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HomeMy WebLinkAbout0149 EAST BAY ROAD - Health .149 East Bay Road Osterville P A 140 159 _ II1 �1 �T l�, f 1 5 t I I No. Fee (f, THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pplitation for Disposal *pstem Construction Permit Application for a Permit to Construct(� Repair( ) Upgrade( ) Abandon( ) Vomplete System ❑Individual Components LocatipnAddr s or Lot No. 1 `Z ZS � Owner's Name,Address,and Tel.No. Ke.II� yv` �1.► CyS}_v r� 1 )4 q �as� �3a c1�}�ry 1� Assessor's Map/Parcel O `1 04 Installer's Name,Address,and fel.No.'(, c-g�e*1 .r+15 Designer's Name,Address,and Tel.No.-o�. Yl1 .6- 1�sjv pG x TI Yv\vle_ � YKAS. vw'vs , 00, B,r"i �. Sancti— t., w►wq 0 Type of Building: Dwelling No.of Bedrooms q Lot Size 0 It sq.ft. Garbage Grinder( ) Other Type of Building R 2 St_\eV% No.of Persons Showers( ) Cafeteria( ) Other Fixtures // Design Flow(min.required) 4 C) gpd Design flow provided 1O gpd Plan Date 7/19 12, Number of sheets Revision Date Title Size of Septic Tank 1400 Type of S.A.S. 3� �� /��[[� 14 (6jt, Description of Soil t Nature of Repairs or Alterations(Answer when applicable) c,\ cesscrrA (.�t Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Boarj_oL4e ; Signed Date Application Approved by 1 HU4 X Z Date Application Disapproved by Date for the following reasons Permit No. Date Issued _?�, i 1 , hI gZ a ,# if Yg �r No. Fee THE.COMMONWEALTH OF MASSACHUSETTS, Entered in computer:Y PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Application for 3 IispoBaf 6pstem Construction j3Prinit Application for a Permit to Construct(NJ) Repair( ) Upgrade( ) Abandon( ) E2 Complete System ❑Individual Components Location Address or Lot No. 1 f;k 5� , Owner's Name,Address;and Tel.No. Kei} Ass esso s Map/Pa�rcel ,#(j(��)< � � ' S t � -�C)(,� •�, . �. Installer's Name,Address,and Tel':No.'t-P11 c '.�' �:U �t Designer's Name,Address,and Tel.No. 1Mt�u G, r.IK l M S 1Miti MA.' i Type of Building: e Dwelling No.of Bedrooms Lot Size 9)) sq.ft. Garbage Grinder( ) Other Type of Building No.No.of Persons Showers( ) Cafeteria( ) Other Fixtures <- Design Flow(min.required) gpd Design flow provided '1 "f G gpd Plan- Date -7119 1.?-1 F/ Number of sheets Revision Date Title Size of Septic Tank K'6n Type of S.A.S. Description of Soil '� V 4. Nature of Repairs or Alterations(Answer when applicable) , Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the'afore described on-site sewage disposal system in ' w accordance;with the.provisions of Title 5 of the Environmental Code and'not to place the system in operation until a Certificate of ' a Co pliance has been issued by this Boarrddj�o,LHealth. k •, ,:F pp y xa ,, Signed �:`'� + 1 ��` �" Date '"7 i J iAPPlication Approved by � r ' Date, t t Application Disapproved by v _ r _ ,r `�. i ` " l Date l for the following reasons ., Permit No. Date Issued _ _ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance -THIS IS TO CERTIFY,that tthe On-site Sewage Dispos]'system Constructed( ) Repaired(k,,) Upgraded( ) Abandoned,(•.,)by F o 1'r C%11 r+J r - at l t l Q_t. 9c\ has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. y� i-4dated 6-7 , �^ Instaler t 1t_.. �`s�'1�4A�.�1c� Designer YKT• F't? •SQX1Stn #bewboms Approvbd design flow f/ god 4 k ' f The issuance of this permit shall not be construed as a guarantee that the system will•function;as des(igne_d. Date .-^� FF Inspector a - --- - - - No. �.ia f'�r . Fee �� THE COMMONWEALTH OF MASSACHUSETTS E PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Bisposal *pstem Construction j3ermit Permission'is hereby granted to Construct(11') Repair( ) Upgrade( ) Abandon( ) System locaied at I f4 q 1'•A sA Rrat,, F r\. -0S• ,P_r%)1}t�e 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 completed within three years of the date of this permit. Date �`� � ; /��-J Approved by 1AAA R Y-- Town of Barnstable Regulatory Services Richard V. Scali, Interim Director ` Public Health Division Ma+ Thomas McKean,Director ti 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304` Installer& Designer Certification Form Date: a� l Sewage Permit# Assessor's Map\Parcel 0 f Designer: M 1° S Cj Installer: fAt S C0 5°[W(A_ 1d, TV, •Address: OK Address: Q6, &_X ? On was issued a permit to install a (d e) (installer) septic system at SST 1�� RZ), 6ST based on a design drawn by (address) dated � °) ��'� (des- er) I � . N�/� I certifyfaWe s, ptic §yste referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State.& Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in compliance with the terms Jhe IAA approval letters (if applicable) OF. (Ins 1 s Signature) M ER . 1140 (Designer's Signature) (Affix ere) PLEASE RETURN TO BA STABLE PUBLIC HEALTH D ON. CERTIFICA E OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Form Rev 8-14-13.doc Commonwealth of Massachusetts :. Title 5 Official Inspection Form �1. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , t 149 East Bay Rd. Rear System Property Address ` Jones Family Pied A Terre LLC. `= Owner Owner's Name information is Osterville Ma. 02655 1-29-21 required for every ~. page. CityTown: 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. a Important:When A: Inspector Information.filling out forms on the computer, use only the tab Michael Sears key to move your Name,of Inspector cursor;-tlo not Robert B Our C0 INC. use the return key. Company Name 363 Whites'Path. Company Address South•Yarmouth Ma. 02664 City/Town State Zip Code 508-477-8877 S114430 Telephone Number License Number B. Certification I certify that: I am a`DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the'information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system; { 1. ® Passes' OFtMgss,,��� 2.' ❑. Conditionally Passes MICHAEL '.N 3. ❑ Needs Further Evaluation by the.Local Approving Authority _o: SEARS No.SI14430 :*S 4. ❑ fails IN 1-29-21 Inspector's Signa a 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 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 DER The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp_doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts . Iti Title 5 Official Inspection Form I a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Rd:- Rear System Property Address Jones Family Pied A Terre LLC. Owner Owner's Name information is required for every Osterville Ma. 02655 1-29-21 page. City/Town State Zip,Code Date of Inspection C. Inspection,Summary Inspection Summary: Complete 1 2, 3,'or 5 and all of 4 and 6. 1) 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 15304 exist. Any failure criteria not evaluated are indicated below. Comments: System.is in working order 2) System Conditionally Passes:. El ,One or more system components.as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will.pass: Check the box for"yes";="no or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced-with a complying septic tank as approved by the Board of Health A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of -Compliance indicating that the tank is less than 20 years old is available. ❑ Y. ❑ N ❑ ND (Explain below): 1 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 commonwealth of Massachusetts - Title 5 Official Inspection Form - �1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............. !% 149 East Bay'Rd. Rear System Property Address Jones Family+Pied A Terre LLC: Owner Owner's Name information is required for every Osterville Ma. 02655 1-29-21 page. Citylrown State _ Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont:): El Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): El broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed.. ❑ Y ❑ N ❑ ND (Explain below): 3) 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. a..System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(4)that the system.is not functioning in a manner which will protect public health, safety.and the environment: t5insp.doc-rev.7/26/2018 Title 5Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Ii, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 149 East Bay Rd. Rear System Property Address, Jones Family Pied A Terre LLC. Owner Owner's Name information is required for every Osteryille Ma.. 02655 1-29-21 pager City/Town . State Zip Code -:,Date of Inspection C. Inspection Summary (cont.) 0 Cesspool or privy is.within 50 feet of a surface water h ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b: 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: 0.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: ' El The system has a septic tank and SAS and the SAS is within 50 feet of a private water Supply well. El The system has a septic tank and SAS and the SASJs less than 100 feet but 50 feet or inore from a private water supply well**. Method use to determine distance: - **This system passes if the well water analysis, performed at a DEP�certified Laboratory, for fecal coliform bacteria:indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached td this form. c. Other: -4) 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 El AE 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 t5insp.doc•rev.,7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 c� Commonwealth of Massachusetts �n Title ,5 Official Inspection Form I y Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 149 East Bay Rd. Rear System u�. Property Address Jones Family.Pied A Terre LLC. Owner Owner's Name information is Osterville i ; Ma. *'' 02655 1-29-21 required for every page. Cityrrown State _• Zip.Code Date of Inspection C. Inspection Summary (cont.) , 4)_ System Failure Criteria Applicable to All Systems:(cont.)' I Yes` No! f ® 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 '/dayflow Required pumping more than 4 times in the last year NOT due to clogged or ❑ ® obstructed pipe(s). Number of times pumped: ❑. S. 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 El tributary to a surface water supply, ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within50 feet of a private water supply well ❑ IK Any portion of a vicesspool 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 2000 gpd- 10,000 9pd El ® 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. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of,10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in,See'tion CA. Yes No , the system is within 400 feet of a surface drinking water supply El ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection El , Area- IWPA) or a mapped Zone Il of a public water supply well l5insp.doc•rev.7/26/2018 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts r� IF Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Rd. Rear System Property Address Jones Family Pied A Terre LLC. Owner Owner's,Name , information is required for every Osterville Ma. 02655 1-29-21 page. CityTrown State Zip.Code Date of Inspection C. Inspection Summary (con,t) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section t.4 above the large system.has failed. The ' owner or operator of any large.system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes".or"rio"for each of the following for all inspections: Yes No ❑ E :Pumping information was provided by the owner, occupant, or Board of Health El ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in they previous two week period? El ®. Have large volumes of water been introduced to the system recently or as.part of this'inspection?" 1 'Q 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? E ❑ Was:the site inspected for signs of break out? ® ❑ Were all,system components, excluding the SAS, located on site? ® ❑ Were1he septic;tank'rrianholes'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)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form + is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 149 East Bay Rd. Rear System Property Address Jones Family Pied ATerre LLC. Owner Owner's Name information is required for every Osterville Ma. 02655 1-29-21 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number.of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Description: Number.of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No „ y . If yes,.discharges to: Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No_ information in this report.)' Laundry system inspected?- ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if"available (last 2 years usage(gpd)): NA Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 . Official Inspection Form I a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 149 East Bay Rd. Rear System Property Address Jones Family Pied A Terre LLC. Owner Owner's Name information is required for every Osterville Ma. 02655 1-29-21 . page. City/Town_ State Zip Code Date of Inspection D. System,Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: - ~ Source of information: NA Was system pumped as.part of the inspection? ® Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Main pool was dry Reason for pumping: Cess pools t5insp.doc-ray.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments - u 149 East Bay Rd. Rear System Property Address' Jones Family Pied A Terre LLC: Owner Owner's Name" . information is ., required for every Osterville Ma. 02655 1'-29-21 - page. City/Town State Zip Code Date of Inspection D..System Information (cont.) 4. Type of-System: - Yp Y ❑ 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) El 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): { w Approximate age_of all components; date installed(if known)and source of information: Were sewage odors detected when.arriving.at the site? _ ❑ Yes ❑ No 5. Building Sewer(locate on site plan): 26" Depth below grade: feet Material of,construction: cast iron ® 40 PVC ❑ other-(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev..7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �ii Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 149 East.Bay Rd.., Rear System Property Address Jones Famiiy'Pied A Terre LLC. Owner Owner's Name information is required for every Osterville Ma. 02655 1-29-21 . page. City/Town State Zip Code Date of Inspection D. System"Information (cont.) 6. ' Septic Tank-(locate on site plan): Depth below grade:" feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, Fist age: years Is age confirmed by,a Certificate of Compliance?+(attach a copy of certificate) ❑. Yes ❑ No Dimensions: Sludge depth`. Distance from top of sludgeto 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? F, Comments(on pumping recommendations, inlet and outlet tee or baffle condition; structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): t5insp.doc-rev.M6/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 ` Commonwealth of Massachusetts Title 5 Official inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 149 East Bay Rd. Rear System Property Address Jones Family Pied A Terre LLC. Owner . Owner's Name.. information is Osterville Ma. 02655 1-29-21 required for every page Clty/Toudn State Zip Code Date of Inspection D..System information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: , feet Material of construction: concrete ❑ metal ❑ fiberglass [I 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 Comments (on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grader .Material,of construction: ❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: : Capacity: gallons Design.Flow:. gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts r Title ,5 Official Inspection Form �1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 149 East Bay Rd. Rear System u Property Address` Jones Family Pied A Terre LLC. Owner Owner's Name information is r` required for every Osterville ' Ma. 02655 1-29-21 page. City/Town State Zip Code Date of Inspection D. Systei>r Information (cont.) 8. Tight or Holding.Tank,(cont.) 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 Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ 'No 9.: Distribution Box if ' resent must be opened)., locate on site Ian ( p P ) ( plan): Depth of liquid level above outlets 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.): t5insp.doc rev.7/26/2018 Title 5 Official Inspection,Form:Subsurface Sewage Disposal System-Page 12 of 18 - Commonwealth of Massachusetts Title 5 Official Inspection Form �0 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Rd. Rear System Property Address, Jones Family Pied A Terre LLC. Owner Owner's Name information is: required for every Osteryille Ma. 02655 1-29-21 page. City/Town ' State Zip Code Date of Inspection D. System Information (cont.). 10. 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.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type. ❑ leaching pits number: El leaching chambers number: ❑ Teaching galleries number: ❑ leaching tenches number, length: ❑ leaching fields number, dimensions: . 1 ® overflow cesspool ,number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form �I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Rd. Rear System Property Address Jones Family Pied A Terre LLC Owner Owner's Name information is required for every. osterville Ma. 02655 1-29-21 page: City/Town State Zip Code Date of Inspection D. System Information (cont.)' 11. Soil,Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation etc.): SAS is a overflow cess pool 'pool is clean and'dry with no sign of failure 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 2 Depth-top of liquid to inlet invert Depth of solids layer Depth of scum layer v Dimensions of cesspool 6x8 Materials of construction Block Indication of groundwater inflow ❑ Yes ® No Comments (note condition of soil, signs-of hydraulic failure, level of ponding, condition of vegetation, etc.): Main pool is block pool with cover at 12" below grade ,system is for 1 bathroom t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 c Commonwealth of Massachusetts Title_ 5 Official Inspection Form Fig Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Rd. Rear System Property Address F Jones Family Pied A Terre LLC. Owner Owner's°Name information is required for every Cisteryille Ma. 02655 1-29-21 _ page. City/Town State Zip Code Date of Inspection D. System,.Infbirmation (cont.) 13. 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.): t5insp.doc-rev.7/26/2018 ,� -Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title. 5 Official Inspection Form �I� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �� a 149 East Bay Rd. Rear System . Property Address p Jones Family Pied A Terre-LLC: Owner Owner's Name information is required for every Osterville Ma: 02655 1-29-21 page. City/Town State Zip Code Date of Inspection D.-System lnf®rmation (cont)_ 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks orbenchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building: Check one of the boxes below: ® hand7sketch in the area below` El drawing attached separately _ 41 : . t .��J(t10F Mq p�i0 6 ► q. 8 .��� ss9O a_ . 8 o• MICHAEL N o: SEARS No.SI14430 IN n a��o��`\ l5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Rd. Rear System ' Property Address Jones Family Pied A Terre LLC. Owner Owner's Name,' ? " information is. required for every- OsteNille . 'Ma. 02655 1-29-21 page. City/Town:z• State Zip Code Date of Inspection D. System Information (cont.) x 15. Site Exam: ED Check Slope ® Surface water - ® Check cellar : ~� ® Shallow wells • 17' Estimated depth to high'ground1water: 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) T❑ Accessed USGS database-explain: , Yob,must describe how you established the;high ground water elevation: No ground water 10'below pool per last report Y Before filing this Inspection Report, please see Report Completeness Checklist on next page. I insp.d.c•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form iI; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Rd. Rear System Property Address Jones Family Pied A Terre LLC. r Owner Owner's Name Y`, information is required for every. Osteryille Ma, 02655 1-29-21 , page. City/Town State Zip Code Date of Inspection `E.`'Report Completeness Checklist r - , complete all applicable sections of this form inclusive of: . fi A. Inspectorinformation: Complete.all fields in this section. ® B. Certification: Signed & Dated and 1, 2,.3, or checked ®-C. Inspection Summary: 1; 2, 3; or 5 completed as appropriate. 4 (Failure Criteria)and 6 (Checklist) completed , ® D. System Information: For 8. Tight/Holding Tank Pumping contract attached For 14: Sketch of Sewage.Disposal System drawn on pg..16 or attached For 15: Explanation of estimated depth to high groundwater included . f t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Commonwealth of Massachusetts ,� Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Rd. Front System • V Property Address lw a Jones Family Pied A Terre LLC. ; Owner. Owner's Name information is Osterville - Ma. 02655 1-29-21 , required for every r. page. City/Town State Zip Code Date of Inspection `Et 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. . fmngoutf omen A. Inspector Information ��, I51 Z(P filling out forms on the computer, Michael Sears use only the tab key to move your Name of Inspector cursor-do not Robert B Our Co INC:' use the return Company Name key. 363 Whites Path. rab Company Address South Yarmouth Ma. 02664 City/Town State Zip Code »n 508-477-8877 SI 14430 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: Passes -\\A OF 2. ElConditionally Passes MICHAEL '.N? 3. ❑ Needs Further Evaluation by the Local Approving Authority =0. SEARS * No.SI14430 r -4. . ❑ Fails �' rq- /�/r g r►1111111111\\O �! 1-29-21 Inspector's Signa a Date The system inspector shall submit a,copy ptthis inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 DER The original form should be sent to the system owner and copies sent to the,buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc-rev.V26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 ' Commonwealth of Massachusetts Title 5 Official Inspection Form` I- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V � 149 East Bay Rd. Front System Property Address Jones Family PiedA•Terre LL"C. Owner Owner's Name information is required for every''Osterville Ma. 02655 1-29-21 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary Inspectior Summary: Complete 1, 2, 3,'or 5 and all of 4 and 6. 1) "System Passes: 1 have not found any.information which indicates.that any of the failure criteria'describedl in 3101 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is in working order 2) System Conditionally.Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of'the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes'; "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank.is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is;replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑;ND (Explain below): - t5insp-doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts �� .. Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V!% 149 East Bay Rd. Front System y Property Address „ Jones Family Pied A Terre LLC. Owner Owner's Name information is Osterville Ma. 02655 1-29-21 required for every page. CitylTown State Zip Code Date of Inspection C. Inspection Summary'(cont.) 2) System Conditionally Passes (cont.): El Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑. Observation of sewage backup or.break out or high static water-level in the distribution box due to,broken orobstructed 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): El obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3). 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. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the systern is not functioning in a manner which will protect public health, safety and the environment: _ f t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspection Form 111 b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,l; G � 149 East Bay Rd. Front System v� Property Address Jones family Pied A Terre LLC. Owner., Owner's Name y information is Osterville Ma. 02655 1-29-21 .required for every page. Citylrown State Zip Code Date of Inspection C Inspection Summary (cont.) ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑-The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. -The system has'a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used,to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,-for 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 forma c. Other: 4) 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 S.AS.or cesspool E ® Discharge orponding of effluent to the-surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Rd. Front System V� Property Address Jones Family Pied A Terre LLC. Owner, --owner's Name 8, information is Ostefville. Ma. 02655_ 1-29-21 'required for every , page. u CitylTown' State Zip Code Date of Inspection C. Inspection' Summary (cont.) 4) System Failure"Criteria Applicable to All Systems: (cont.) Yes No El Z. 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 ❑ ® ' rthan 1/day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times,pumped: ® •Any.portion of the SAS, cesspool or privy is below high ground water elevation. ® -.Any portion of cesspool or privy is within 1,00 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 water supply ❑ ® well. ❑ . ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. `❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet ,from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered..A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® 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. 6) Large Systems:, To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must'indicate either"yes" or"no to each of the following, in addition to the questions in Section CA. Yes 'No ❑ ❑ the system is within 400 feet of a surface drinking water supply ?❑ ❑' the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a"nitrogen sensitive area (Interim Wellhead Protection .Area—IWPA) or a mapped Zone Jl of a public water supply well t5insp.doc-rev.7/26/2018 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments.. V � 149 East Bay Rd. Front System Property Address Jones Family Pied A Terre LLC. ' Owner Owner's Name information is required for,every Osterville Ma. 02655 1-29-21 page. City/Town State Zip Code Date of Inspection C. Inspection Summalry(cont) } If you have answered 'yes"to any question"in Section C.5.the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has.failed. The owner or operator`of any large system;considered a significant threat under Section C:5 or failed under Section'.C.4 shall upgrade the system in accordance with 310 CMR 15.304. The system owner a should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for,each of the following for all inspections: Yes.- , No Pumping information was provided.by the owner; occupant, or Board of Health El ® 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? s a ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® El' Were as built plans of.the system obtained and examined? (If they were not available note as N/A) Z ❑ Was the facility or dwelling.inspected for signs of sewage back up? Z ,, ❑ Was the site inspected.for signs of break out? Were allsystem components, excluding the SAS, located on site? r 0 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 Z Ell 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. P Determined in the field (if any of the failure criteria related to Part C is at issue El z approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form I a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I V � 149 East Bay Rd. Front System Property Address Jones Family Pied A Terre LLC. Owner Owner's Name information is required.for every Osterville Ma. 02655 1-29-21 page. City/Town State Zip Code Date of Inspection j D. System Information 1. Residential Flow Conditions: Number of,bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN'flow'based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes Z No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter'readin s if available last 2 ears usage NA 9 ( Y 9 (9Pd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: PresentDate t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 f Commonwealth of Massachusetts I Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments F 149 East Bay Rd. Front System Property Address Jones Family.Pied A Terre.LLC. Owner Owner's Name information is required for every Osterville Ma. 02655 1-29-21 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) 2. 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 Water treatment.unit present? ❑ Yes ❑ No 1f yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: . Date Other(describe.below): 3. Pumping Records: ` NA Source of information: Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 500'gal gallons How was.quantity pumped determined? Pump Driver Reason for pumping: Cess pools t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 I - Commonwealth of Massachusetts �w Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c u � 149 East Bay Rd. Front System Property Address 4 Jones Family'Pied A Terre LLC. . Owner Owner's Name information is required for every Osterville Ma 02655 1-29-21 page. Cityjown t State Zip Code' Date of Inspection D.. System Information (cont:) 4. Type of System: ❑i 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 lie obtained from system owner)and a copy of latest inspection of the 1/A system by system operator under contract El Tight tank. Attach a copy of the DEP approval- ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected,when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): Depth below grade: `feet ::Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from•private water supply well or suction line: feet Comments (on condition of joints, venting,..evidence of leakage, etc.): t5inspAoc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V!% 149 EastBay'Rd. Front System Property Address, Jones Family Red A Terre LLC. Owner Owner's Name information is Cisterville . >' w Ma. 02655 1-29-21 required forevery page. City/Town State Zip Code Date of Inspection D. Systerh Information (cost.) 6. ..Septic Tank(locate on site plan): bepth,below grade: feet ,r 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' 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 ' Y . , 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.): R i, t5insp.doc•rev.7/26/2018 Titles Official Inspection Form:'Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts �n Title 5 official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u � 149 East Bay Rd. Front System ' Property Address ^ - Jones Family Pied A Terre LLC. Owner Owner's Name, information is Osterville Ma. 02655 1-29-21 required for every ' page. City/Town State '. Zip Code Date of Inspection D.,System Information (cont.) 7. Grease Trap (locate_on site plan): Depth below grade: .= feet Material of,construction: ❑ concrete i . ❑ metal El fiberglass ❑ polyethylene ❑ other(explain):. Dimensions: a 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels'as related to outlet invert, evidence of leakage, etc.): 8. Tight or.Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grader Material of construction: El concrete 0 metal ❑,fiberglass ❑ polyethylene ❑ other(explain): Dimensions: . Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 11 of 18 j Commonwealth of Massachusetts Title. 5 Official Inspection Form III I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Rd. Front System' Property,Address: Jones Family Pied A Terre LLC. Owner Ownehs'Name- information is required for every— OStervllle Ma. 02655 1-29-21 page. Cityrrown State Zip Code . Date of Inspection D: System Information (cont.) 8. Tight or Holding Tank(cont.)' Alarm-present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑' Yes ❑. No Date'of last pumping: Date Comments(condition of alarm and.float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No A. Distribution Box(if present must be opened) (locate on site plan): Depth of,liquid level above outlet invert Corments (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.): . p. t5insp.doc-,rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u � 149 East Bay Rd. Front System Property Address Jones Family Pied A Terre LLC. Owner Owners Name information is required for every Osteryille Ma. 02655 1-29-21 page. City/Town. State Zip Code Date of Inspection D. System Information (cont.) 10. 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.): * If pumps'or alarms are not in working order, system is a,conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspools number: 1 ❑ innovative/alternative system Type/name.of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u � 149 East Bay Rd. Front System Property Address Jones Family Pied A Terre LLC. Owner Owner's Name information is required for every Osterville Ma. 02655 1-29-21 page. City/Town State Zip Code Date of Inspection D. System Information (coat.) 11.,Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of _ vegetation, etc.): SAS is a overflow cess pool , pool is clean and dry with no sign of failure 12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration 2 - _Depth—top of liquid to inlet invert 2 Depth of solids layer, 0 Depth of scum layer 0 Dimensions of cesspool 6x8 Materials of construction Block Indication of groundwater inflow ❑ Yes ® No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Main pool is block pool with cover at 10" below grade t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth. of Massachusetts Title 5 Official Inspection Form �1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Rd. Front System Property Address; ` Jones Family Pied A Terre-LLC. Owner Owner's Name information is required for every Osterville. Ma. 02655 1-29-21 page. City/Town State Zip Code Date of Inspection D. Systerro Information (cont.) 13. 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.): / t , t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 r Commonwealth of Massachusetts . n Title 5 Official Inspection Form �i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 149 East Bay Rd. Front System Property Address Jones Family'Pied'A Terre LLC. Owner Owner's Name: information is required for every Osterville Ma. 02655 1-29-21 page." City/Town State Zip Code. Date of Inspection D. System Information (cont.), 14. Sketch Of Sewage Disposal System: Provide a view.of the.sewage disposal system,.including ties tout least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate.where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below '❑ drawing attached separately From as q3 \�\. �,�N OF o MICHAEL .m= =o; SEARS *'. No.SI14430 )c A' O ter' F!? I���' O �SmmSp`SG`SO t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 t r Commonwealth of Massachusetts 1 Title 5 .Official Inspection Form }Ia Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '149 East Bay Rd. Front System u . Property Address' Jones Family Pied A Terre LLC. Owner Owner's,Name information is required for every Osterville =. Ma ; 02655` 1-29-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope `. ® Surface..water ® Check.6ellar Shallow'weilsr Estimated depth to high ground water: 17' - feet Please indicate all methods used to determine the high ground water elevation:- El Obtained from system design plans on record If checked, date of design;plan reviewed: Date Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: Checked with local excavators, installers (attach documentation) '.Accessed USGS database-explain: You must describe how you established the high ground water elevation: . No ground water 10' below pool per last report Before filing this Inspection Report, please see,'Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 i Title 5 Official Inspection Form:'Subsurface Sewage Disposal System-Page 17 of 18 f Commonwealth of Massachusetts �n _ Title 5 Official Inspection Form . I Subsurface.Sewage Disposal System Form- Not for.Voluntary Assessments 149 East Bay Rd. Front System Property Address Jones Family Pied A Terre LLC. Owner Owner's Name information is' Osterville Ma: . 02655 1-29-21 required for every page. City/Town State Zip Code Date.of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed&.Dated.and 1,-2, 3, or 4 checked ® C. inspection.Summary: 1; 2,31 or,5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist) completed , ® D..System Information: For 8: Tight/Holding Tank 7 Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 No Fee Fee ��` -- THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2[ppYication for 0sposal 6pstem Construction permit Application for a Permit to Construct( ) Repair X Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. 1 4q GAS T 044 94A-b Owner's Name,Address,and Tel.No. Assessor's Map/Parcel q® 5 9 1�6T. 0R1 m Awg-" 11/4F f::!L 3 I0 0�- Installer's Name,Address,and Tel.No.5OS—tfZ1—U 77 Designer's Name,Address,and Tel.No. I ' Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Jate Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 0 i4&1&-E L4 0 ES Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date 3 0-to�� Application Approved by �` Date -��6 '�(� C Application Disapproved by Date for the following reasons Permit No. Q O 1(a—Z) '-20 Date Issued 3(14,t�1 Fee' ,. ~ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 0[ppliCation,for Disposal .6pstem Construction Permit Application for a Permit to Construct( ) Repair X Upgrade( ) Abandon( ) ❑Complete System Individual Components /Location Address or Lot No. (P4cr GAS•T 0M a,00-b Owner's Name,Address,and Tel.No. DST. gRP�ttJ 3oN�.5 Assessors Map/Parcel 5 9 Awn Avf5 Al IVAPan-, $=7(— 3 4(0 2- Installer's Name,Address,and Tel.No.5OS-4-n Designer's Name,Address,and Tel.No. C'APEW(K tNTWXASE'S LLL N/4 } Type of Building: Dwelling, No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) t. Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures J r Design Flow(min.required) / gpd Design flow provided gpd Plan Date ' Number of sheets Revision Date Title - Size-of Septic Tank Type of S.A.S. . i Description of Soil Nature of Repairs or Alterations(Answer when applicable) C 14&ArGG L4 0 ES Date last inspected: K � , Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage dispos,'systemx* . accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certhcate.oaf• � Al �r Compliance has been issued by this Board of Health. * h/' f . Signed Date l �1 �m ,� Ali Application Approved by. /►� Date �6 rQ�f � J, r � . Application Disapproved by U i D�e j for the following reasons �A Permit No. Date Issued 3 / &'r - -------------- ' ------------------- ------- ------------------------------------------- --- '------------------------------- THE COMMONWEALTH OF MASSACHUSETTS P e S T(oj 11r,9 1 BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(X) Upgraded( ) Abandoned( )byuA nQ950 � � 1,LC— at -.� '� 65��/L.� has been cons ucted in accordance ' with the provisions of Title 5 and the for Disposal System Construction Permit No. Gl C ld?dated �. Installer eabc_ E�1)['E-]Q bSETS (XX_ Designer lV(A #bedrooms t_/ ,!"/�i Approved design flow gpd. � 1 'The issuance o this ermit shall not be construed as a guarantee that the system will fun tio'n j desi Date 1 I 1 Inspector 1.r - — ---------------------------------------------------- No. �O tD �t!/ Fee -751 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction 3pPrmit Permission is hereby granted to Construct( ) Repair(� Upgrade( ) Abandon( ) System located at 1 4 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. J Provided:Construction must be completed within three years of the date of this permit. 41 Approved by Date L "`up- AsBuilt-. Page l .of 2 14,9 SEWAGE INSPECTIONS LOCATION 4-34 Ea,6t Bar{ Road DATE 5128103 VILLAGE Ozteau.i2ie,Ras4. ASSESSOR'S MAP&LOT 1-40-,1,59 •INSPECTOR lo.seph P.(1r com&e z aa. ' SEPnC TANK CAPACITY None 1-6'X8' Ce.ez/2oo ea T zont eyatem. nd 1-8'X10' ceiej2oo.2. Rea4 .system ha.a �. '. LEACHING FACILrN: (type NO,OF BEDROOMS 5 BUILDER OR OWNER_ nnry Bong •• OWNER NAILING ADDRESS -Same of �ra � r M\ �nl� jr http://issgl2/intranet/propdata/prebuilt.aspx?mappar=140159&seq=1 3/16/2016 / Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a M 149 East Bay Road (Front System) Property Address Diane & Brian Jones Owner Owner's Name information is required for every osterville MA 02655 3-17-16 page. City/Town State Zip Code Date of Inspection ,p. Inspection results must be submitted on this form. Inspection forms may not be altered nany way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out formsE' �S'J �p on the computer, 't�U►ulufU!//��� ��`` TI�OF Mq use only the tab 1. Inspector: key to move your o: cursor-do not =g. JAMES :m= use the return- James D.Sears _ _ key. Name of Inspector �; S AIRS -+e Capewide Enterprises, LLC 153 Commercial Street ��SR N SPE� o'`•` Company Address rem Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S 1623 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ .Fails ❑ Needs Further Evaluation by the Local Approving Authority 3-17-16 spector'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 the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts 53 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Road (Front System) Property Address Diane & Brian Jones Owner Owner's Name information is required for every Osterville MA 02655 3-17-16 page. Cityrrown 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: The system is two block c.pool,s B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined;" please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. El Y ❑ N ❑ ND (Explain below): t5ins•3/13 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 149 East Bay Road (Front System) Property Address Diane & Brian Jones Owner Owner's Name information is required for every Osterville MA 02655 3-17-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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 obstructedpipe(s). The � • p 9 Y System will pass Inspection If(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑, obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Road (Front System) Property Address Diane& Brian Jones Owner Owner's Name information is required for every Osterville MA 02655 3-17-16 ` 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: ** 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 lv# El ❑ 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 t5ins•3113 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 GSM , 149 East Bay Road (Front System) Property Address Diane & Brian Jones Owner Owner's Name information is Osterville MA 02655 3-17-16 required for every page. City/Town 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: ® Any portion of the SAS, cesspool or privy is below high groundwater elevation. ❑ ® ' Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. El ® 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. 0 ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system.owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 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 149 East Bay Road (Front System) Property Address Diane & Brian Jones Owner Owner's Name information is requireCisterville MA 02655 3-17-16 d for every page. CityrFown 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? Z El Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the manholes uncovered, opened, and the interior inspected for the condition of the tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? El ® 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): NA Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Road (Front System) Property Address Diane & Brian Jones Owner Owner's Name information is required for everyOsterville MA 02655 3-17-16 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is two old block c. pools. l Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage NA 9 ( Y g (gpd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 149 East Bay Road (Front System) Property Address Diane & Brian Jones Owner Owner's Name information is required for every Osterville MA 02655 3-17-16' page. CitylTown 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: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ® Single cesspool ® Overflow cesspool Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Road (Front System) Property Address Diane & Brian Jones Owner Owner's Name information is required for every Osterville MA 02655 3-17-16 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: NA Were sewage odors detected when arriving at the site? ❑ Yes E No Building Sewer(locate on site plan): Depth below grade: 40" 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.): Pipeing is cast iron and both main lines are new 3-2016 PVC SCH -40. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts d Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 149 East Bay Road (Front System) Property Address Diane& Brian Jones Owner Owner's Name information is required for every Osterville MA 02655 3-17-16 page. Cityrrown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts 9-2 W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 149 East Bay Road (Front System) +, Property Address Diane & Brian Jones Owner Owner's Name information is required for every Osterville MA 02655 3-17-16 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.): ail Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required).is copy attached? ❑ Yes ❑ No l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Road (Front System) Property Address Diane & Brian Jones Owner Owner's Name information is required for every Osterville MA 02655 3-17-16 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.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M s 149 East Bay Road (Front System) Property Address Diane & Brian Jones Owner Owner's Name information is required for every Osterville MA 02655 3-17-16 page. City/Town State Zip Code bate of Inspection D. System Information,(cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: 6'X10' El 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.): Over flow is a old block c. pool 6'x10'w/cover at 27". 2"water in pool w/no sign of over loading. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 Depth—top of liquid to inlet invert 18" 41' Depth of solids layer 01. Depth of scum layer Dimensions of cesspool 6'x8' Materials of construction Block Indication of groundwater inflow ❑ Yes ® No t5ins•3/13 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 149 East Bay Road (Front System) Property Address Diane& Brian Jones Owner Owner's Name information is required for every Osterville MA 02655 3-17-1.6 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.): Main pool is a old block c. pool w/cover at 10".Two inlets w/tee's cast iron out let tee. Both main lines are new 3-2016, 4" PVC SCH 40. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 BAY o S7" LI gQicV YTo. I PAT v Y S PR), v g R Commonwealth of Massachusetts w Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Road (Front System) Property Address Diane & Brian Jones Owner Owner's Name information is required for every Osterville MA 02655 3-17-16 page. City/Town State Zip Code Date of Inspection D.. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments East Bay Road (Front System) Property Address Diane & Brian Jones Owner Owner's Name information is required for every Osterville MA 02655 3-17-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water. ❑ Check cellar Shallow wells O Estimated depth to high ground water: 17+ feet Please indicate all methods used to determine the high groundwater elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date El Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: - ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Past report. No G.W. 10' below bottom of c. pool. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Road (Front System) Property Address Diane & Brian Jones Owner Owner's Name information is required for every Osterville MA 02655 3-17-16 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 -/69 Commonwealth of Massachusetts w W Title 5 Official Inspection Form ` Subsurface Sewage Disposal System Form - Not for Voluntary Assessments zi ,M 149 East Bay Road Rear System) Property Address Diane & Brian Jones Owner Owner's Name information is required for every OSterville MA 02655 3-17-16 page. City/Town 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 A. General Information filling out forms ����utumfpu� on the computer, N OF M,q i use only the tab ���� ..........,s'q 1. Inspector: AN• ' o key to move your O? '•yG' cursor-do not James D.Sears = JAM ES :m use the return Name of Inspector IRSkey. v *: :co Capewide Enterprises, LLC 0- _o Company Name153 Commercial Street '''� %rF RINSP Q�O�\``` Company Address Mashpee MA 02649 Cltyrrown State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and.experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes. ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority A 3-17-16 Spector'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 the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 a Commonwealth of Massachusetts - Title 5, Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Road (Rear System) Property Address Diane& Brian Jones Owner Owner's Name information is required for every Osterville MA 02655 3-17-16 page. Cityrrown 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: The system is two block c. pool. New main line 3-2016. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 149 East Bay Road (Rear System) Property Address Diane & Brian Jones Owner Owner's Name information is required for every Osterville MA 02655 3-17-16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): El Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval.of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Road (Rear System) Property Address Diane & Brian Jones Owner Owner's Name information is required for every Osterville MA 02655 3-17-16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The.system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 El ® 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 A19 ❑ ❑ 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 149 East BayS Road (Rear System) ) Property Address Diane& Brian Jones Owner Owner's Name information is Osterville MA 02655 3-17-16 required for every 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: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and.chain of custody must be attached to this form.] El ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes . No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply Ej ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.a04. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Road (Rear System) Property Address Diane & Brian Jones Owner Owner's Name information is required for every Osterville MA 02655 3-17-16 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 manholes uncovered, opened, and the interior jjWutdM inspected for the condition of the Offbamtees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Z 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): NA Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -149 East Bay Road (Rear System) - Property Address Diane& Brian Jones Owner Owner's Name information is required for every Osteryille MA 02655 3-17-16 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is two old block c. pool's, w/new main line 3-2016. Number:of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d NA 9 ( Y 9 (gp ))�- Detail: Sump pump? ❑ Yes ® No NA Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc,): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water,meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 149 East Bay Road (Rear System) Property Address Diane& Brian Jones Owner Owner's Name information is required for every Osterville MA 02655 3-17-16 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: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system Single cesspool ® Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑. Tight tank. Attach.a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts 4 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 149 East Bay Road (Rear System) Property Address Diane& Brian Jones Owner Owner's Name . information is required for every Osterville MA 02655 3-17-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet 26" 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.): Pipeing is cast iron and PVC SCH -40. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 . Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Road (Rear System) Property Address Diane & Brian Jones Owner Owner's Name information is required for every Osterville MA 02655 3-17-16 page. Cityrrown 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 149 East Bay iRoad (Rear System) Property Address Diane & Brian Jones Owner Owner's Name information is required for every Osterville MA 02655 3-17-16 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.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Road (Rear System) Property Address Diane & Brian Jones Owner Owner's Name information is required for every Osterville MA 02655 3-17-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 149 East Bay Road (Rear System) Property Address Diane& Brian Jones Owner Owner's Name information is required for every Osteryille MA 02655 3-17-16 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: ❑ leaching fields number, dimensions: overflow cesspool number: 6,X8" ❑ 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.): Over flow is a old block c.pool-6'x8"w/cover at 1'. Pool is dry w/no sign of over loading. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 Depth—top of liquid to inlet invert Dry Depth of solids layer Dry Depth of scum layer Dry 6x8 Dimensions of cesspool Materials of construction Block Indication of groundwater inflow ❑ Yes ® No t5ins-3/13 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 149 East Bay Road (Rear System) Property Address Diane& Brian Jones Owner Owner's Name information is Osterville MA 02655 3-17-16 required for every page. CitylTown 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.): Main pool is a old block c.pool Win and outlet tee's. Pool is dry w/cover at 1'. This system is for one bath room. — -- 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Road (Rear System) Property Address Diane & Brian Jones Owner Owner's Name information is required for every Osterville MA 02655 3-17-1.6 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate r where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ®drawing attached separately t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I`lY �:_ NY Q o S7- gQ�c� ' E}}l 5 o.� _ S PR Iv v FR Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Road (Rear System) Property Address Diane & Brian Jones Owner Owner's Name information is required for every Osterville MA 02655 3-17-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope Surface water ❑ Check cellar ❑ Shallow wells Na Estimated depth to high ground water: 1T+ feet Please indicate all methods used to.determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Past report no G.W.10' below bottom of c.pools. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 f ' Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Road (Rear System) Property Address Diane& Brian Jones Owner Owner's Name information is required for every Osterville MA 02655 3-17-16 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 s ..ru Name& ru m r`- Certified Mail Fee ru $ ru Extra Services&Fees(check boy add lee as appropriate) []Return Receipt(hardcopy) - $ 0 ❑Return Receipt(electronic) $ f Postmark,° p ❑Certified Mail RwWcted Delivery $ Q ❑Adult Signature Required- _ .$ � � ❑Adult Signature Restricted Delivery$ ` r O Postage �( ru rq Total Postage and Fees a SJ Mr. & Mrs. Brian Jones 265 2"d j Ave. N Naples, FL 34102 i ` Certified Mail service provides the following benefits: ■A receipt(this portion of the Certified Mail labeq. for an electronic return receipt,see a retail ■A unique identifier for your mailpiece. ( associate for assistance.To receive a duplicate ■Electronic verification of delivery or attempted return receipt for no additional fee,present this delivery. USPS®-postmarked Certified Mail receipt to the ■A record of delivery(including the recipients retail associate. signature)that is retained by the Postal Service- Restricted delivery service,which provides for a specified period. delivery to the addressee specified by name,or, to the addressee's authorized agent Important Reminders Adult signature service,which requires the ■You may purchase Certified Mail service with signee to be at least 21 years of age(not First-Class Mail®,First-Class Package Service®, available at retail). or Priority Mail®service. Adult signature restricted delivery service,which ■Certified Mail service is notavailable for requires the signee to be at least 21 years of age international mail. and provides delivery to the addressee specified ■Insurance coverage is notavailable for purchase by name,or to the addressee's authorized agent with Certified Mall service.However,the purchase (not available at retatq. of Certified Mail service does not change the ■To ensure that your Certified Mail receipt is Insurance coverage automatically included with accepted as legal proof of mailing,it should bear a certain Priority Mail items. USPS postmark If you would like a postmark on ■For an additional fee,and with a proper this Certified Mail receipt,please present your endorsement on the mailplece,you may request Certified Mail Rem at a Post Office'for the following services: postmarking.R you don't need a postmark on this Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion (, of delivery(including the recipient's signature). of this label,affix itto the mailpiece,apply You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece. electronic version.For a hardcopy return receipt j complete PS Form 3811,Domestic Return 1 Receipt attach PS Form 3811 to your mailpiece;^IMPORTANT:Save this receipt for your records. Ps Form 3800,April 2015(Reverse)PSN Imo-62-000-gov Barnstable ;HE Town of Barnstable Regulatory Services Department p , * snaxsrn8M • ,, FXASS Public Health Division m NO Main Street,Hyannis MA•02601 NO ,h 200.7 Office: 508-862-4644 Richard V.Scali,Director ` FAX: 508-790-6304 - Thomas A.McKean,CHO CERTIFIED.MAIL# 7014 1200 0001 2273 2626 January 21, 2016 y Mr. &Mrs. Brian.Jones ro 265 2nd Ave N Naples FL 34102 RE: Front System ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE TITLE 5 The septic system located at 149 East Bay Road, Osterville,MA was last inspected on 11/30/2015,by James D. Sears, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Needs Further Evaluation" under the guidelines of 1995 TITLE 5.(310 CMR 15.00) due to the following: • Front system: Both broken pipes need to be replaced_ You are ordered to repair/replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. Per order of the Board of Health { omas McKean, R.S., CHO r' ,• Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\149 East Bay Rd Ost Jan 2016.doc Parcel Detail Page 1 of 4 77 F. Logged In As: Parcel Detail Wednesday,January 20 2016 Parcel Lookuo Parcel Info Parcel ID 140-159 DeveloperLot LOT 13 ��..,,..w».,�.,.,.",,.�,w...,.�,.,�.,m.. <,..� � Location 149 EAST BAY ROAD I Pri Frontage 110 I Sec Road YORK TERRACE �I Sec 50 I Frontage Village STERVILLE ._ - — °" °� ° `� Fire District Town sewer exists at this address No ( Road Index O468 � �I Asbuilt Septic Scan: Interactive f � 140159_1 Map l - Owner Info Owner IJON ES, BRIAN B & DIANE G m co-Owner Streetl 765 2ND AVE N Street2 city ;NAPLES State fF—Lj zip ;34102 Country - Land Info Acres use tSingle Fam MDL-01 zoning RC -— Nghbd 0117 � Topography Level Road Paved Utilities Septic,Gas,Public Water Location Rear Location Construction Info Building 1 of 1 Yearr1958—I Roof be/Hip I ExtWoodShingle Built Struct` Wall . Living2545 . Roof Wood Shingle AC Central I ' Area Cover_ Type J pT PTa .. 8 62 7 iseo(2I" T y8 `1A> Int" Bed style Cape Cod w'au Plastered I Rooms ,5 Bedrooms � - a A1. -^ Int Bath q; -, 8 J Model Residential Harwood 3 Full-1 Half Floor" Rooms c �4 T4S o 8 34 Grade Average Plus Heat Hot Air f Total 10 UiAType Rooms Heat Stories 1 1/2 Stories yl Fuel ouind- Oil F ation Mixed Gross 5539 ) Area Building 1 of 1 Year Built Struct Wall 008 Roof Ex Gable/Hip Built Wood Shingle W� http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=8850 1/20/2016 Town of Barnstable anxrrsr�at.E, Regulatory Services Department Public Health Division 200 Main.Street,Hyannis MA 02601 Office: 508-862-4644 Richard Scab,Director FAX: 508-790-6304 Thomas A McKean,CHO Feb 6,-2007 Rev. 7/6/15 DE_ ADLINE$ TO REPAIR FAILED SYSTEMS (Town Code§360-44 and Title V: 310 CMR 15.000) An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑Discharge or.ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year.not due to clogged,.or obstructed pipe _ I ❑ Backe of sewage into the house due to an overloaded or clogged SAS or cesspool p g gg p ONE (1)YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or,cesspool o Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑Any portion of the cesspool within'a Zone 1 to a public well o Any.portion of a cesspool within 50 feet of•a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑Any"conditionally passed systems" (broken cover,relocation of a pipe,relocation of a driveway due to H-10 components..etc) ❑.Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code §360-9.1) OTHER F4-6 ell f�t it Need replAce enl�,. �roker, Dt�a _ Repair deadline: WSEPTIMDEADLINES TO REPAIR FAILED SYSTEMS.doc �,SENbtR:,GOWPLETE • •MPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Signat item 4.if Restricted Delivery is desired. ❑Agent ■ Print your name and address on the reverse X ❑Addressee so that we can return the card to you. B. Received b (Printed Name) C. A of elivery■ Attach this card to the back of the mailpiece, 5��p � p ""or.on the front if space permits. t 9 V 1 D. Is delivery address different fro item 1 ❑ es 1, Article Addressed to: If YES,enter delivery address below: ❑No y Mr. &Mrs.-.'Brian Jones I 265 21Aue. N I Naples;FLj[:34102 I 3. Service Type ❑Certified Mail® ❑Priority Mail Express'" ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑Collect on Delivery 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Articl'e Number ;i {: , ; (transfer from service labeq 7 015,' 15 2 0 2 2 0 1 2 2 7 3 2626 t � PS Form 3811,July.2013 Domestic Return Receipt UNITED STATEStPORALIZI=AVICE First-Class Mail ��,.1 ;; Postage&Fees Paid USPS ` e Permit No.G=10 • Sender: Please print your name, address, and ZIP+4®in this box• i I jTown of Barnstable Public Health Division ! 200 Main Street I Hyannis, MA 02601 I i ! ! =iJ'„`0_ l�i,llilll{sl,i��{.,I' 11J�{�{�itii�+ll��iil11►il�i�l�a>>>lir��i! a Barnstable.. Town of Barnstable * . Regulatory Services Department Q p ELUMSrna MAW 039- . Public Health Division 200 Main Street,Hyannis MA 02601 2007 ti Office: 508-862-4644 z,r _" Richard V.Scali,Director ' FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7014.1200 0001 2273,2626 x January 21, 2016 . Mr. &Mrs:BrianJones 265 2nd Ave N Naples FL 34102- - r RE: Rear System ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 149 East Bay Road, Osterville,MA was last inspected on 11/30/2015,by James D. Sears, a certified septic inspector for the State of -, Massachusetts.-,-, ' The inspection of the septic system showed that the system"Needs Further Evaluation" under the guidelines of 199..5 TITLE 5 (310 CMR 15.00) due,to the following: + Rear system: IF cesspool is collapsing it must be replaced. e Line to,.main cesspool needs to be unblocked. You are ordered to repair/replace the septic system within sixty (60) days from the date you receive this notification: t; Failure to repair/replace the septic system within the deadline period will result in future enforcement action. Per order of the Board of Health s • omas McK[/ean, R.S., CHO X - r , Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\149 East Bay Rd Ost Jan 2016.doc Town of Barnstable lAxrrsrAELE, 9 ,�� Regulatory Services Department "rEa ru►y" - . Public Health Division 200 Main Street,Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 W Thomas A.McKean,CHO Feb 61•2007 • Rev. 7/6/15 DEADLINES TO REPAIR, FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMfZ 15.000) , f An"x"marked in the o is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA o Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. o Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1)YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or.cesspool ❑Any portion of the SAS, cesspool,or privy below high groundwater elevation ❑Any portion of the cesspool within'a Zone 1 to a public welI ❑Any.portion of a cesspool within 50 feet of a private water supply well with no acceptable water.quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑Any"conditionally passed systems'-' (broken cover,relocation of a pipe,relocation of a_driveway,due to H-10 components; etc) o.Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code §360-9.1) OTHERs S , m �. � re(es�uu/ i Pltice�f/.e"T S' s M : LIbiQ_4 wciIri C65 ov ✓1ee/vl 4D e_.7 VIi 41000E Repair deadline: WSEPTIGMEADLINES TO REPAIR FAILED SYSTEMS.doc ��c ,22 2015 1225 Jim The Inspector Man 5085349919 page 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Road (Rear System) 'm Property Address A Diane & Brian Jones Owner Owner's Name information is required for every Osterville MA 02655 11-30-15 page. City/Town 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 A. General Information filling out forms �»w�lrrnrrpr� use onlon the y a tab �e%r ,I 3#61 \.�`� �SN OF RgS key to move your 1. Inspector: �`�� cursor-do not \� .:.... .•���G' James D. Sears �; JAMES• •.m use the return Name of Inspector y Ca ewide Enterprises,LLC P p Company Name %TRTIFC 'O 153 Commercial Street INSPE�� Company Address Mashpee MA 1 02649 CitylTown State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification . I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ❑ Fails ® Needs Further Evaluation by the Local Approving Authority 11-30-15 ;, pectoerr'sSiMgnatre Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. '"""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. • �0/r/�y�w//� VS t5ins•3113 Thle 5 Official Inspection Form:Subsurface Sewage Disposal y5 am Page 1 of 17 Dec .22 2015 1225 Jim The. Inspector Man 5085349919 page 2 Commonwealth of Massachusetts Title 5 Official Inspection. Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 149 East Bay Road (Rear System) Property Address Diane & Brian Jones Owner Owner's Name information is Osterville MA 02655 11-30-15 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A.B,C,D or E/always complete all of Section D' A) System Passes: ❑ 1 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: Two system's-four block c. pool's. Orange Burge pipeing and one septic line in garage going under drive way goes to no ware. Need futher evaluation by B.O.H.. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or,repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old" or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): 15ins•3113 Tft 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Dec _22 2015 12:25 Jim The Inspector Man 5085349919 page 3 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Road(Rear System) Property Address Diane & Brian Jones Owner Owner's Name information required for every Osterville MA 02655 11-30-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ` ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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 P ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ 'obstruction Is removed. ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy Is within 50 feet of.a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t6ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Dec 22 2015 1225 Jim The Inspector Man 5085349919 page 4 Commonwealth of Massachusetts 3 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 149 East Bay Road (Rear System) Property Address Diane & Brian Jones Owner Owner's Name information is required for every Osterville MA 02655 11-30-15 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the'SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 Lj ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow [Sins•3/13 Tdle 5 Official nspection Form:Subsirface Sewage Disposal System•Page 4 of 17 Dec 22 2015 12:25 Jim The Inspector Man 5085349919 page 5 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' 149 East Bay Road (Rear System) Property Address Diane & Brian Jones . Owner Owner's Name information is required for every. Osteryille MA 02655 11-30-15 page. City/Town 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: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed At a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ' ® > The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ 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 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-M3 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Dec 22 2015 12:25 Jim The Inspector Man 5085349919 page 6 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments F 149 East Bay Road (Rear System) Property Address Diane & Brian Jones Owner Owner's Name information is Osterville MA 02655 11-30-15 required for every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently-or as part of this inspection? ® Q 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): NA Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Dec 22 2015 12:25 Jim The Inspector Man 5085349919 page 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface.Sewage Disposal System Form-Not for Voluntary Assessments Y , r 149 East Bay Road (Rear System) Property Address Diane & Brian Jones Owner Owners Name information is required for every Osterville MA 02655 11-30-15 page. cityrrown . State Zip Code Date of Inspection D. System Information Description: The system is two old block c. pool's. Old orange bur a pipein . Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ® Yes ❑ No Water meter readings, if available last 2 ears usage d na 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 15ins•3113 Title 5 Official hspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Dec 22 2015 12:25 Jim The Inspector Man 5085349919 page 8 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 149 East Bay Road (Rear System) Property Address Diane & Brian Jones Owner Owner's Name information.is required for every Osterville MA 02655 11-30-15 page. Cityrrown 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: NA 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): t51ns•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Dec 22 2015 12:25 Jim The Inspector Man 5085349919 page 9 Commonwealth of Massachusetts Title 5 official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 149 East Bay Road (Rear System) Property Address Diane& Brian Jones Owner Owner's Name information is required for every Osterville MA 02655' 11-30-15 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: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 2611feet 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.): pipeing is cast iron and orange burge. Orange burge pipeing is old- in bad shape. W/no in or outlet tee's. Main line is blocked. Line's should be replaced. Note: Blocking in c.pool's around pipeing not solid. 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•3/13 Title 5 Mcial Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Dec 22 .2015 1226 Jim The Inspector Man 5085349919 page 10 Commonwealth of Massachusetts Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Road(Rear System) Property Address Diane & Brian Janes Owner Owner's Name information is required for every Osterville MA 02656 11-30-16 page. Cityrrown 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 15ins•3113 Title 5 Official Ins pection Form:Subsurface Sewage Disposal System•Page 10 of 17 Dec 22 .2015 12:26 Jim The Inspector Man 5085349919 page 11 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments H 149 East Bay Road (Rear System) Property Address Diane & Brian Jones Owner Owner's Name ation Isrequired for every Osteryille MA 02655 11-30-15 page. Cityrrown State Zip Code Date of lnepection 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.): "Attach copy of current pumping contract(required), Is copy attached? ❑ Yes ❑ No t5ins-3/13 •Title 5Oificial Inspeclion Forth:Subsurface Sewage Disposal System•Page 11 of 17 Dec 22 •2015 12:26 Jim The Inspector Man 5085349919 page 12 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 149 East Bay Road (Rear System) Properly Address Diane & Brian Jones Owner Owner's Name information is required for every Ostervllle MA 02655 11-30-15 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.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•.3113 Title 6 Official Inspection Form:Subsurface Sewage Disposed Sys'em-Page 12 of 17 Dec 22 2015 12:26 Jim The Inspector Man 5085349919 . page 13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 149 East Bay Road (Rear System) Property Address Diane & Brian Jones Owner Owner's Name information is required for every Osteryille MA 02655 11-30-15 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: leaching fields number, dimensions: ® overflow cesspool number: 6'x8' ❑ 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.): Over flow is a old block c..pool -6'x8'w/cover at 1' Pool is dry w/no sign of over loading Cesspools (cesspool must be pumper)as part of inspection)(locate on site plan): Number and configuration 1 Depth-top of liquid to inlet invert Dry Depth of solids layer -Dry Depth of scum layer Dry Dimensions of cesspool 6'x8,, Materials of construction Block Indication of groundwater inflow ❑ Yes' ® No t5ins-3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Dec 22 -2015 12:26 Jim The Inspector Man 5085349919 page 14 Commonwealth of Massachusetts I upTitle 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 149 East Bay Road(Rear System) Property Address Diane & Brian Jones Owner Owner's Name information is required for every Osterville MA 02655 .11-30-15 page. CiryfTown 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.): Man pool is an old block c.pool. W/no in or outlet tee's. Pool is dry w/cover at 1". Blocking around pipeing not solid. Pipeing is old orange bur e. Main line is blocked 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•3/13 Title 5 Official Inspecton corm:Subsurface Sewage Disposal System•Page 14 of 17 Dec 22 2015 1226 Jim The Inspector Man 5085349919 page 15 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Road (Rear System) Property Address Diane& Brian Jones Owner Owner's Name information is required for every Osterville MA 02655 11-30-15 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch In the area below ® drawing attached separately t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Dec 22 2015 12:26 Jim The Inspector Man 5085349919 page 16 r f' !V i 1 , M zb Dec 22 •2015 12:26 Jim The Inspector Man 5085349919 page 17 � Commonwealth of Massachusetts . Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 149 East Bay Road Rear System) Property Address Diane& Brian Jones Owner Owner's Name Information is Osterville MA 02655 11-30-15 required for every page. Cityrrown 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. 17'+ feet Please indicate all methods used to determine the high ground water elevation: . �] Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet'of SAS) ® Checked with local Board of Health -explain: ❑ Checked with local'excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground.water elevation: Past report no G.W.10' below bottom of C.pool's Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•3113 Title 5 official Insoect.on Form:Subsurface Sewage Disposal system•Page 16 of 17 Dec 22 `2015 12:27 Jim The Inspector Man 5085349919 page 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 149 East Bay Road (Rear System) Property Address w Diane &Brian Jones Owner Owner's Name information is Osterville MA 02 - - required for every 655 11 30 15 page. City/Town State Zip Code Dale of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Titte 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 17 of 17 Dec 22 2015 12:27 Jim The Inspector Man 5085349919 page 19 Commonwealth of Massachusetts rya /�f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •t t�9 . 149 East Bay Road (Front System) Property Address Diane & Brian Jones 4= Owner Owner's Name x. .information is required for every osterville MA 02655 11-30-15 i• 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 �/ //��� \`\dUnututuunii on the computer; � �� OF use only the tab � ;si4��'��i 1. Inspector: • .Y key to move your S o�:• �G cursor-do not James D. Sears g; JA M ES a use the return key. Name of Inspector = SEARS :—r Capewide Enterprises LLC * ' co VII� II Company Name TIf��4'O�:\ 153 Commercial Street Company Address Mashpee MA 02649 City[Town State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes ❑ Fails ® Needs Further Evaluation by the Local Approving Authority a 11-30-15 erector'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 the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 15ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•pagA'1 1'd Dec -22 2015 1227 Jim The Inspector Man 5085349919 page 20 Commonwealth of Massachusetts Title 5 Official Inspection Form .5 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Road,(Front System) Property Address Diane &Brian Jones Owner Owner's Name information is required for every Osterville MA 02655 11-30-15 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: ❑ 1 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. failure criteria not evaluated lu r Any a ated are indicated below. Comments: Two system's-four block c. pool's. Orange Burge pipeing and one septic line in garage going under drive way goes to no ware. Need futher evaluation by B.O.R. B) System Conditionally Passes, ❑ One or more system components as described in the"Conditional Pass'section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tanK is metal and over 20 years old' or the septic tank(whether metal'or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3113 Title 6 Official Inspection Fonn:Subsurface Sewage Disposal System-Page 2 of 17 Dec 22 2015 12:27 Jim The Inspector Man 5085349919 page 21 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Vo 149 East Bay Road (Front System) Property Address Diane & Brian Jones Owner Owner's Name information is OSteryllle required for eve MA 02655 11-30-1.5 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumpslalarms are repaired. B) System Conditionally Passes (cont.): ❑` Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh (Sins•3113 - Title 5 official Inspection Form Subsurface Sewage Disposal System•Page 3 of 17 Dec 22 2015 12:27 Jim The Inspector Man 5085349919 page 22 t Commonwealth of Massachusetts Titles Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 149 East Bay Road(Front System) Property Address . Diane & Brian Jones Owner Owner's Name information is required for every Osteryille MA 02655 11-30-16 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a.private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 ED than %day flow 15ins 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Dec 22 2015 1228 Jim The Inspector Man 5085349919 page 23 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 149 East Bay Road (Front System) Property Address Diane& Brian Jones Owner Owner's Name information is required for every psterville MA 02655 11-30.15 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: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply O the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 15ins-3/13 Title 5 official Inspection Form:Subsurface Sewage.Disposal System•Page 5 of 17 Dec 22 2015 12:28 Jim The Inspector Man 5085349919 page 24 Commonwealth of Massachusetts Title 5 Official Inspection Form Y e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Road (Front System) Property Address Diane & Brian Jones Owner Owner's Name information is required for every Osteryille MA 02655 11-30-15 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): NA Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 151ns-3/13 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Dec 22 2015 12:28 Jim The Inspector Man 5085349919 page 25 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 149 East Bay Road (Front System) Property Address Diane& Brian Jones Owner Owner's Name information is required for every Ostervllle MA 02655 11-30-15 , page. City/Town State Zip Code Date of Inspection D. System Information Description:. The system is two old block c. pool's. Old orange burge pipeing and one one septic line in garage going out under drive way. Note: Line go's to no wear. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ® Yes ❑ No Water meter readings, if available last 2 ears usage na 9 ( Y 9 (gPd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date CommerciallIndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203), Gatlon5 Per day(gpd) Basis of design flow(seatslpersonslsq.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•3l13 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 117 Dec 22 2015 12:29 Jim The Inspector Man 5085349919 page 26 Commonwealth of Massachusetts a Title 5 Official Inspection Form "s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 149 East Bay Road (Front System) Property Address Diane & Brian Jones Owner Owners Name required fn is every Osteryille required for eve MA 02655 11-30-15 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of oocupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA 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): Other septic line in garage. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Dec 22 2015 12:29 Jim The Inspector Man 5085349919 page 27 Commonwealth of Massachusetts 2 l ug Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Road(Front System) - Property Address Diane &Brian Jones Owner Qwner's Name information is required for every Osterville MA 02655 11-30-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information. NA Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 40"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.): Pipeing is cast iron and orange burge. Orange burge pipeing is old- in bad shape. Two line's in wl no tee's. Both inlet lines are blocked. 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•3/13 Title 5 Official Irspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Dec 22 2015 1229 Jim The Inspector Man 5085349919 page 28 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �= 149 East Bay Road(Front System) Property Address Diane & Brian Jones Owner Owner's Name information is required for every Osteryille MA 02655 11-30-15 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 El 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•3113 Title 5 Official Inspect.on Form:Subsurface Sewage Disposal System•Page 10 of 17 Dec 22 2015 1229 Jim The Inspector Man 5085349919 page 29 Commonwealth of Massachusetts Title 5 Official Inspection Form p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 149 East Bay Road (Front System) Property Address Diane & Brian Jones Owner Owner's Name information is required for every Osteryille MA 02655 11-30-15 page. CitylTown 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.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 15ins•3113 Title 5 Official Inspect an Form:Subsurface Sewage Disposal System•Page 11 of 17 Dec 22 2015 12:29 Jim The Inspector Man 5085349919 page 30 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 149 East Bay Road (Front System) Property Address Diane & Brian Jones Owner Owners Name information ati is every Osteryllle required for eve MA 02655 11-30-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins 3113 Title 5 Otlicial Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Dec 22 2015 1229 Jim The Inspector Man 5085349919 page 31 Commonwealth of Massachusetts - W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Road(Front System) Property Address Diane & Brian Jones Owner Owner's Name information is required for every Osterville MA 02655 11-30-15 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ID leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: 6'x10' ❑ 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.): Over flow is a old block c. pool -6'x10'wlcover at 27". 2"water in pool wino sign of over loading. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 Depth =top of liquid to inlet invert 18" Depth of solids layer 4" Depth of scum layer 0 Dimensions of cesspool 6'x8' . Materials of construction Block Indication of groundwater inflow ❑ Yes ® No t5ins•3113 Title 6 Official Inspection Form,Subsurface Sewage Disposal System•Page 13 of 17 Dec 22 2015 12:29 Jim The Inspector Man 5085349919 page 32 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 149 East Bay Road (Front System) Property Address Diane & Brian Jones Owner Owner's Name information is required for every Cisterville _ MA 02655 11-30-15 page. Citylrown State tip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Main pool is an old block c.pool w/cover at 10". Two inlets w/no tee's. Cast iron out let tee. Both main lines are broken Note: Septic line in garage goes out under drive way. Line go's to no wear. Privy(locate on site plan): a Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i t5ins•3113 - Title 5Official Inspection Forth:Subsurface Sewage Disposal System Page 14 of 17 Dec 22 2015 12:30 Jim The Inspector Man 5085349919 page 33 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 149 East Bay Road(Front System) Property Address Diane & Brian Jones Owner Owner's Name information is required for every Osterville MA 02665 11-30-15 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a'view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3113 Title 6 ONicial Inspection Form:Subsurface Sewage Disposal Syslem•Page 15 of 17 Dec 22 2015 12:30 Jim The Inspector Man 5085349919 page 34 fr . .J A n G"s � c to 1401 Dec 22 2015 12:30 Jim The Inspector Man 5085349919 page 35 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 149 East Bay Road (Front System) Property Address Diane & Brian Jones Owner Owner's Name information is required for every Osterville MA 02655 11=30-15. page. Cityrrown 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: 17'+ 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) t ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Past report no G.W.10'below bottom of c.pool's Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 -Title 5 Official Inspection Farm:Subsurface Sewage Disposal Syslem•Page 16 of 17 Dec 22 2015 12:30 Jim The Inspector Man 5085349919 page 36 Commonwealth of Massachusetts _ Title 5 Official Inspection Form M1 A - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 149 East Bay Road (Front System) Property Address Diane&Brian Jones Owner Owner's Name information is required for every Osterville _ MA 02655 11-30-15 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 t5ins•3f13 Tltle 5 Official Inspect on Form:Subsurface sewage blsposal System-Page 17 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Road M Property Address Brian Jones j Owner Owner's Name information is Osterville Ma. 02655 11/12/2007 required for every page. City/Town State Zip Code Date of Inspection I Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer,use 1. Inspector: �1 only the tab key l5i to move your Robert Paolini cursor-do not Name of Inspector use the return . 1 1 C r_a key. Capewide Enterprises,LLC Company Name r� P.O.Box 763 r' Company Address Centerville Ma. F.02632 " City/Town State FZip Code (508)428-4028 S14454 Telephone Number License Number ' r ' B. Certification I certify that I-have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and,complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 11/12/2007 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 the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time..This inspection does not address how the system will perform in the future under the same or different conditions of use. 149 east bay rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GSM , 149 East Bay Road Property Address Brian Jones Owner Owner's Name information is required for Osterville Ma. 02655 11/12/2007 ' _ every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 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: House has a split system 2 cesspools in front and 2 in back.Septic systems are in.proper working order at the present time. r � B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and.over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved-by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of+Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed 149 east bay rd.•08/06. Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 149 East Bay Road Property Address J Brian Jones Owner Owner's Name information is required for Osterville Ma. 02655 11/12/2007 every page.. City/Town State Zip Code Date of Inspection B: Certification (cont:) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass-inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: 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: J 1 ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy.is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. 0 The system has aseptic 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. 149 east bay rd. 08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 149 East Bay Road Property�Address Brian Jones Owner Owner's Name information is Osterville Ma. 02655 11/12/2007 required for every page. City/Town State Zip Code Date of Inspection B. Certification'(cont.) . 1 C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. Acopy 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 El Discharge-or ponding of effluent to the surface of the ground or surface waters ® due to an overloaded or clogged SAS or cesspool ❑ N� 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 Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary,to a surface water supply. 149 east bay rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 r. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Road Property Address Brian Jones Owner Owner's Name information is required for Osterville Ma. 02655 11/12/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone,1 of a public well. El ® 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, j J 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 exisfas described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in'Section D. Yes No .❑ ❑ the system is within.400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary,to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. ` 149 east bay rd.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 J Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 149 East Bay Road Property Address Brian Jones Owner Owner's Name information is required for Cisterville Ma. 02655 11/12/2007 every page. City/Town 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? El ® 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? ® El Was the facility owner(and occupants if different from owner) provided with information on the,proper maintenance of subsurface sewage disposal systems? _1 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)] 149 east bay rd.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 149 East Bay Road Property Address Brian Jones Owner Owner's Name information is required for Osteryille . Ma. 02655 11/12/2007 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design):. 6 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660 Number of current residents: 2 Does residence have a garbage grinder? , ❑ Yes 0 No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): i 2005:344,000 2006:153 000 Sump pump? ❑ Yes ® No Last date of occupancy: 11/12/2007 Date Commercial/Industrial Flow Conditions: ' Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ 'No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 149 east bay rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 149 East Bay Road Property Address Brian Jones . Owner . Owner's Name information is required for Osterville Ma. 02655 11/12/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Capewide Enterprises,LLC J Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped:. cesspool 1000 gallon gallons How w quantity pumped determined?as qua y o measured Reason for pumping: Check for ground water intrusion. 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) ElInnovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1958 Were sewage.odors detected when arriving at the site? ❑ Yes ® No 149 east bay rd.•08/06 Title.5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 - 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C�M 149 East Bay.Road Property Address Brian Jones Owner Owner's Name information is Osterville Ma. 02655 11/12/2607 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 1 g°feet Material of construction: ® cast iron ❑ 40 PVC ® other(explain): `Orangeberg pipe Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.Systems vented throught the house vents. t 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: 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? 149 east bay rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 r . Commonwealth of Massachusetts u, W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 149 East Bay Road Property Address Brian Jones Owner Owner's Name information is required for Osterville Ma.. 02655 11/12/2007 every 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.): 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 r Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Outlet tees in both cesspools are in place.Pump main cesspools every 2-3 years. 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): 149 east bay rd.•08/06 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 L Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments „M 149 East Bay Road Property Address r Brian Jones Owner Owner's Name_ information is required for Osterville Ma. 02655 11/12/2007 - every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm,and float switches, etc.): Attach copy of current pumping contract(required). is copy attached? ❑ Yes . ❑ No 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 149 east bay rd.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . �M 149 East Bay Road Property Address Brian Jones Owner Owner's Name information is required for Osterville Ma. 02655 11/12/2007 i every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ , leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: 2 ❑ 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.): 149 east bay rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 149 East Bay Road Property Address Brian Jones Owner Owner's Name information is required for .Osterville Ma. 02655 11/12/2007 , every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 4/2 main and 2 overflow Depth—top of liquid to inlet invert Front CP Full Back CP Empty Depth of solids layer Front 4" Rear 10" Depth of scum layer Front 3" Rear 0" Dimensions of cesspool F/6'x8',8'x10' R/2/6'x8' Materials of construction Concrete block , Indication of groundwater inflow ❑ Yes '® No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Sandy dry soil.No signs of hydraulic failure.Front main cesspool was full.Front overflow cesspool water to invert was 47".Back cesspool and overflow cesspool were dry at time of inspection. Privy(locate on site plan): R Materials.of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 149 east bay rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts' W Title 5 Official Inspection Form W Subsurface Sewage Dispolsal System Form - Not for Voluntary Assessments . 149 East Bay Road Property Address / 1 Brian Jones Owner Owner's Name information is required for Osterville Ma. 02655 11/12/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. wdk r 1 149 east bay rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts , W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 East Bay Road M Property Address Brian Jones Owner Owner's Name information is required for Osterville Ma. 02655 11/12/2007 every 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 ground water: Bottom of Cesspools 10' 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: http://town.barnstable.ma.us. You must describe how you established the high ground water elevation: USED:Gaherty& Miller Model 12/16/94 ground water elevations above sea level. USED:USGS Observation well data June 1992.USED::Technical bulletin 92-000-01 plate#2 annual ranges of ground water elevations. 149 east bay rd.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Town of Barnstable OF THE Tp� hP� do Regulatory Services Thomas F. Geiler,Director MMA�$ 9. �0� Public Health .Division �rED MA'S p Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts; Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms a " roved at a articular roe would-be listed pp p property rtY st don the Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. • c DATE:5/28/03 PROPERTY ADDRESS:149 Eazt Bay_ oad_______ RECEIV�� 0%te2viPPe, Na,3.6. ---------------------- = - - JUN 0 4 2003 -0. -65-5- -- ' ------------- TOWN OF BARNSTABLE HEALTH DEPT. On the above date, I inspected the septic system at the above address. This system consists of the following: 7. T2ont 6y-6tem. 7-6 'X8 ' &Pock ce•s.s/2oo2 & 7-8'X10' ce.6,612ooP. (Ovea'z.Pow. 2. /?ea,z 6y,6tem. 2-6 'X8' &-Pock ce.6.6/2ooiz in ze2iez. MAP VV I*0 Based :on my inspection, I certify the following condition ARCE� 5 3. 7hi.h .i.6 not a i-i.t-Pe P—ive aept.ic .6yztem. SOT 4. 7h.iz .i.6 ' a Sewage .6y,3tem. 5. The •sewage .6yztem is in Pao/2e2 wo2k.ing oade2 ---�� at the flae,6ent time. SIGNATURE: *Iz f 2+ - Name:_J_P _ Macomber Jr ._—__ Company: Jose-ph_P_ Macomber_& Son , Inc . Address: Box 66 - Centerville , Ma . 02632-0066 -------------------- Phone: 508-775-3338 THIS CERTIFICATION DOES NOT CONSTITUT&A GUARANTY OR WARRANTY a JOSEPH P. MACOMBER & SON, INC. Tan ks-Cesspools-Leachflelds Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775-3338 775-6412 • ' COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ,i TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Nancy 13o zg ta.6t Bay Road Owner's Name: ear e e, N ah,6. U76 5 5 Owner's Address: Same- Date of Inspection: Name of Inspector: (please print)lozeph P.. Nacom&ea aa. Company Name:. P oacom&e2 & Son Inc. Mailing Address-/30x 66 C ¢nfea)) LPe, MrjAt 02632 Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: _4 y l Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fa Is Inspector's Signature: r Date: The system inspector shall Zmit a copy of-this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner.shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 14 9 Ea,3 t Bay. Road eay.c 11 Z e, M ahT. Owner: Nancy 13o2g Date of Inspection: 5128103 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. e'm Passes. f ,00 1 have not found any information which indicates that any of the failurecritt� r)'a described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not'evaluated are;indicdted�6elow, Comments: 7_he._ iv_waap iu�31arn i,3 .in RaoRe2 woak.ing iho paeA of 7la0 b i B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. Xbl)l�;The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally, unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A•metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: A?WObservation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3ofII OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A , CERTIFICATION(continued) Property Address:14 9 f¢,6.t /3a y 1?o¢cl 0�te2vcQQe, ('la.6.6 Owner: Nancy Boaq Date of Inspection: 5128103 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: /1�J Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health,safety and environment: AJd 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. .(mod The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. 40 The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 10 The system has a septic tank and SAS and the SAS is less than 1 OQ feet bu 0 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria 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. Other: 7h.L6 -Lh a 612P.it zyz. em. Rea2 0)e houze. 2-6 'X84 &Lock c sn/zooP In .ton.iv.s Tn 4nnni 9 6 ' XR PPnrk n¢aG,QnoR a n d n n o R' X 9 n' 0. 0 n t-k C_¢_A L�n n n L�b-.— —6-g1b..b.g g�I 3 Page 4 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 149 Ea.6t Buy Road b t e/tL) e, a.bb. Owner: Nancy o2g Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes ��a ckup of sewage into facility or system component due to overloaded or clogged SAS or cesspool scharge 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 /Lilquid sspool depth in cesspool is less than 6"below invert or available volume is less than '/ day flow equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number ,eff times pumped_0 Any portion of the SAS,cesspool or privy is below high ground water elevation. — Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. — Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but eater than 50 feet from a private water P �'Y B — supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free 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.) lt,lJ (YesfNo)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. 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 a system is within 200 feet of a tributary.to a surface drinking water supply — — the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—1WPA)or a mapped Zone 11 of a public water supply well If you have answered"yes';to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304, The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 7 4 9 E¢zt Bay 12oad ,6 t e,zL.i e, aza. Owner: Nancy 2371g Date of Inspection: 3 Check if the following have been done. You must indicate`yes"or"no"as to each of the followine• 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 ? v _ Has the system received normal flows in the previous two week period ? Have large volumes of water been introduced to the system recently or as pan of this inspection ? /Were as built plans of the system obtained and examined?(If they were not available note zi( /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,Were the SAS, located on site? _aZVWere 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 ? ,/th _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no , � Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of d is unacceptable) [310 CMR 15.302(3)(b)) pP distance r 5 Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 14 9 Ea.6 t /3at/ /toad 0�.te2v•i-�.�e, l'1a�s�s. Owner: Na n c u d o a Date of Inspection: 5/,,)3/0 FLOW CONDITIONS RESIDENTIAL ' Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): 6709D Number of current residents: Does residence have a garbage grinder(yes or no): • 13 Is laundry on a separate sewage system(yes or no):i✓d (if yes separate inspection required) Laundry system inspected(yes or no): Seasonal use: (yes or no):�t/c) Water meter readings, if available(last 2 years usage(gpd))?001—6 3, 000 ya-Q Pori,- 1 72. 6 1 gl)D Sump pump(yes or no):X),O = ya-Uonh= 126. 03 qPD Last date of occupancy: .—AdludIdL COMMERCIAL/INDUSTRIAL Type of establishments 14M Design flow(based on 310 CMR 15.203): 04 gDd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no):A /F Industrial waste holding tank present(yes or no):XA Non-sanitary waste discharged to the Title 5 system(yes or no):f� Water meter readings, if available: X16+7 Last date of occupancy/use: OTHER (describe): A-M Pumping Records GENERAL INFORMATION l 99 rm Source of infoation: _r 7 Was system pumped as part of the inspection(yes or no):" If yes, volume pumped:_gallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM �D Septic tank, distribution box, soil absorption system Single cesspool Overflow cesspool s 4)d Privy Kb Shared system(yes or no)(if yes,attach previous inspection records, if any) 4-'i)Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) X4?Tight tank A$ Attach a copy of the DEP approval /1J!)Other(describe): ,1JJ Approximate age of all cgjnponents, date installed (if known) and source of information: Were sewage odors detected when arriving at the site(yes or no):44 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: 149 Eazt 13au /toad 0,6t e2y.i�e.Qe, Pia,3,3. Owner: Nancu Bo2g Date of Inspection: 5128103 BUILDING SEWER(locate on site plan) 4" 02nagegeag pil2e 9 Depth below grade:' 9 � titt.ing6 th2ough out Materials of construction: cast iron �d40 PVC s/other(explain): j h v J ,,o Auzinmz, Distance from private water supply well or suction line: f Comments(on condition of joints, venting, evidence of leakage, etc.): 1oin1-6 aR12ea2 tight No evidence of leakage The zt/ztemz ate vented th2ough the houze ventz. SEPTIC TANK4 tie{locate on site plan) Depth below grade: 4_ Material of construction:,concrete 00 metal 4�jfiberglass,t�olyethylene .(,,fother(explain) A/A If tank is metal list age: �/� is age confirmed by a Certificate of Compliance(yes or no),, (attach a copy of certificate) Dimensions: A1,�Q Sludge depth: i// Distance from top of sludge to bottom of outlet tee or baffle: AIA Scum thickness: _ Distance from top of scum to top of outlet tee or baffle: itlr4 Distance from bottom of scum to bottom of outlet tee or baffle: How.were dimensions determined: e—* Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as r lated tR outlet invert, evidence of leakage, etc.): C,21ni r frank iA nnf nnoAonf GREASE TRAP,II_6ocate on site plan) Depth below grade:lA Material of construction:140concrete/ metal�Afiberglass• polyethylene4/Aother (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: A10 Distance from bottom of scum to bottom of outlet tee or baffle: elA Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): 7 Page 8 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 149 Ea,3 t Bay /toad (2A 1 9R)) 0LP 170 jA Owner: -tia a c,, Pn a�l Date of Inspection: 5128,1 n3 TIGHT or HOLDING TANKll"mnk must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction:&Aconcrete X4 metal 64 fiberglass N olyethyleneV4 other(explain): Dimensions. Capacity: gallons Design Flow:E4. gallons/day Alarm present(yes or no): Alarm level: -M Alarm in working order(yes or no): AM Date of last pumping: Comments(condition of alarm and float switches, etc.): 71rrht .tanks ate no-t /?/ze.6ent DISTRIBUTION 130?0(�/ if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_(i� Comments(note if box is ievel and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box,etc.): DIAiniPUi10 n &ox .ie not /?neZent PUMP CHAMBERrQ&Z(locate on site plan) Pumps in working order(yes or no): 1)/4 Alarms in working order(yes or no):� Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): l� i .c nnf nno%onf 8 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:749 Eaet l3ay Road O�te2u.i.P.Pe, l'la��s. ' Owner: lVancrd i3o/�u Date of Inspection: 5/28/0 3 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) 72onit= l-6 'X8' 9 18 'X10' ce�3zpooez. 13ack=2-6 'X8' giock ce,3.a/?ooiz If SAS not located explain why: Located: See Rage 10 Type AM leaching pits, number: C> leaching chambers, number: ,A leaching galleries,number: AJO leaching trenches,number, length: 3 22�)eaching fields; number, dimensions: overflow cesspool, number: ,tL)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.): CESSPOOLS: ZZ(Cesspool must be p ped as part of ection)(locate on site plan) ltiu Number and configuration: L L/ e ,e ,y Depth—top of liquid to inlet'invej-t: " '/ �_ — Ag'-*l e,v&�,o Depth of solids layer: Depth of scum laver: Dimensions of cesspool: e .6,�8__ Materials of construction: Indication of groundwater inflow(yes or no): D Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Loamy .Sand to medl.ium fine zancl. No zigne o� hydAau.P.ie �a.iivae .n,7 onnrJinC� VPr�Ptr/.Z`./ O o ma.L PRIVY (locate on site plan) Materials of construction: Dimensions: i Depth of solids: Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition o(vegetation, etc.): i A nn} inn e/ion f 9 Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 14 9tt Fast d Owoer: Nrnry /3o.? Date of lnspectioo: �T SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public.,water supply enters the building. lyq East y lZoa�l (gs-�e���'11�e From - of w�Gf r�w-zR c� �q/ 10 Page 11 of I 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 149 Eaz t Bay Road e2v7 e, 77 a.6.6. Owner: Nancy 130.,Zg , Date of Inspection: 03 SITE EXAM Slope Surface water Check cellar Shallow wells 1 Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: N() Obtained from system design plans on record-If checked,date of design plan reviewed: NR q Observed site(abutting property/observation hole within 150 feet of SAS) N() Checked with local Board of Health-explain: NA Checked with local excavators, installers-(attach documentation) Accessed USGS database-exp lain:.Ai I n .jLfown 0.nnn AtaP.Pe. ma. uh. You must describe how you established the high ground water elevation: U,6ed: Gah2e.ty � PIi.PPe2 Nodee. 12116194 G2ound wa.tea e-Peva .ionz agove sea .PeveP. U,�ed: USQ: OPee zvat.ion we i data. Tune 1992 U,3ed: IISC.S: 7echnicaP &u.P.Pet.ia 92-000- 1 P.Pa.te #2 lanua2y Janua2y 1992 Annua0 Rrpge 5 cP gaounrd wriiPlt oPevat.ion,6. n 4-cea,6/2ooP6 1G Feet Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore,the vertical separation distance between the bottom Of the leaching pit and the adjusted groundwater table is 6G feet. 11 `` nrnr+.-nt'r�.'-TT\tnrmr•..taw+•o-+rrt 'enmlrr.7e+:*R�rt1RT71rrrsrrnlu Tl�7rtntRn .. V TOIN OF Bann�ta��e BOARD OF HEALTH 1 ,SUDSURFACF SEHAGE D1SPU,SAL ,SYSTEM' INSPECTION FORM - PART D •- CERTIFICATION I•••4T1.7•'-„1_T.1.II,��TTt.Tr.n•11.1s1rlTlrs+rrnlmr—\-1r{tRT../r'IRn-TTR,e.pr,R..n...wA�� _ PnnnYnsrrnsl�+T�T.Rr.S•.-.r r.-•r•1. �. A ' -TYPL OR PRINT C1.EARLY- PROPERTY INSPECTED STREET ADDRESS 149 Ea,64 Day Road Oz4Q2v.iiie, 17a,6Z. ' ASSESSORS MAP, BLOCK AND PARCEL # 140- 159 OWNER' s NAME Nancy /3o/zu PART D - CERTIFICATION 1 NAME OF INSPECTOR Joseph P. Macomber Jr. COMPANY NAME Joseph P. Macomber & Stlfi ' Inc COMPANY ADDRESS Box 66 Centerville Mass 02632 Street Town or City state SLIP COMPANY TELEPHONE ( 508 ) 775 - 3338 . FAX ( 508 ) 790 _ 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at arlecoinmenda his address and that the information reported is true , accurate , and omplete as of the time of -inspection . The inspection was performed and any tiOtis 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 Lhe environment as defined in 310 CMR 16 . 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* \\ The inspection w1lich I have con t-icted has found that the system fails to Protect the j)ublic he-alth and the environment in accordance with Title 5 , 310 CMR 1.5 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this . inspection fo m . Inspector Signature ADate Xnecopy of this tification must be provided to the OWNER, the BUYER re applicabl and the DOARD OF HEAL'i'll. * If the inspection FAILED, the owner or""operator shall upgrade within one year of the date of the inspection , unless allowwedortrequiredm otherwise as provided in 3.10 CFiR 16 . 305 . partd . doc j 4,9 SEWAGE INSPECTIONS to-o. LOCATION - Ca,3t Bay Road DATE .5128103 VILLAGE 0,6teZv.ii te, 1Pa.6.6. ASSESSOR'S MAP & LOT 140- 159 -INS#%ECTOR 7o.6eph %. N comCe2 a2. SEPTIC TANK CAPACITY None 1-6'X8' Ce.6.6/2ooe.6 F/zont .6y6tem LEACHING FACILITY: (type)nd 9-8'X l 0' Ce.s,3/2o o,iz Rea z 6 y,34em ha. NO. OF BEDROOMS 5 BUILDER OR OWNER Nan�U 3oag OWNER MAILING ADDRESS -Same r r 14`i �ast��y '�a�ci �s-+�rvi1��' Z 203 498 561 US PostaTService Receipt for Certified Mail No Insurance Coverage Provided. Do not use for International Mail See reverse Sent to Stre r !2 hoe° P0§1office,State &ZIP C 'e/ Postage $ Certified Fee Special Delivery Fee Restricted Delivery Fee rn Return Receipt Showing to Whom&Date Delivered a Return Receipt Showing to Whom, Q Date,&Addressee's Address 0 TOTAL Postage&Fees $ co M Postmark or Date n a Stick postage stamps to article to cover First-Class postage,certified mail fee,and charges for any selected optional services(See front). 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attached, and present the article at a post office service y window or hand it to your rural carrier(no extra charge). In 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the QQ) return address of the article,date,detach,and retain the receipt,and mail the article. 1 LO 3. If you want a return receipt,write the certified mail number and your name and address on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article a RETURN RECEIPT REQUESTED adjacent to the number. Q 4. If you want delivery restricted to the addressee, or to an authorized agent of the O O addressee,endorse RESTRICTED DELIVERY on the front of the article. M 5. Enter fees for the services requested in the appropriate spaces on the front of this E receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. ri 6. Save this receipt and present it if you make an inquiry. 1 o25s5-s7-a-ot 45 a Town of Barnstable • BARNSTABLF, 9 MAS Department of Health, Safety, and Environmental Services �pr i639' A\0 13� Public Health Division P.O. Box 534, Hyannis MA 02601 Office: 508-790-6263 Zhomas A-McKean,RS,CHO FAX: 508-790-6304 Director of Public Health August 31, 1998 Mrs. Nancy& Linda Borg 125 Arnold St. E.Providence, RI 02915 NOTICE TO ABATE VIOLATIONS OF THE TOWN OF BARNSTABLE REGULATION REGARDING FUEL AND CHEMICAL STORAGE SYSTEMS Our records indicate that you have an old underground fuel oil tank located at-L49_E._Bay Rd.,, Osterville, MA . This tank is listed on Parcel 140 on Assessor's Map 159 and registered as tank tag 9 374. This tank is located in a critical zone of contribution to our public drinking supply and tank is 20 years old or older._You must have vour underground tank removed within 30 days from the receipt of this order letter. For the removal of the tank you must first obtain a removal permit from the Fire Department. I have enclosed tank removal information for you. Upon removal of your tank, please return valve tag 9 374 to the Health Department. You may request a hearing before the Board of Health if written petition requesting same is received within seven (7) days of receipt of this notice. Sincerely yours, cKean Director of Public Health Enclosure: Tank Removal Information c, TOWN OF BARNSTABLE LOCATION 7 y � - �, Qom, SEWAGE# e0Z/ 9®1a VILLAGE r V( ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. a(C�j '� SC -gC�Sz! SEPTIC TANK CAPACITY LEACHING FACILITY:(type) i Q'bAIM k7_ (size) NO.OF BEDROOMS OWNER e( CU; PERMIT DATE: Q7,1 COMPLIANCE DATE: ,� 1 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY a r vs B 4 s 66 r/z m SENDER: I also wish to receive the V. ■Complete items 1 and/or 2 for additional services. tp ■Complete items 3,4a,and 4b. following services(for an ' ■Print too ou.ame and address on the reverse of this form so that we can return this extra fee): card ■Attach this form to the front of the mailpieoe,or on the back if space does not 1. ❑ Addressee's Address permit. m ■Write'Retum Receipt Requested'on the mailpieoe below the article number. 2, ❑ Restricted Delivery rn -S ■The Return Receipt will show to whom the article was delivered and the date,: a c delivered. Consult postmaster for fee.., m v 3.Article Addressed to: 4a.Article Number IZ� � 4b.Service Type v ❑ Registered [ Certified cc a W �� �� �CPi Express Mail ❑ Insured 1 1 �i ❑ Return Receipt for Merchandise ❑ COD 11 Date of Delivery z �.-,* >- p 5.Received By:(Print Name) Addressee's Address(Only if requested 19 W and fee is pai© 6d) t 6.Signatur (Addressee or Age 1S 0 Ps For,3811, December 1994 i t Tl 102595-97-8-0179 Domestic Return Receipt UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid USPS Permit No.G-10 • Print your name, address, and ZIP Code in this box O Public Health Division Town of Barnstable-:-, PO Box 534 Hyannis, Massachusetts 02601 Fax(508)775-3344 Phone(508)790-6265 {li n Irk{i{r{{�.,{{rier�rr{{{{rilr{'i{fry{tll�illYlr�7lfr rt i { : r : { i , I ; I I r L IOP : I : I I : : I RGA I f Oil , I i I P : y I �� /N EXiS�ivLG,C -r -� I t t I I I I .. ... i... I. .. .: L... .L.. I , .-,. .� I IFL r I I i . y _j TO - - NS� �N GEoN ��Eru9iU� • C �X�sf'�Ncr (1FNiN[s'' I I � o , : I I 1. : O THE OIL . p.0 i • (Hereinafter referred to as Company or Seller) INSTALLATION ORDER Date..... .... ..........19 .J. Kindly enter my order subject to the terms and conditions on the front and back of this page. DESCRIPTION OF EQUIPMENT 7_01 6r::� ............Tangible Personal Property............................... Engineering,.Installation,Service To be furnished and installed by you at:. Total........................•.........•....... (o� Ae t..... / .F.................................. .........t .... :...........V J / .........?W ........ ....................................... .. City..... Number Street or Avenue or lbvm State LIMITED WARRANTY:It is understood that this equipment is warranted against defects to the-extent of the LIMrrED:WARRANTY,a copy of which is attached hereto,made part hereof,and incorporated into this Installation Order by this reference;-, In consideration for the equipmentlinstallation described above Uwe agree to pay Company the Total Cash Price as reflected below: .,,.Cash Price $ Sales Tax $ G Replacement bf the heating unit will be performed after ASBESTOS has been removed,at Buyer's qp� -: Total Cash Price $ W expense,by a licensed ASBESTOS removal contractor,and disposed of in accordance with Less Cash Down Payment $ government regulafions.Price does not include ASBESTOS removal. Unpaid BMror of Cash Price $ ,/ 'W Payable: thly installments of$ d0 , commencing on or about 3D S TERMS:Payment due upon receipt of statement.In the event Uwe do not make payments when due,Company may declare the entire unpaid balance Intn at I ue andable.IIWe also understand that if Vwe do not make payments in,accordance with stated terms,Uwe may become obligated to pay costs of collection,including reasonable attorneys fees,as permitted by law. NOTICE TO BUYER: 1. Do not sign this Agreement if any of the spaces intended for the agreed terms are left blank. 2. You are entitled to a copy of this Agreement at the time you sign it. 3. You may at any time pay off the full unpaid balance under this Agreement. 4. You may under certain circumstances redeem the property,if repossessed because of your default,and you may,under certain conditions,require a resale of the property it repossessed. 5. The seller has no right to unlawfully enter your premises or commit any breach of the peace to repossess Goods purchased under this Agreement 6. YOU MAY CANCEL A PURCHASE UNDER THIS AGREEMENT IF IT HAS BEEN CONSUMMATED BfA PARTY THERETO AT A PLACE OTHER THAN THE ADDRESS OF THE SELLER WHICH MAY BE HIS MAIN OFFICE OR BRANCH THEREOF:PROVIDED,YOU NOTIFY THE SELLER IN WRITING AT HIS MAIN OFFICE OR BRANCH BY.ORDINARY MAIL POSTED,BY TELEGRAM SENT OR BY DELIVERY,NOT LATER THAN MIDNIGHT OF THE THIRD BUSINESS DAY FOLLOWING A PURCHASE UNDER THIS AGREEMENT. SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. 7. THIS TRANSACTION MAY GIVE COMPANY A LIEN ON YOUR PRINCMA`DWELLING.SEE SEC.2&3ON REVERSE SIDE FOR DESCRIPTION OF SECURITY INTEREST RETAINED BY COMPANY IN GOODS PURCHASED PURSUANT TO THIS AGREEMENT AND EXPLANATION OF LIEN ON PRINCIPAL DWELLING.YOU SHOULD READ THOSE SECTIONS BEFORE SIGNING THIS AGREEMENT. BUYER(S)ACKNOWLEDGE RECEIPT OF(a)AN EXACT COPY OF THIS ORDER SIGNED BY SELLER'S REPRESENTATIVE AND COMPLETELY FILLED IN WHERE APPLICABLE PRIOR TO BUYER'S EXECUTION,AND(b)TWO COPIES OF NOTICE OF CANCELLATION,OR NOTICE OF RIGHT TO CANCEL(as appropriate). Signed' C;�.(� �f In Presence of (Buyer) Signed Accepted on ��' 19 • ) (Co-Buyer-if any) Billing Address: (On behalf of COMPANY) THE TERMS OF THIS AGREEMENT ARE CONTAINED ON BOTH SIDES OF THIS PAGE. Form 22 9.7.83 NO`J6"7 THE A Town of Barnstable MASS. Board of Health ,erEp A P.O. Box 534, Hyannis MA 02601, Office: 508-8624644 Susan G.Rask,R.S. FAX: 508-790-6304 Ralph A.Murphy,M.D. Sumner Kaufman,M.S.P.H. To: BORG,NANCY J& Date Monday,March 05,2001 BORG,LINDA A P O BOX 113 OSTERVILLE M 02655 RE:Underground Storage Tank at 149 EAST BAY ROAD Map Parcel: 140159 Tank NO: 01 Tag NO: 00374 Our records indicate that your underground fuel(or chemical)storage tank is over 30 years old,and has not been removed as required by section 03: subsection 2 of the Town of Barnstable Health Regulation regarding fuel and chemical storage systems. You are directed to remove this tank sixty(60)days from the date of this notice. After your tank is removed, please furnish this office evidence in the form of a permit from your local Fire Department within ninety(90)days of the receipt of this notice. You may request a hearing provided a written petition requesting same is received by the Board of Health within ten(10) days after this order is served. Per Order of the Board of Health Thomas A.McKean,RS,CHO Health Agent THE TOWN OF BARNSTABLE T O�y� OFFICE OF = BAH3STOBL BOARD OF HEALTH y MAs s. p� ao0 MnY' �m 367 MAIN STREET HYANNIS, MASS.02601 March 26, 1999 Nancy Borg 149 East Bay Road Osterville, MA 02655 Dear Ms. Borg: The Board of Health is in receipt of an "installation order" dated March 19, 1999 in regards to the installation of a 275 gallon oil tank in your basement. However, it appears that the underground oil tank, which is greater than 40 years of age, would remain in the ground. The contents of that oil tank will be pumped at the time of the installation of the new basement tank. You are ordered to remove the underground storage tank from the ground at the time you transfer this property to another owner, or sooner if possible. This order shall be recorded on the deed at the Barnstable County Registry of Deeds. If you should have any questions, please feel free to call the Public Health Division Office at 862-4644. Sincerely yours, (usa'n G. Ra , S. Chairperson Board of Health Town of Barnstable SGr/bcs borg Town of Barnstable oFt T Regulatory Services Thomas F. Geiler,Director Public Health Division BARNSfASLE, Thomas McKean,Director 9Gb �63; 200 Main Street, Hyannis,MA 02601 ArFD MP'i A Phone: 508-862-4644 Email: health(a)town.barnstable.ma.us Fax: 508-790-6304 Office Hours: M-F 8:00—4:30 February 1, 2006 Mr.Frank Puzio 60 A Grand Ave. Falmouth,MA 02540 Dear Mr. Puzio: Recently a letter has been released to homeowners and commercial business owners regarding the removal-of,Underground=Storage Tanks(UST). When removals, abandonment,and testing of the tanks have'occurred;'our electronic files are updated. We have found that many files have not been correctly updated and/or the proper notification was not received by our Department. Out,records.indicate'thaf"you,have been contacted several times regarding an underground fuel oil tank_located at'349 East Bay Road, Osterville,MX This tank is listed on Parcel 140-on Assessor's Map 159 and is registered with the Health Department as tank tag#374. We do not have record showing the tank was ever removed. This tank is located in a critical zone of contribution to our public drinking supply and this tank is well over 20 years old. It is necessary for us to update our records at this time and in order to do so; we will need the proper documentation of the removal if any. If we do not hear from you or receive information regarding this tank, corrective action shall be taken. Should you have any questions, comments, of if you need further information, guidance or assistance,please do not hesitate to contact the Public Health Division. Sincerely, hTRI;.. ......... } my .. T onlasA.'i1 Keari,'RS,,C. '^ ,-i a�.a [ E i Director of Public.Health F. .... i� R'� momw .°``"e r � Town of Barnstable Public Health Division NA BARNnAB L e0 79. 200 Main Street �, .' "•. a�4��« i�FY'iVi'BOWES Hyannis, MA 02601 �`��0 �V __. . Aff 0.3,90 . 0004606238 FEB02 2006 MAILED FROM ZIPCODE 02601 a� ►n9R l . I.�, �•,�'. �, e'et,an3�''�,��ttltttt�.��. fat:'i_..��ittashaLi?it•�t�ist_st tit s: Town of Barnstable OFZNE T Regulatory Services ��► p � Wti Thomas F. Geiler,Director Public Health Division *' aaxrrsraB *k E Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 �;rE�,N10►'l�A,� -Phone: 508-862-4644 Email: health(c�town.barnstable.ma.us Fax: 508-790-6304 Office Hours: M-F 8:00—4:30 February 1, 2006 Mr.Frank P_uzio 60 A and Ave. Gr Falmouth,MA 02540 Dear Mr. Puzio: Recently a letter has been released to homeowners and commercial business owners regarding the removal of Underground Storage Tanks(UST). When removals, abandonment,and testing of the tanks have occurred, our electronic files are updated. We have found that many files have not been correctly updated and/or the proper notification was not received by our Department: Our records indicate that,you have.been contacted several times regarding an underground fuel oil tank located at 149 East Bay Road, Osterville,MA. This tank is listed on Parcel 140-on Assessor's Map 159 and'is registered with tthe Health Department as tank tag#374. We do not have record showing the tank was ever removed. This tank is located in a critical zone of contribution to our public drinking supply and this tank is well over 20 years old. It is necessary for us to update our records at this time and in order to do so; we will need the proper documentation of the removal if any. If we do not hear from you or receive information regarding this tank, corrective action shall be taken. Should you have any questions, comments, of if you need further information, guidance or assistance,please do not hesitate to contact the Public Health Division. Sincerely, Alisha L. Parker Hazardous Materials pecialist T omas A. McKean,RS, C Director of Public Health t E TOWN OF BARNSTABLE �OQ N Taw OFFICE OF HJHd9TdHL i BOARD OF HEALTH o°,ems 1639. `em 367 MAIN STREET CEO MAY k. HYANNIS, MASS.02601 a February 12, 1999 Nancy Borg P. 0. Box.113 Osterville, MA 02655 Dear Ms. Borg: You are granted an extension of time, six (6) weeks, until March 23, 1999 to completely empty the oil contents from your underground fuel storage tank. Then you will be required to remove the underground fuel storage tank from the ground within two years, on or before March 23 2001. This extension is granted because you testified that additional time is needed due to your financial situation and the amount of time it takes to obtain a loan from the Federal Farmers Home Loan Administration. Sincerely yours, Aa � /h M, Acting'C airman Board of Health Town of Barnstable RAM/bcs - borg 3 lk `M e. 4cn.N tt\a_ o i t -��k S T t V o \a�\c lr \At s- USA32 !'SO Mq a r�., „y Pm J 21 0,1 ®� iL ��•��.�i'J w�.+ Ill.ltlil'!�1'�11 �11111111111'fill 11.%III 11111.1111111 �a � ff ' II li � � iil � li � ifil� ii � I�� i li - i �, ii 11II 11 1 � iy r .. - _ C i �` A �, i _. __ _. _ _ ._. . - _ - _. �__.�. �. J ) ., I! :..- ... .. � ... .. ���/ � HIM ] -81 H E A .L T H M A S T E R ] HELP [ ] R E C O R D ] ACTION Cl For Parcel Number 1401 1591 ] ] Rental Property(Y/N) [ ] Owner Name BORG, NANCY J & ] Zone of Contrib (Y/N) [N] Location 149 E BAY RD OST ] Contaminant Rel (Y/N) [ ] Business Name [771-1189 WORK ] Area Number Contact Person [NANCY BORG ] Phone [000] [42862231 Fuel Storage Tank Permit [N] Card on File [Y] Perc Test Well Septic File/Permit No. [ ] [ ] [ ] Issuance Date [ ] [ ] Completion Date [ ] [ l Last Communications [0401881 (MMDDYY) Comments [ ] Cancel [ ] NEXT SCREEN [HM ] ACTION [ ] PARCEL NBR [ ] [ ] [ ] TANK NBR [ ] ] TANKS] • 7] FUEL STORAGE TANK RECORDS ] HELP [ ] FOR PARCEL NBR: 1401 1591 ] ] MAIN ACTION C] Action Tank Nbr Tag Nbr Installed Location ----Notification Dates----- [ ] [ 1], [ 3741 [0101571 [B ] Test ] Rem 1123981 ---- Test --- --Abandoned-- -- Removed -- -- Variance - Fuel Reason Capacity Constr Status Leak-Det Cath-Det [D ] [H ] [ 5001 [SS] [MR] [N] [N] Additional Details [WILL BE REMOVING (8/88) ] -------------------------------------------------------------------------------- Action Tank Nbr Tag Nbr Installed Location ----Notification Dates----- [ ] [ ] [ ] [ ] [ ] Test ] Rem ] ---- Test --- --Abandoned-- -- Removed -- -- Variance - Fuel Reason Capacity Constr Status Leak-Det Cath-Det [ ] [ ] [ I ] [ ] [ ] [ ] [ l Additional Details [ ] -------------------------------------------------------------------------------- Cancel [ ] END OF DATA NEXT SCREEN [HMENU] ACTION [ ] PARCEL NBR [ ] [ ] [ ] ] TANK NBR [ ] Make licaon to local re Fire Department retains orig nal applications andissues dupartmenplicate as Permit. � � --- ;s APPLICATION and PERMIT for storage tank removal and transportation of M.G.L. Chapter 148, Section 38A 27 CMR 9.00, application sank dispohereb sal r mla accordance with the provisions Y de by: Tank Owner Name(please print) Nancy Borg X Address 149' East Bay Road Osterville, MA 02656 9nalurepapp9a���� Sneer City • • • Stare Z(p Company Name Enviro—Safe Corporation Pnn� Co. or Individual. Enviro—Safe Corp Address 14B Jan Sebastian Drive P11111 Sandwich, MA OZM3 Address 14B Jan Sebastian Dr, Sandwich, MA Signature(if I ' g fo pe t) Pmt Signature(if applying for pe it) ❑ IFCI•Certified Other ❑ IFCI'Certified ❑ LSP# AQA Other Tank Location 149 East Bay Road, Osterville, MA S(ee(Add�ass Tank Capacity gallons) 500 cry Substance Last Stored #2 o i 1 Tank Dimensions(diameter x length) Remarks: J4 1 ------------ • Firm transporting waste Enviro—Safe Corporation State Lic.# 329 Hazardous waste manifest# MAN799759 E.P.A.# MAD985269323 Approved tank disposal yard Turner Salvage Tank yard# 002 Type of inert gas Tank yard address 235 Commerc:i al Street, Lynn, MA Conservation Dept. : City or Town �Pn _e,.v;1 1 e Date FDID# �192_�_Permit# May 8, 2003 May 22, 2003 Date of issue Date of expiration Dig safe approval number: 20031903935 Dig Safe Toll Free Tel. Number-800-322-4844 Signature/Title of Officer granting permit r— S After removal(s) ("Consumptive Use"fuel oil tanks exempted)send Form FP-290R signed by Local Fire Department State Fire Marshal, UST Regulatory Compliance Unit, P.O. Box 1025, Stow, MA 01775. to Office of the 'International Fire Code Institute 4 y � Town of Barnstable 1 Public Health Division HAANSTAB b' "'^s& m 200 Main Street ,. JJ ; - zliz 'TEO nu+E`e Hyannis, MA 02601 ' 0 2 1 A � V• � 0.004606238 JAN 05 2006 MAILED FROM ZIP CODE 02601 Nancy J. Borg & �0 A Linda A. Borg P. O. Box 113 Ostoir 4 B0RG11.3 RETUR-55025E JDER`3�� r1. N FORWARD ORDER ON FILE UNABLE TO FORWARD RETURN TO n ' qr, ' 1 � ...� .. '. . `_ i- .. i�' .. r F.Y x �� ,. « , j .,^\ .. � � -...= .*\\ ��_. .e _���`� m "� .. �. •\ .rP' Town of Barnstable Regulatory Services P --rA Thomas F. Geiler, Director ~A' 16 - Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 To: BORG,NANCY J& Date Thursday,January 05,2006 BORG,LINDA A • P 0 BOX 113 - _ - -OSTERVILLE__ _ MA` 02655 ��._ • RE:Underground Storage Tank at: 149 EAST BAY ROAD Map Parcel: 140159 Tank NO: 01 Tag NO: 00374 Our records indicate that your underground fuel(or chemical)storage tank is over 30 years old,and has not been removed as required by section 326-3: subsection 2 of the Town of Barnstable Code regarding fuel and chemical storage systems. You are directed to remove this tank within sixty(60)days from the date of this notice. After your tank is removed, please furnish this office evidence in the form of a permit from your local Fire Department within ninety(90)days of the receipt of this notice. You may request a hearing provided a written petition requesting same is received by the Board of Health within ten(10) days after this order is served. Per Order of the Board of Health .�.; r ., E , , :�,;�; t, F Thomas A.McKean,RS,CHO •p,ct-, Health"Agent s A ll Townoft3arnstabie FindMap/Parcel 140159 t u � Health Dep#tin i ,ealfh System -� r A ;• h r A 4 Map/Parcel, 140159 Tank Nbr -^01 Tag Nbr 00374 A w In tailed 01/01/1 � L cation g Test NotificationyDate Status� aLiate ` t RemovaliNotification Date Test' Ab�and011:Ar ` 05/08/2003 ce F eI�StoResoHuelStored � ` Capacity Construction Leak Detection Cathodic Detection �StorageTank Info 000500 SSA ' , �,• �Adrliional Details Tank removed wilcox ti fi A►dd q �F� �Change ' � �� �� ,x � r _, NOTE.• CESSPOOL LOCATION PER TITLE V INSPECTION DATED.°05-28-03 y 1J �' tV Ia q LOCUS \_o t V I jye 1g rro '�O a LOT 13 5 1 SIR LOT 24 1 ASSESSORS140-159 • AREA 40,999fS.F. / LOCUS MAP w 11 PLAN REF 15967D oo�++ , . . CERT 173828 PROPOSED T ►QQ ZONING. RC FROST• � 37 • _ , WALL �i ,r- 1�Q, SETBACKS. 20 -10 =10 ti FLOOD ZONE. "C" PANEL NUMBER.- 250001 0016 D g DATED.- 07-02-92 A i LOT 7 6�. PLOT PLAN OF LAND �- e.,lo,%� CESSPOOLS r-s 3 04 fJ LOT 25 �Q ti� i LOCATED AT 149 EAST BAY ROAD """' f OSIER VILLE; MA CESSPOO LS """' a' PROPOSED oatgc, { 3 l4 CO VERED . 1 TERRACE 1. .CEDAR LOT 5 PREPARED FOR. -4 SPRUCE �OF BRIAN JONES �G1 c,q� �yG v o up . NO VEMBER 29, 2007 STEPHEN - SPRUCE d J. , r D,�� ' REV APRIL 09, 2008 LOT Al (('' o• V Y :®9��0 ����y°�° REV APRIL 24, 2008 REV MAY 21, 2008 �. (9SiZp _pce, YANKE.E' LAND SURVEYORS & CONSULTANTS. GRAPHIC SCALE P. O. Box 265 UNIT 1, 40 INDUSTRY ROAD O I 50 0 25 so i 0o MARSTONS MILLS, MA 02648 TEL• 508-428-0055 FAX 508-420-5553 1 inch 50 ft. SHEET 1 OF 1 JOB 54307 JF i # ol 77`17 -z 777-77� Z, it 0. ...... `tt., 7 i2 .... ........ Z. ...... .... 41j®r" 44 M_t —:4 • m p 0, -A 114 �0 IL rN ............. a F.tx- `7 r 77 3 0 3- c,- -7; f a 7 ;b. v 7Fa. ID .777.777777, :7 _j q —7 LN 77777 Or qt & i- -A,Amw �w N it Ar 71, A 44. 7— 77=- 7" "t ,j.- T: �4 77 ter rt 7 1�4` kt, y ......... Y -.14 yr !�A v. 4 Gt 7� Z- kn. A, m"IA i -- . w��-—, q, -, X, ,*Ze, Oi�tEl W6 WSW. -A. A v tr! Tj 7% ti tZ n. .,... .. ....-, ..-....... r, �..> . ,.^ :, „' *�� j rL �•c.- �YX t :+''4'�•faMf ate 1 - 4. �riZ3 4 j�r p',t 7T Mng 10 UTILITY LEGEND POLE OSTERVILLE PROPOSED CONTOUR WATER GATE MAIN ST. tHA►N ST' ® PROPOSED SPOT GRADE EXISTING CONTOUR 19` / ' ''° °� 90 Aq�F O�O �qS'T + 96.52 EXISTING SPOT GRADE _ liT W— EXISTING WATER SERVICE 20,, / ® TEST PIT a L O T 13 GF 21, \ ` uj Q� AREA = 41011 sf+— ` /., LAND COURT PLAN 15967—D p LOCUS \ \ Assn MAP 140 PCL 159 2 2 r 149 EAST BAY RD. �� �' _ �'► , ' ' % ; i / LOCUS MAP I I �• I I / ' ' LOCUS INFORMATION 6 I PLAN REF: LCP 15967—D TITLE REF: C225489/0 PARCEL ID: MAP 140 PAR. 159 23 1 / / I PROPERTY IS NOT WITHIN ZONE II/ESTUARIES PROT. DIST. FLOOD ZONE: "X" 1 I I / I % I COMMUNITY PANEL- 25001 C0757J DATED:07/16/14 I % 1 / �� SEPTIC SYSTEM UTILITY POLE / ti 1 1rr O P-1 / O REPAIR PLAN LOCATED AT: 248° o� 149 EAST BAY ROAD I ' OSTERVILLE, MA o PREPARED FOR KELLY J. CURLEY PROP. 1,50OG SEPTIC TANK' JULY 19, 2021 REV: AUG 19, 2021 C) OF s9 RE R G o 25\ 1 \ 2 6 \ \ \ \� 20 MEYER & SONS, INC. 21 ; P.O. BOX 981 PLAN <1, 1 1 1 1 � � �`, / 22 EAST SANDWICH, MA. 02537 11 11 �� / BENCH MARK PH: (508)360-3311 1 SCALE: 1 in = 30 ft \ it 111 �\\ � TOP OF FOUNDATION 23 FAX: (774)413-9468 0 30 60 11 \� 22E GI meyerandsonstitle5@gmail.com �sr 1 11 � BARNSTABLE GIS DATU 0 10 20 30 60 °O. 1 1 ', 11 SHEET 1 OF 2 J 2076 NOTE: MAGNETIC TAPE 16-BEa.PLACED OVER ALL COVERS NOTE: TO PREVENT BREAKOUT, THE PROPOSED FINI$F9" '�" GENERAL NOTES: TOP OF_FND SEPTIC TANK GRADE SHALL NOT BE < EL:14.70 FOR A DISTANCE INSTALL RISERS & COVERS OVER INLET & PROPOSED D-BOX 15' AROUND THE PERIMETER OF THE S.A.S. 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL EL.=22.95t OUTLET PROPOSED S.A.S. BOARD OF HEALTH AND THE DESIGN ENGINEER. j INSTALL RISER & LOCKING INSTALL A RISER OVER ONE CHAMBER (MIIN) 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS COVER TO FINISH GRADE AND SET TO 3" OF F.G. OF THE STATE ENVIRONMENTAL CODE, TITLE v, AND ANY APPLICABLE >•� F.G. EL.=22.Ot LOCAL RULES AND REGULATIONS. F.G. EL.=21.30t F.G. EL: 17.50t ,s f F.G. EL: 17.50(MAX.) 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE DESIGN ENGINEER. 9" MIN COVER/ 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING 36" MAX COVER L 20' L ; 25'(MAI FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN O S=1`$ (MIN.) EL=20.10 ® S=1% (MIN.) ® S=196 (MIN.) a " ENGINEER BEFORE CONSTRUCTION CONTINUES. 4"SCH40 PVC 4"SCH40 PVC 4"SCH40 PVC 2 OF 3/8 DOUBLE WASHED • 3/4" - 1-1/2" STONE OR FILTER FABRIC 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. DOUBLE WASHED STONE 10" g � 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF INV.=19.03 74 - THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF 48"LIQUID INV.=18.78 ®®®®, ®®®® HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. LEVEL EW�0 ®®®® ®®®®® 7. DWEWNG IS SERVICED BY TOWN WATER. GAS BAFFLE PROPOSEDT ®®®®®®®®®® 8.ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED D-BOX INV.=14.25 E3 E3 E3 E3 E3 E3 E3 E3 EM E3 TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. INV.=14.45 � 9. IT SHALT. BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE PROP. 1.500 GALLON SEPTIC TANKS Q' 3 X $,5' 4' LOCATION OF ALL UNDERGROUND UTILITIES. PRIOR TO STARTING WORK. 10. EXISTING LEACHING TO BE PUMPED. CRUSHED AND FILLED PER TITLE 5. 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION EXIST. SEWER OUTLET EFFECTIVE LENGTH = 33.5 O INV.=20.45 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY 'A INV. ELEV.= 13.702 AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY © INV.=19.53 BREAKOUT 13. NO KNOWN ABUTTING PRIVATE WELLS WITHIN 150 Fr. OF PROPOSED LEACHING EL. 14.70 14. ALL PIPING TO BE 4" SCH 40 0 1/8-/FT (UNLESS,SPEC. ) TOP CONIC. ELEV.= 14.70 15. THE DESIGN OF THIS SYSTEM DOES NOT ALLOW NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING INV. ELEV.= 13.70 ®a® FOR THE USE OF A GARBAGE GRINDER. PIPE INVERTS PRIOR TO CONSTRUCTION aaaa®aaa 16. NO WETLANDS WITHIN 100 FT. OF PROPOSED LEACHING 2) TANK/D-BOX SHALL BE SET LEVEL AND TRUE TO BOTTOM EL.= 11.70 aaaaaaa 17. NO PROPOSED INCREASE IN FLOW. GRADE ON A MECHANICALLY COMPACTED SIX 3.75' 5 FT. 3.75' 18. PLACE 6" SLEEVE ON SEWER LINE.. 10 FT EITHER SIDE OF WATER SERV. 19. INTERNAL PLUMBING TO BE MODIFIED TO MEET PROPOSED OUTLETS INCH CRUSHED STONE BASE, AS SPECIFIED IN EFFECTIVE WIDTH = 12.5' SHOWN, PERMIT REQUIRED. 310 CMR 15.221(2) SEPARATION 5.50, FT. SOIL ABSORPTION SYSTEM (SECTION) 3) INSTALL LEE AS&REQU RED S W/ BOTTOM OF TESTHOLE EL. 6.20 (500 GALLON H-20 LEACH CHAMBER) 4) PLACE SANITARY TEE IN D-BOX SEPTIC SYSTEM PROFILE SOIL LOGS TPT: 21-186 N.T.S. DATE: JUNE 30, 2021 ��� OF Mgsf SOIL EVALUATOR: DARREN MEYER, CSE 1614 WITNESS: DAVID STANTON, BARNSTABLE HEALTH o DAR N �, M -{ Elev. TP-1 Depth Elev. TP-2 -Depth o. 1 16.70 A 0" 16.70 A o" t LOBSADSAND 3/2 OYR DESIGN CRITERIA **NO PROPOSED INCREASE IN FLOW** G/ tRy 15.37 B 16" 15.55 B 14" 4N IT00 NUMBER OF BEDROOMS: 4 BEDROOM DWELLING _ �-� 4�i PERc TEST 1OYR 5/6OAMY SAND L AMY IOYYR�s SOIL TEXTURAL CLASS: CLASS 1 (0.74 GPD/SF) 4 oa 12.70 DESIGN PERCOLATION RATE: <2 MIN/IN 11.70 C 60" 11.70 C 60" DAILY FLOW: 110 G.P.D. X 4 BR DESIGN FLOW: 440 G.P.D. MEDIUM MEDIUM SAND SAND GARBAGE GRINDER: NO (not designed for garbage grinder) 2.5Y 6/4 2.5Y 6/4 SEPTIC TANK: 440 gpd x 200% = 880 gpd USE PROP. 1,50OG SEPTIC TANK 6.20 126" 6.20 126" LEACHING AREA REQUIRED: (440)/0.74 = 594.59 S.F. PERC RATE <5 MIN/IN. ("B` HORIZON) NO GROUNDWATER OBSERVED USE THREE (3) 500 GALLON H-20 PRECAST LEACH CHAMBERS PROPOSED SITE AND SEPTIC UPGRADE PLAN W/ 4' STONE ON ENDS AND 3.75' ON SIDES: 33.5' L x 12.5' W x 2' D 149 EAST BAY ROAD, OSTERVI LLE, MA BOTTOM AREA: 33.5 x 12.5 = 418.75 SF Prepared for: Kelly J. Curley SIDE AREA: (33.5 + 12.5) X 2 X 2 = 184 SF System Design and Topography Plan by: SCALE DRAWN DATE MEYER&SONS,INC. N.T.S. DMM 07/19/21 TOTAL SQUARE FEET PROVIDED = 602 vs. 445.94 REQ'D • 1. Darren M. Meyer. R.S.. CSE, hereby certify that i am currently approved by MADEP pursuant to 310 CMR 15.017 Po BOX981 to conduct soil evaluations and that the above analysis has been performed by me consistent with the EAST SANDWICH,MA 02537 REV DATE CHECKED SHEET NO. DESIGN FLOW PROVIDED: 0.74(602 S.F.) = 446 G.P.D. vs. 440 G.P.D. req'd requirements of 310 CMR 15.017. 1 further certify that I have passed the Soil Eval. Exam In October, 1999. 508362-2922 08/19/21 DMM 2 of 2