERIFYING THE LOCATION OF ALL UNDERGROUND & NOT TO SCALE *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL NO GROUNDWATER FOUND OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS WORK. ASSESSORS MAP 140 PARCEL 170 PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM 11. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE REMOVED 5' BENEATH AND AROUND THE PROPOSED LEACHING FACILITY. 12. EXISTING LEACHING FACILITY SHALL BE PUMPED AND REMOVED OR PUMPED AND FILLED.WITH CLEAN SAND. SYSTEM DESIGN: GARBAGE DISPOSER IS NOT ALLOWED 7 DESIGN FLOW: 3 BEDROOMS @ 110 GPD = 330 GPD USE A 330 GPD DESIGN FLOW 43 6.5 , SEPTIC TANK: 330 GPD (2) = 660 ■ 14" OAK USE H-10 1500 GAL. SEPTIC TANK ' 0.30 TEST HOLE LOGS LEACHING: 1.40 14" OAK DANIEL E. GONSALVES, SE #13587 30.23 SIDES: 2 (30 + 9.83) 2 (.74) _. 118 GPD ENGINEER: �o, 30.00 �` BOTTOM 30 x 9.83 (.74) = 218 GPD DON, DESMARAIS, IRS TH 1 WITNESS: W 6 30.32 DATE: 4/23/13 ml�p � TOTAL: 454 S.F. 336 GPD o PERC. RATE _ < 2 MIN/INCH H2� GRAVEL USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL) PARKING I WITH 2.5' STONE AT SIDES, 4 AT ENDS AND 5 CLASS I SOILS p# 13931 119 SLAB 4 h BETWEEN UNITS 2j. x 1. �.45 30. 5 31.4 30.36 rm ?j. PATIO Tm OP � O PATIO ELEV. ELEV. .� 4 4 �Qa EXIST. DWELL. 0" 31.3 0» 31.3 �9 r �^ x 30.15 \�y 1 TF = 31,T I m MA A A ^ry 30 6P P 31 N I APPROVED DATE BOARD OF HEALTH SL SL 6fl 14" FULL �1 1,30.49 10YR 3/1 10YR 3/1 70 BASE, 12 B 1019B \9 RCH x 29.38 �° W W _ _ _ TITLE 5 SITE PLAN LS LS �28.69 30 / OVER HEAD UTILS. 0.76 OF I 34" 10YR 5/6 28.4' 32» 10YR 5/6 28.6' \ VVV . - \ 4" 07AK 256 CRYSTAL LAKE ROAD x,� 1 BENCH MARK - COR. O S T E R V I L L E \ \73 (BULKHEAD. ELEV. = 31.7.7 C C �I� LOT 10 I PREPARED FOR PERC 29.13 11,747t S.F. I MS MS 40 1-1 \ 30.17 BORTOLOTTI CONSTRUCTION/ + oq 29.83 x.�25 YOUNG O \ 2.5Y 7/6 2.5Y 7/6 \ APRIL 24, 2013 \ -2 . 2 29 A=27.30' 'u °ter r fr _ 1,-�. off _ _ R-11.83' ;Va�e��H of Mys` �N d�^ti\`' fax 508-362-9880 » DAN ti o �� 21.3 120 'fro 11�I A � ..�, DANIEL m � downcape.com 120 21.3 �; o Al�A A. . CIVIL OJALA down cope engineering Inc. v IP' No.G 1 NO GROUNDWATER ENCOUNTERED a�q ��GISTrFk �s o�� �f' civil engineers Scale: 1 = 20 FSs 4 4rf suR�. r land surveyors 939 Main Street ( Rte 6A) 13-06 > 0 10 20 30 40 50 FEET DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675