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HomeMy WebLinkAbout0142 EVANS STREET - Health 142 Evans Street Osterville A= 142 - 138 i I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT.OF ENVIRONMENTAL .PROTECTION TITLE S OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 142 Evans Street p�_/3d Osterville, MA 02655- Owner's Name:. Phyllis Dente Owner's.Address: Date of Inspection: z, August 15. 2008 Name of Inspector: (Plea§e'Prm JanzesM. Ford c , Company Name: James M.Ford .Mailing Address: P.O.Box 49 t ;. Oste.rville.MA 02655-0049 OD Telephone Number: (508)862-9400 s� CERTIFICATION STATEMENT I certify that I have person.ally inspected the sewage disposal system at,this address and that the m ormatio por below is true,accurate and complete as of:the time of the inspection..The inspection was perfo it 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 Need Further Evaluation by the Local Approving Authority Fail Inspector's Signature: Date: August 19, 2008 The system inspector shall subm' .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 describesconditions.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 j Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART A CERTIFICATION (continued) Property Address: 142 Evans Street Osterville, MA Owner: Phyllis Dente Date of Inspection: August 15, 2008 Inspection Summary: Check AB,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ Lhave not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure.criteria not evaluated are indicated below: Comments: B. System Conditionally Passes: 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,N.D)in the for the following statements. If"not determined",please explain. The septic tank is imetaf.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,knot 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 distribution box is leveled or replaced ND explain: The system required pumping more than 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 3 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS S. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: •142 Evans Sheet Osterville, MA Owner: Phyllis Dente Date of Inspection: August IS, 2008 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 MO 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 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 SA is within 50 feet of a private.water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method'used to determine.distance "This system passes if the well water analysis,performed at a DEP.certified laboratory, .for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of armnonia nitrogen and nitrate nitrogen is equal to or less than 5 ppni,provided that no other failure criteria are triggered: A copy of the analysis must be attached to this form. ' 3. Other: =3 i Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 142 Evans Street Osterville. MA Owner: Phyllis Dente Date of Inspection: August 15, 2008 D. System Failure Criteria applicable to all.systems: You must indicate either"yes"or no to each of the following for all inspections: Yes No ✓' Backup,of sewage.inio facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an.overloaded or clogged SAS or.cesspool _ ✓ Static liquid level.in the distribution box above outlet invert due to an.overloaded or,clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than"/2 day flow' ✓. 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 i of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply-well with no acceptable water quality analysis. [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.] No (Yes/No)The system fails.. I have determined that one or more of the above failure criteria exist.as described in 310.CMR 15.303,therefore the system fails...The system.owner should contact the Board of Health to detennine what will be necessary to correct the failure. E. Large System: 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 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 . a If you have answered"yes to any question in Section E the system is considered a significant threat or an "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 accordatice with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 - Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART B CHECKLIST Property Address: 142 Evans Street Osterville;MA Owner: Phvllis Dente Date of Inspection: August 15. 2008 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: Yes No . ✓ _ Existing information. For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.3020)(b)]. Page 6 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY$ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 142.Evans'Street Osterville. MA Owner: Phyllis Dente Date of Inspection: August 15. 2008 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms'(actu' 3 DESIGN flow based on 310 CMR 15.203 (for example: I fO gpd x#of bedrooms): 330 Number of current residents-, 0 y Does residence have a garbage grinder(yes or no)- No Is laundry on-a'separate sewage system,(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): `No. Seasonal use(yes or no): No Water meter readings, if available(last 2.years usage(gpd))' Unavailable Sump Pump(yes or no): No Last.date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc):' Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no); Water meter readings,if available: " Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping.Records < Source of information: Unavailable f Was system pumped as part of the inspection(yes or no):. 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) Tight Tank Attach a copy.of the DEP approval Other(describe)'. Approximate age of all components;.date installed(if known)and source of information: Date of installation unknown Were sewage odors detected when arriving at the site(yes or no): No 6 s 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: 142 Evans Street Osterville MA Owner:. Phvllis Dente Date of Inspection: August 15, 2008 BUILDING SEWER(locate on siteplan) s Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: . Coimnents(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 16" Material of construction: ✓ concrete.,_metal. . fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed.by a Certificate.of Compliance(yes or.no): (attach a copy.of certificate) Dimensions: .1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 5" Distance from top of scum to top.of outlet tee or baffle: 6 1 Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Conunents(on pumping.recommendations; inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.). Cement tees were resent: .The:li uid.level was even with the outlet invert. There did not appear to`be a ly sigh Lo leaka e. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete._metal _fiberglass =polyethylene _other. (explain): Dimensions: Scum thickness:. Distance from top of scum to top of outlet tee.or baffle: Distance from bottom of scum to bottom.of.outlet tee or baffle: Date of last.pumping Coni vents(on pumping recominendatioiis, inlet and outlet*tee or baffle condition;structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 . Page 8 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGErDISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 142 Evans Street Osterville'MA Owner: Phyllis Dente Date of Inspection: August 1 S. 2008 TIGHT or HOLDING TANK: . None (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/day Alarm.present(yes.or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches;etc.): DISTRIBUTION BOX: None (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.): I PUMP CHAMBER: None (locate on'site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY-ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 142 Evans Stmet Ostarville, MA Owner: Phyllis Dente Date of Inspection: August 15. 2008 SOIL ABSORPTION SYSTEM.(SAS): . ✓ (locate on site plan;excavation not required) If, SAS not located explain why: Type ✓ Teaching pits,number: 1 -6'x 671006 ate- . leaching chambers,number: leaching galleries,number: leaching trenches,number; length: leaching fields,number;dimensions: overflow cesspool,number: Innovative/alternative system . Type/naine of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding;damp soil,condition of vegetation,etc.): The pit was dry. The scum line was approxiniately T up from the bottom. There did not appear to be any signs offailur e T17e bottom to grade was 9'. The.cover was 32 below zrade. CESSPOOLS:. None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration:.' Depth top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction`. Indication of groundwater inflow(yes or no):. Comments (note condition of soil,signs of hydraulic failure, level of ponding;condition of vegetation,etc.): PRIVY: ".None. (locate on site plan) Materials of construction: ' Dimensions: Depth of solids: Conunents(note condition of soil,signs of hydraulic failure;level.of ponding, condition of vegetation;etc.): . 9 f _ Page 10 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 142 Evam Street Osterville MA Owner: Phyllis Dente Date of Inspection: August 15;.2008 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. /7-�S_ 10 to 3 - _ f f ►'' Page 11 of 11 OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 142 Evans Sheet Osterville MA Owner: Phyllis Dente Date of Inspection: August.15, 2008 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 20+/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record=If checked;date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain:- Topographic and water contours maps Chec ked with local excavators -installers (attach documentation Accessed USGS database-explain: ) You must describe how you established.the high ground water elevation: Using Barnstable topographic and water contours traps the in dos were showin 2 appr oxiinately 20'+/ to ground water at this site. This report has been prepared only for the septic system and components described herein. This septic system has been inspected and passed as-of the..date of inspection. This report is not.a warranty or guarantee that the system will function properly in the future.'There Have been no warranties or guarantees, either expressed, written or iinplied, relating to the septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected. ti . 1.1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PARTA ��/a /3 K CERTIFICATION J�' G Property Address: 142 Evans Street Osterville, MA 02655 Owner's Name: Estate of Phyllis Wadsworth Owner's Address: 130 Enterprise Street Duxburv, MA 02332 Date of Inspection: May 22. 2006 m . Name of Inspector: (Please Print) James M. Ford Company Name: James M.Ford . 9 Mailing Address: P.O.Box 49 '=- Osterville.MA 02655-0049 Telephone Number: (508) 862-9400 „ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the inf�rmation`reportgd below is true,accurate and complete as.of the time of the inspection. The inspection was performed based on Amy 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 e ds Further Evaluation by the Local Approving Authority ai s Inspector's Signature: Dater June 4, 2006 The system inspector shall sub 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 gti ****This report only describes conditions at the time of inspection and under the conditions of use at that. . time. This inspection does not address hoVv the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 142 Evans Street Osterville" MA Owner: Estate ofPhvllis Wadsworth Date of Inspection: May 22, 2006" 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. . S Comments: 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 distribution box is leveled or replaced ND explain: The system required pumping more.than 4 tunes 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 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 142 Evans Street Osterville, MA Owner: Estate ofPhyllis Wadsworth Date of Inspection: May 22, 2006 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 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the j system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface.water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a. private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria 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. r 3. Other: 3 f Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 142 Evans Street Osterville, MA Owner: Estate of Phyllis Wadsworth Date of Inspection: May 22, 2W D. System Failure Criteria applicable to all systems: You must indicate either"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 t ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped— ✓ 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 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.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: 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 _ 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 answered es to an question in Section E the system is considered a significant threat or answered,. If you have ans y y q y g "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 i Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 142 Evans Street Osterville, AM Owner: Estate of Phyllis Wadsworth Date of Inspection: May 22, 2006 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? i ✓ _ 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: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 142 Evans Street Osterville, MA Owner: Estate ofPhyllis Wadsworth Date of Inspection: May 22. 2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: - 0 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n1a (if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown y COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Date of installation unknown Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 142 Evans Street Osterville, MA Owner: Estate ofPhyllis Wadsworth Date of Inspection: May 22, 2006 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade. 16" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee.or baffle: 30" Scum thickness: S" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.). ' Cement tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage_ GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: concrete metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 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.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 142 Evans Street Osterville, MA Owner: Estate of Phyllis Wadsworth Date of Inspection: May 22, 2006 TIGHT or HOLDING TANK: None (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/day. Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None (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: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 142 Evans Street Osterville, MA Owner: Estate ofhyllis Wadsworth Date of Inspection: Ma 22, 2006 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 -6'x 6'(1000 gal.) leaching chambers,number: leaching galleries,number: leaching trenches,number,length: . leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): The pit was dry. The scup:line was approximately 2'up from the bottom. There did not appear to be any signs offailure. The bottom to grade was 9'. The cover was 32"below grade. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) E Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: :Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 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: 142 Evans Street Osterville, MA Owner: Estate ofPhyllis Wadsworth Date of Inspection: May 22, 2006 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. ------- 3 ask A boor,SIB dc.r B, Qj a 1 aC` I� �3a a l 10 Page 1 I of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 142 Evans Street Osterville, MA Owner: Estate ofPhyllis Wadsworth Date of Inspection: Me 22, 2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water. 20+/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps the maps were showing approximately 20'+1-to ground water at this site This report has been prepared only for the septic system and components described herein. This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected. 11 No.....................[.. FEB....`..................... THE COMMONWEALTH OF MASSACHUSETTS 13� BOAR® F H A TH -- -- ------------OF........ ----- Appliratiun for Dispati al Works Cnunutrurtiun Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Sy ..at_...._ ..... .. ..._.. .. .. —p p Location- e �y _ Owner Addr s. w - � Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms................ --------------•Expansion Attic Garbage Grinder Ajo Other—Type of Building PV,1`_ '. 1.. No. of persons............................ Showers ( ) — Cafeteria ( ) 0.' Other fixtu es --•--------••-------------•---•. ------------------------- w Design Flow............... _.....__...___...._::__.gallons per person per day. Total daily flow__._........._._.._._ _�........... WSeptic Tank—Liquid capacit/ ..gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No}}.................... Width.....a........... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..........l._._.__._ Diameter.100.__-_-_- Depth beloW inlet.................... Total leachin area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) D h— 101C/12t— 11— /`T—7 ~' Percolation Test Results Performed by.......... _ose....................... Date..... ----_------ aTest-Pit No. 1.. ._..minutes per inch Depth of Test Pit.................... Depth to ground water........................ Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ¢.�.. ....... O --- a- / �-- r Description of Soil �� - �AL...............� �-. �......../�..---- r......'�.2'............. x w U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ...=................................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITA IE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b i by,the board of h lth. Signd_ ••--- -----------------------------•--------- --------- --------_--- � D to Application Approved BY F " 1 &. 11j . -2F � 7 / Date F+ Application Disapproved for the following reasons:................................................................................................................ ...............•...................---------•---•--.._-•--------••-----......_.------._._....------.........----•---------------•--__._..._....._...----._...-•----'•--_..-----....- -•••---------- Date PermitNo......................................................... Issued....................................................... Date ► tj No...........t!. .., ............._............... F� •� THE COMMONWEALTH OF MASSACHUSETTS BOARD YF Hf A TH Applira tiou for Disliusa1 Works Tonstrnrtinn Vamit Application is hereby made.for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at .! . . ..._ Or...." ......... we" ............ ... .--- ------- . ' r LocationjokV - rf�I/��i ---- ..................................... Owner a5 / ' .-�.....�r�f ........................................... f[t Installer Address Type o Building k Size Lot----------------------------Sq. t Dwelling No. of Bedrooms Expansion Attic t Garbage Grinder a Other hype of Building _. No. of persons Showers,,( ) — Cafeteria ( )Y ®ther, fixtu es ..... W Design 'Flow.......... •-------_........gallons per person per day. Total daily flow.................... ___ ................gallons. P4 Septic Tank—Liquid;capacit gallons Length........,_:.____ Width................ Diameter................ Depth................ Disposal Trench 4 No .................... Widt�hh++yy�C� ____ Total Length......._. ____ Total leaching area....................sq. ft. Seepage Prt No _______ _________ Diameter_/ --------- Depth belo inlet___.____ : Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) - Oe Percolation Test Results Performed.by............. ........ ........ _.... _______. Date_ _____ ____ .......... , .. . Test Pit No 1_______________minutes per inch Dep� Of 1st �.A+�_►____. Depth to ground water........................ Test Pit No. 2......,,.,,,minutes per inch Depth of Test Pit____________ ______ Depth to-ground water........................ 0 Description of Soil............................................ ,' y,fit __ � UNature of Repairs or Alterations—Answer when applicable........................ __._._.____..._____.,_._._.._._.___.____._.____._._.__ .___. Agreement: u ' The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITL i;. 5 of the State Sanitary de,+ The,undersigned further agrees not to place the system in operation until a Certificate of Compliance has b ' he boa kd of I th. -' Signed: .. v --- •--• -----..... ----•- --------_'__Date--•---........ ,,,Application Approved By __--• --- ..... Application Disapproved for the o as n : "'!'� �.: ................................................ ......................:...:...........:....... =---------------••---•••••-•=••------.._.... . •-------••----••----•------------ ••-••-•-•••--•--------••-•---•----•- et;.. Date PermitNo......................................................... Issued...................................................... Date ' THE COMMONWEALTH.OF MASSACHUSETTS r BOARD OF.' HEALTH f Y. ..........................................OF...-.......-............. ..................................-..__................... di rate THIS IS TD CERTIFY;-That the Individual Sewage(Disposal System constructed ( ) oy Repaired ( ) by--................9 --•---•---....•••---•---•.....::......................................---------..................._..........-•--••-•••---••-----•- "'"^ --......••--•---_...._ s Installer at........... has been I t e 1 rd n wit e rov o o Y' T h ate a ode as described in the d/ C applicat"io r 1 s ��V t tibn .erm �o.---- br ---`--..______.r_. dated- ......................................... THE ISSUAAI'CE OF THIS CERTIFICATE SHALL NO 6d�1#IJED AS A GUA6'N?1k TRAR THE SYSTEM WILL :FUNCTION SATISFACTORY � DATE........d .................... � .may ............._:.' Inspector..::•_ . - .. ....-- - ................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....... ........OF................... No... / s ... FEE._.......__ H . ; Permission is hereby granted=--=- ----• ..................... ... -----•-- ••••-•-----•-••-••............... ._......---__•-•-•- to Construct ( ) or Repair ( ) an'I rage 1Sy at No._.......... :. - ---- ------ ---- s tic /� '�j ry Street as shown on�ie p icati os kb�Cc n �'r 1 "P o '------6 Y?dl ----•._.... --•- >,, ► = --•-• '; ealth DATE.......................................•--•-•••-------•....._; _ h, FORM 1255 HOBBS-& WARREN, INC.. PUBLISHERS _ TOWN OF BARNSTABLE LOCATION _ I loZ 'EVi4/U Ss I SEWAGE# t?I'LLAGE OSTfVAL ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY UIJI) LEACHING FACILITY:(type) PT (size) /6W NO.OF BEDROOMS 3 OWNER (N/��.SG►D� PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY I (3 AL-k A JB Door ,. 13 3 6 3c a I LOCATIgN .� S�E7�7WAGE7 ]PERMIT NO. / / VILLAGE INSTALLER'S NAME & ADDRESS U Z! �L`fi 1l GktrS .S B U I'L D E R OR OWNER 14 r ><.6An` C o-nrs:j' r DATE PERMIT ISSUED DATE COMPLIANCE ISSUED M W4r . ;.. U) Q�o N � V)WtNDo - - - - SUNROOM ROOF BELOW - - CL, A A5 . O ¢x.¢ (NEW SHED DORMER) .. _ . _ t , a`a z-1P z-+o z-10 s-10 rs 5d B SHELVES r xs' -m w LNZ NEW °` " >A ` BATH o �•�• 4 lr� It _ 'ACCESS _ WALL IUMBINO I I L 'ABOVE -- PANEL _—_ - 2VXW - .. ..., - INSTALL NEW 2x/STUDS - ` r . : To THE EXIST.2x 4 STUDS- I " FRAMED ON THE FIAT NEW ,,-' . REMOD..Q I «' I HALL a FAMILY : TE se y ROOM — ON. X � .. L l BEDROOM#2 . EXIST. - r - CLOS.- 1 ACCESS PANEL. - — --- ------------------- - - _—_——__——__———_ - - _ - ,..'. ACCESS:. . PANEL ~ cn w " Q `" Cn A , 14'Z* EXISTING) IEXIsnNDI w �" cq UFLOOR PLAN 7 r .' SCALE: 1/4" DATE: 1/12/2009 DRAWING IyO: . (ADDITION) . . (ADDITION) (EXISTING) (EXISTING . . - .. f. r _ O NCDV N - DN. . . mb � - g EXIST. EXIST. EXIST _ .. - Li]�.,�• .. _ r-r-r1-7-T-r-ri-1-T- -r- l_ [C�" fi7 � W^OO p lC> : Fb ..%L_L_LJ_1_1_L_LJ_1_1_ 0-�*- . - L___________________ z FVJGBOR B a $ NEW ANDE _ . «o DECK EXIST. N y . y F SUNROOM — 4 A5 - �_ll- A Fl�nlO APU2 EXIST: EXIST. ... - t Lmt t t Im- P'---VRI IJI DWI IS ,;�;_ ; - BATSI'IREMODELE KITCHEN 1 I;(VERIFY IQTCHENO. EXIST.wYourWiowNER, iREMODELED MASTER , ''� I; DINING Q EXIST. BEDROOM - i TALI PANTRY _ISLANDCABINET i ii I . I i. I CLOS. REMOVE EMO E Plan ,f=a n 1 BATH W W I ® N W Ci7 EXIST. - -. u'St.. O LIN. --- p EXIST. � - - ——— ON. GARAGE EXIST. © .. —————— tx HALL © cLos. w W W _ : 0 EXIST. r ; v :. ..• ,:. -. - ..- NEW BUILT-IN . . - i B ILT-IN © E"'1 EXIST. - .. _ OQw �CABINETS . � EXIST. I EXIST. LIVINGcn w Z I _e BEDROOM#1 OFFICE (FORMER BEDROOM) UP'�. ,. EXIST. EXIST. ,.. EXISL.- EXIST. - A5 ' (EXlsnwo) (EXIISTING) SCALE . _ 1/4" 1'-0" WINDOW•�SCHEDULE FIRST FLOOR PLAN DATE: TYP MANUFACTURER'S UNIT ROUGH OPENING REMARKS THE DESIGNER SHALL BE NOTIFIED IF ANY . 1/12/2009 LEGEND. ERRORS OR OMISSIONS ARE FOUND ON A ANDERSEN C 235 4'-0 1/2"x T-5 3/Ir STORMWATCH CASEMENT THESE DRAWINGS PRIOR To START OF CONB " TW 24310 Z'-6-1/8"x C-1 1/4" STORMWATCH DOUBLEHUNG Q EXISTING WALLS ®SMOKE DETECTOR WILL BE RESPONSIBLE HE FOR CONTRACTOR . �;•+ ... ,: - " - N THESE ORAVNNO FCONSTRUCTICONTENT M . DRAWING NO. C TW 2446 2'r6 1/6"x 4'-9 114" STORMWATCH DOUBLEHUNG �__] CONSTRUCTION TO BE REMOVED ©CARBON MONOXIDE DETECTOR coMMENcFs WTHOUr NOTIFYING THE 1.CONTRACTOR TO VERIFY ALL WINDOWS WITH OWNER AND ROUGH OPENINGS CONSTRUCTION _ DESIGNER OF ANY ERRORS OR OMISSIONS. 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