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HomeMy WebLinkAbout0051 FALLING LEAF LANE - Health 51 , .Failing Leaf—Lane Osterville 2 Bed _ r A = 144 003021 J 0 C Commonwealth of Massachusetts Title 5 Official Inspection -Eorrr� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t M 51 FALLING LEAF LN Property Address Owner LEN CIVITTOLO information is Owner's Name required for every OSTERVILLE - - MA 02655 FEBRUARY10,2012 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 A. General Information filling out forms on the computer, use only the tab / 3 1. Inspector: key to move your cursor-do not MARK L WHITE use the return Name of Inspector key. -- A.B. CANCO Company Name "4 Cj 350 RT 28 a . Company Address Fi4mWEST YARMOUTH MA City/Town State 02673 ! Zip Code 508-775-2820 S-13381 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 15.009).The system: 0 0 Elp,,,llUllltfl,,,,, N OF�L95+��iOi ,,,....., S i Passes � Conditionally Passes � Fang��,P, .9�; MARK Needs Further Evaluation by the Local Approving Authority =o WHITE No.S13381C. RT10 FEBRUARY 10, 2012 t Inspector's Signature Date mnm4ma 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. �) (%/� C v t5ins 11/10 Tdle 5 Official Inspection Foim:Subs ce Sewage D pIrN ys m•Page 1 of 20 Commonwealth of Massachusetts, Title 5, Official Inspection Form . Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 51 FALLING LEAF LN Property Address Owner LEN CIVITTOLO information is Owner's Name required for every OSTERVILLE MA, 02655 FEBRUARY 10,2012 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/a/ways complete all of Section D A) System Passes: ❑x 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 S Conditional) Passes: Y ❑ 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 unsou nd,,.exhi bits 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•11/10 idle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 51 FALLING LEAF LN Property Address Owner LEN CIVITTOLO information is Owner's Name required for every page. OSTERVILLE MA 02655 FEBRUARY 10,2012 4. i R wn C t o _ State Zip Code' Date of Inspection y P , P B. Certification (cont.) B1 System Conditionall Passes Cont. :Y Y ( ) ❑ •;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 ❑Y 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): D broken pipe(s)are replaced ❑ Y 0 N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 20 Commonwealth of Massachusetts t Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 51 FALLING LEAF LN f Property Address Owner LEN CIVITTOLO information is Owner's Name required for every page. OSTERVILLE MA 02655 FEBRUARY'10,2012 City/Town State Zip Code Date of Inspection . i C) Further Evaluation is Required by the Board of Health: i ❑ 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 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. 11 The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water. supply. ❑ Jhe system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has aseptic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: s - "*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. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 20 i } � 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 51 FALLING LEAF LN Property Address ' Owner LEN CIVITTOLO information is Owner's Name required for every OSTERVILLE MA '02655" FEBRUARY 10,2012 page. City/Town State Zip Code, Date of Inspection 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 0 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 Tess than '/a'day flow F, B. Certification (cone.) Yes No Required pumping more than 4 times in the last year NOT due to_clogged or obstructed pipe(s). Number of times pumped: ❑. xZ 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. ❑ px n 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. t5ins•11/10 , Title 5 official inspection Form:Subsurface Sewage Disposal System•Page 5 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage.Disposal System Form-Not for Voluntary Assessments 51 FALLING LEAF LN ` Property Address Owner LEN CIVITTOLO information is Owner's Name required for every page. OSTERVILLE; MA 02655 FEBRUARY 10,2012 City/Town State Zip Code Date of Inspection ❑ 0 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 0. ❑ 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 Well 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. C: Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No - px Pumping information was provided by the owner, occupant, or Board of Health ❑ x❑ Were any of the system components pumped out in the previous two weeks? px ❑ Has the'system received normal flows in'the previous two week period? t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 20 ' Commonwealth of Massachusetts Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 51 FALLING LEAF LN Property Address Owner LEN CIVITTOLO information is Owner's Name ; required for every page. OSTERVILLE MA 02655 FEBRUARY.10,2012 Cityrrown State Zip Code Date.of Inspection ❑ 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)N/A M ' ❑ Was the facility or dwelling inspected for signs of sewage back up? D ❑ Was the site inspected for,signs of break out? ❑x ❑ Were all system components, excluding the SAS.Jocated on site? ❑x ❑ 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? 0 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: x❑ ❑ Existing information. For example, a plan at the Board'of Health. 10 El 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): r 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): ` 330 D. System Information Description: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 20 c Commonwealth of Massachusetts A - Title 5 Official Inspection ®rm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 51 FALLING LEAF LN Property Address Owner LEN CIVITTOLO information is Owner's Name required for every page. OSTERVILLE MA 02655 FEBRUARY 10,2012 Cityrrown State Zip Code Date of Inspection Number of current residents: 2 ❑ Yes 0 Does residence have a garbage grinder? No Is laundry on a separate sewage system? [if yes separate inspection required] 0 Yes ❑ sNo Laundry system,inspected? El Yes ❑ No Seasonal use? 0 Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): ., 2010-156,000 20117111,000 Sump pump? 0 Yes ❑ No Last date of occupancy: CURRENT 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? El Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 20 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal,System Form-Not for Voluntary Assessments 51 FALLING LEAF LN Property Address LEN IVITT LO Owne r r C O information is Owner's Name required for every page. OSTERVILLE MA 02655 FEBRUARY 10,2012 City/Town State Zip Code Date of Inspection Non-sanitary waste discharged to the Title 5 system? NI Yes El- No Water meter readings, if available: D. System Information (cont) Last date of occupancy/use: pate Other(describe below): General'Information Pumping Records: Source of information:*'., Was system pumped as part of the inspection? El Yes © No If yes, volume pumped:. gallons How was quantity pumped determined? Reason for pumping: t Type of System: p Septic tank,+distribution box, soil absorption system f ❑ Single cesspool ❑ Overflow cesspool , i , ❑ Privy t5ins•11/10 y Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 20 Commonwealth of Massachusetts ugTitle 5 Official Inspection-. Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 51 FALLING LEAF LN Property Address Owner LEN CIVITTOLO information is Owner's Name required for every OSTERVILLE _MA 02655 page. FEBRUARY.10,2012 Cityrrown State Zip Code Date of Inspection ❑ 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 l/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. Other(describe): D. System Information (cont.) Approximate age of all components, date installed (if known)and,source of information: January 8,1998 Were sewage odors detected when arriving at the site? ❑ "Yes No. Building Sewer(locate on site plan): Depth below grade: 26 INCHES 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.): INSPECTED MAINLINE WITH CAMERA. LINE IS CLEAR OF OBSTRUCTIONS AND/OR BREAKS. Septic Tank(locate on site plan): Depth below grade 1 feet Material of construction: FX]concrete ❑ metal ❑fiberglass' ❑ polyethylene,. ❑other(explain) t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 20 Commonwealth of Massachusetts , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 51 FALLING LEAF LN Property Address Owner LEN CIVITTOLO information is Owner's Name required for every OSTERVILLE �'MA 02655 FEBRUARY 102012` page. Cityrrown State Zip Code, Date of Inspection a l f If tank is metal, list age: years ' ❑ Yes ❑ Is age,conflrmed by.a Certificate of Compliance?(attach a copy of certificate) No Dimensions:, 3INCHES Sludge depth: { D. System Information (cont.) Septic Tank(cont.) Distance from top ofsludge to bottom of outlet tee or baffle 20 INCHES ` Scum thickness 4 INCHES 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 SLUDGE JUDGE AND TAPE Comments'(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.)-TANK IS IN GOOD SHAPE, INLET t5ins-11/10 Title 5 Official Inspection Form'Subsurface Sewage Disposal System-Page 11 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 51 FALLING LEAF LN e Property Address Owner LEN CIVITTOLO information is Owner's Name required for every page. OSTERVILLE MA 02655 FEBRUARY, 10,2012 Cityfrown state Zip Code Date of,Inspection Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal 0 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 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.): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 20 �. Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface.Sewage Disposal System Form-Not for Voluntary Assessments " 51 FALLING LEAF LN Property Address Owner LEN CIVITTOLO information is Owner's Name required for every page. OSTERVILLE MA 02655 'FEBRUARY 10,2012 — Citylrown State Zip Code Date of Inspection 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 C7 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. D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 - I t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 51 FALLING LEAF LN Property Address Owner LEN CIVITTOLO " information is Owner's Name required for every OSTERVILLE . MA 02655 FEBRUARY 10 2012 page. City/Town State Zip Code Date of Inspection 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.): DISTRIBUTION BOX IS 60 INCHES DEEP AND WAS INSPECTED BY A CAMERA FROM THE OUTLET OF THE SEPTIC TANK. NO HIGH STAINING, LEVELERS IN PLACE AND BOX APPEARS IN VERY GOOD SHAPE. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order:. ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil,Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: . t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 20 ' Commonwealth of Massachusetts Title 5 Official- Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 51 FALLING LEAF LN Property Address Owner LEN CIVITTOLO information is Owner's Name required for every OSTERVI LLE MA 02655 FEBRUARY,10 2012 page. Citylrown State Zip Code Date.of Inspection e D. System Information (cont.) Type; E ❑ leaching pits number: - ❑ leaching chambers number. ❑ leaching galleries number: 4, ❑ leaching trenches° number, length: ❑x Teaching fields ' number, dimensions: 1-12'X40' ❑ 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.) NO SIGNS OF HYDRAULIC FAILURE, NO PONDING OR.DAMP SOIL. VEGETATION IS NORMAL. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 20- } Commonwealth of Massachusetts Title 5 Official Inspection Foam Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M °"y 51 FALLING LEAF LN Property Address Owner LEN CIVITTOLO information is Owner's Name required for every OSTERVILLE MA. 02655 FEBRUARY 10 2012 page. Cityfrown State Zip Code Date of Inspection. 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 0 No D. System.Information .(cont.) Comments(note condition of soil, signs of Hydraulic failure, level of ponding, condition of vegetation,' etc.): 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.): F t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 20 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal,System Form Not for Voluntary Assessments M 51 FALLING LEAF LN Property Address Owner LEN CIVITTOLO F information is Owner's Name required for every page. OSTERVILLE MA 02655 FEBRUARY 10,2012 Cityfrown 4 State Zip Code Date of Inspection • �f 4 a, c i • 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 8 drawing attached separately - i t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 20 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 51 FALLING LEAF LN Property Address Owner LEN CIVITTOLO information is Owner's Name required for every page. OSTERVILLE MA 02655 FEBRUARY.10,2012 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Check Slope t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 20 ` Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M s•'• 51 FALLING LEAF LN Property Address Owner LEN CIVITTOLO information is Owner's Name , required for every OSTERVILLE ° MA 02655 FEBRUARY 10 2012 page. _ , City/Town State Zip Code Date of Inspection Surface water ' Check cellar 0 -Shallow wells. Estimated depth to high groundwater. fee+ Please indicate all methods used to determine the high ground water elevation: ❑x Obtained from system design plans on record If checked, date of design plan reviewed: 1/Daatete 8/98 ❑ 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: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 19 of 20 `A r Commonwealth of Massachusetts I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M s 51 FALLING LEAF LN - Property Address Owner LEN CIVITTOLO information is Owner's Name required for every OSTERVILLE MA 02655 FEBRUARY 10 2012 Page. , Cityrrown State Zip Code Date of Inspection TEST HOLES PERFORMED ON 1/8/98 TO ADEPTH OF:12+ FEET WITH NO GROUNDWATER ENCOUNTERED. Before filing this Inspection Report, please see;Report Completeness Checklist on next page. E. Report Completeness Checklist F Inspection Summary: A, B, C, D, or E checked Inspection Summary,D(System Failure Criteria Applicable.to All Systems)completed O System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in,separate file 4 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 20 of 20 VWAk e : 37- , 3.0 oZ7f 84 �ssessing/HMdisplay.asp?mappar=144003021&seq=1 TOWN OF ARNSTABLE OP 6/W 10V Q- LOCATION Z SEWAGE # VILLAGE ASSESSOR'S MAP & LOT D INSTALLER'S NAME&PHONE NO. caul SEPTIC TANK CAPACITY TaO LEACHING FACILITY: (type) (size) r2 x yo NO.OF BEDROOMS 2— BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted-Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by h l _ g c 3zl a, : 1ya t 8t.Z3i r43� 47 J y Z5-1 A4 s Z7 Fee E COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS application for ]0t!6poga1 *p.5tem Con5tructton permit Application for a Permit to Construct( IXpair( )Upgrade( )Abandon( ) 2Djedmplete System ❑Individual Components Location Address or Lot No. Owner's Name,Addres and Tel.No. �bclklf& L,eLAr ,. v s, fu LN(` ,Pei �� l� Assessor's Map/Parcel. Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. /65 /,*C)L Type of Building: 4iI3welling No.of Bedrooms� Lot Size 3�--sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flows gallons per day. Calculated daily flow gallons. Plan Date — umber of sheets ! Revision Date " '"7" Title &U tl / = Size of Septic Tank �'C�C� G t f Type of S.A.S. c Description of Soil a r L � 5 yy,UL I Mot C� i/ : � 9rr WWI Nature of Repairs or Alterations(Answer when applicable) Date last inspected: `� ► ', _� ,,9T S Agreement: IN ITIN The undersigned agrees to ensure the construction and maintenance of ttH�E �oy Site sewage TAI5�sa517tem in accordance with the provisions of Title 5 of the nvironmental Code and oft to p ace a system'in'operation until a Certifi- cate of Compliance has been ' s e b'y""l,his Bo of Health. Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No, *-- ' Date Issued N�o '� a, —v, ,Fee E COMMONWEALTH OF MASSACHUSETTS Entered in computer: ; _ Yes 1*m PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS.+ Application for �Biopooar 6psom,Cone;truction Permit - Application for a Permit to Construct( jWepair( )Upgrade( )Abandon( ) ZIPbinplete System O Individual Components l Location Address or Lot No. Owner's Name,Addres and Tel.No. d S��xw& Assessor'sMap/Pazcel /I/ I� `3 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. /f7jjlr�/ `�� Type of Building: 1i-f welling No.of Bedrooms,1 a?- Lot Size a r-?Isq.ft. Garbage Grinder(� Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 3 gallons. Plan Date umber of sheets / Revision Date y - -7` ��, Title /Q =- Size of Septic Tankt *-, Type of S.A.S. r 4409YA27iiW Description of Soil ' �5 ea/4 q '1 ��- / )[b Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement• r The undersigned agrees to ensure the construction and.maintenance of the afor cribed on- to sewage disposal system in accordance with the provisions of Title 5 of the nvironmental Code and.not to place a system in operation until a Certifi- ;F, cate of Compliance has been ' e t is Bo of Health. a k Signed Date Application Approved by Date �'' ,' -; - Application Disapproved for the following reasons Permit No. + Date-Issued THE COMMONWEALTH OF MASSACHU E BARNSTABLE, MASSACHUSETT Certificate of Compliance THIS IS TO CERTIFY,,drat the O -site ew ge Dis sal S em Construc ed( / Rep •red )Ug,ra ed( ) Abandoned( )by ! p at [.tom C91 /�[.G. ca r has been constructed-m accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer > The issuance of this pens 'a t e/� ued as a guarantee that the syste wi nation as desigrbe ' Date r (/ Inspector x/ � •,�-� /i` C _ No. ee O THE COMMONWEALTH OF MASSACHUSE �S PUBLIC HEALTH DIVISION - BARNSTABLES MASS CHUS TTS Mtg;pogar *p�tem Construction •per ' Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( I` r-- System located at Z42f. f "L 1.�� �� 1'�LZE and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction ust b completed within three years of the date of thi Date: 00 Approved b PP Y - L hJ e 1 VA.TA FAM IL ( 2. gt�¢ 13�.Gov p ;AU33AI Q 6Zu.b S'C. VIA4L� PLOW _ 3 x 1►0 =3ao _ sync TAN1: , b W �c?m'/.=GGD use 15oo GAS. , \ /i 1� srs�N t...AGt}►L1G 5`( I ZO 3w � 4� it l vs E 3 p GPD . p.7 NSF d- L DPP uG�.T►ol-1 A¢s� ��516� �, / / �§o' j Slr�wacL A�= o � M AZaA = 12� 0 «j 5frjq ?' I ^�� ;ortG T)CL _� N (- PE:24oCAT1Q1'1 pt� WILLIAM �JS 4- AV c NYE ,pNo' 19334 QI8TEP �0, � SOU ,y `�Jli°lily k3 ''L) TK- 4416 ?� l� - 3 — — 7 L� �u p�( ►�n[ Iµt ¢u.�. S e: p Pipe- -fir.) V"— P , WD .l nGAT tcl t 3 lA- � n Wn.5HED '5TvUc Scat_ ( _ v=I (b •3v t� LF.>zTl F`f T-PAT Tf1 E ?Ed. Raw E SIA0WN (�LA�1 IZF�Y E�•1G� Z� I-�a?BOF•I CON(Pt-`�S 1�t/iTµ '1'11� SI DELIIJS A� Z� nL PSG.��s PG AGt�- QUIZE.� & T D1= Tie -ro vjK1 of 'l JAF 14-4- PAZCC= - 3• Zd '5 A-a1J$T�i�A►JV l s poi I.oc T� w I T"I�1 N B� Q- Hyrs 1 h1G .SpEca AL Flsr�v HAZAl-a 7-OH E � ) c �b11D SL)ZvayC25 • r.1Ja1�.1 ��Q a oSrEevl:�-� ASS. oFFS�S mom .501LD1W-6 -il000:1 No'r 13,S A(?pLICANT: G A,ySGCIA l>SED STEPHEN 6S'r�BUS►i PROpaTy LIu�S. :, ALLYN �, o WILSON No;310216 j �t The dwelling shall be limited to 2 bedrooms unless the septic system is modified to include enhanced nutrient removal as approved by the Board of Health in which case a _ % - J. dwelling served by a modified system may be permitted to have not more than 3 bedrooms i z , 1�. 7 REVISED:.. � — ���tM t�Fwy /--7- S o war 4. QfsTs1` rsi DATA �L \ 1 c.. L �r y L►J FAMIL`( 2_ UEMa 5M l3�•cov �p GA�►3AL� Gw�.,b�. � PLO us>: 15oo GAL. 1 �411 sTS�N �J �AG�IllG 5`{ I Zo 3w � 1 - 4� 'II , , USE jpp u4M cd-noN A¢r� ��516'� 3i 1 / ac, 111 51t�wACL AtaEA= o ,, I� e.� Z-rOM Ae�4 �2•� 4aO ��� — I. ,,��I SI S'IG Ty- (r V�oLn -rara. AMA k>O al x wiui 41 C.AM N,Y E `^ `` / WT ZI ,Q No. 19334 Oh, Z I) t 3 Z 5 SU v / Try ?ret "• 1.0 . 4,a 4o,r 1So�C dAd dU �►t_ TA►Y. p v ti 4D a - vE FZOFkLE— eve- x,ke, 40 P1.0 PLAN LC) 2 A W n,5 H ED 5Tv VG � _ � VATE i i o •3v-lt- rd E �. �E 5t�owr�! P11�1.1 tZ aZENG� D Z Z. I F �OF�! CAMIR-`1S. 1dI lTi� 'T�4E ' SIDELlt 1E A►.In �T- Z1 FL f - r•� c,�g,aGk. ?u12F�nEuT D1= T4c ToOl � MAP 14-4- PAIL 3, Z.� BArZNSI�i�A�ti 15 p'" l.GY14T T� WtT'►liN BA Q- `0 Hym ING Sp6U4L FIs�D HAZ1�Y� NE� �A,►4D SUtNEYG>ZS • J61�16E>ZS �, ',� oSrEevI, 1 � • - ,y�a,ss. Viers VIZOM bo I LDI I�&5 "!No �� 14o r' $� Ar -1 C4NT: G�E�,y SGC!A uS�d Tb 6s'n�Bc�s+-1 'Pt�op�z-ry L�i.IES. / c --- STEPHEN ALLYN `o WILSON N4.302;6 � t The dwelling shall be limited to 2 bedrooms unless the septic system is modified to_. 071 include enhanced nutrient removal as approved by the Board of Health in which case a dwelling served by a modified system may be permitted to have not more than 3 bedrooms. REVISED:, C� 11 OffT6�`� i f 4r t, Foundation Certification in Osterville , Ma. Prepared For McShane Construction T Assessor's Map : 144 Lot: 3-21 Baxter Nye & HOlmgren Community Pane! Number. 250001 0016 d Registered Professional F.I:R.M. Map Zone: C Engineers and Land Surveyors f Plan Reference : Book: 388 Page: 22 812 Main.Street t Ostervifle;-W 62655 Owner. :'" M-cSfiane Consfrucfiori ' 98=98023 S AB 21 Scale 1" = 40' Date 02-04-2000 1� O a E C1.y6- �J& z _. F ti y 19 o v'�F opv O Y ,r 4 CERTIFY THAT TO THE BEST OF MY KNOWLEDGE THE FOUNDATION SHOWN HEREON .IS IN COMPLIANCE WITH THE APPLICABLE BARNSTABLE L; ZONING DISTRICT SIDELINE AND SETBACK REQUIREMENTS, IS LOCATED IN RELATION TO THE MONUMNENTS SHOWN, AND IS NOT LOCATED WIM A-SPECIAL FLOOD HAZARD ARE& m u THIS PLAN IS NOT 70 BE RECORDED NOR IS IT TO BE USED TO ESTABLISH PROPERTY-LINES. .. R STERED SIONAL LAND SURVEYOR QATF w 5� TOWN OF ARNSTABLE LOCATION Z SEWAGE # VILLAGE,- ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE N0. SEPTIC TANK CAPACITY MOO. LEACHING FACILITY: (type) (size) /Z X 7 NO. OF BEDROOMS Z BUILDER OR OWNER i PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: i Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist . within 300 feet of leaching facility) Feet Furnished by n s ► -?a i 1 w.+✓� 7 2 �pF tNE Town of Barnstable snxrrsrnBt,E, 9�p•E MASS.9- Board of Health 367 Main Street,Hyannis MA 02601 ' Office: 508-790-6265 Susan G.Rask,R.S. FAX: 508-790 6304 Brian R.Grady,R.S. Ralph A.Murphy,M.D. Decision of the Board of Health Regarding Lots 1 Through 14 and Lots 16 Through 25 Falling Leaf Lane, Osterville, Shown on Subdivision Plan dated February 11, 1984, revised April 23, 1984 and Identified as Parcels 3.001 Through 3.014 on Assessor's Map 144, and Parcels 3.016 Through 3.025 on Assessor's Map 144. PROCEDURAL HISTORY On November 18, .1996, the Board of Health agent, Thomas McKean, R.S., C.H.O., received twenty-four (24) disposal system permit applications along with two checks totaling $2,400.00 from Peter Sullivan,.P.E., of Baxter and Nye Incorporated, who was representing O.R.E. Associates Incorporated and Osterville Highlands Trust pertaining to proposed construction along Falling Leaf Lane, Osterville. The lots are located off of Acorn Drive, Osterville Massachusetts, and are identified as parcels 3.001 through parcels 3.014 on Assessors Map 144, and parcels 3.016 through 3..025 on Assessor's Map 144. The disposal system construction applications indicated that parcels 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, and 24 (all the even numbered lots) were owned by Osterville Highlands Trust. The remaining.applications indicated that parcels 1, 3, 5, 7, 9, 11, 13, 17, 19, 21, 23, and 25 (all the odd numbered lots) were owned by O.R.E. Associates. I On or about November 21, 1996, Mr. McKean disapproved all twenty-four disposal construction permit applications due to the fact that the plans lacked maximum feasible compliance with the State Environmental Code, Title's. He also returned the checks totaling $2,400.00 to Peter Sullivan, P.E., of Baxter and Nye, Incorporated, and invited him to attend a Board of Health hearing scheduled on Tuesday December 17, 1996 in order to provide Mr. Sullivan the opportunity show why he, and the owners of the parcels, believed it would be feasible to construct septic systems on theseN24 lots which would meet the provisions of Title 5, the State Environmental Code. During the first hearing which was held on December 17, 1996, the applicant requested a 1, continuance. Then the Board members voted to continue this matter to the February 4, 1997 public meeting. On February 4, 1997, the applicant again requested a continuance; then the Board members voted to continue this matter to the March 4, .1997 public meeting.. Continuation hearings were also held 'on the following dates during-1997: June 17th, July 1st, and August 19th. Many documents were submitted into the record by both the applicants) and the Board of Health. The Board members rendered a decision on September 3, 1997 during a special public paring. 2 A FINDINGS OF THE BOARD OF HEALTH After discussion and based upon the evidence submitted, the Board of Health made the following findings: I. All 25 lots in the subdivision fall within a DEP approved Zone II of a public water supply: the Centerville-Osterville-Marstons Mills Water district wells CO# 10, CO AR#3,4, and CO MC#2. The Zone 11 for these wells was approved by DEP May 3, 1994. Further, these wells are showing nitrate levels in the range of.J1 3 mg/L; these levels clearly exceed background nitrate levels (generally <0.5 mg/L) and are indicative that nitrogen from human sources is reaching these wells. Septic sy stems are known to be the largest source of nitrogen to groundwater on Cape Cod. 2. All lots.in the subdivision are within a DEP-defined nitrogen sensitive area as defined in 310 CMR 15.215(1). 3. Further, the majority of lots.in the subdivision (lots 1-10 and 16-25) fall within the town of Barnstable defined WP zone,,the five year time of travel contribution zone to a public water supply. - 4. Septic system effluent is a known source of nitrate and other possible contaminants to the public water supply. 1 5. Increasing density of housing is associated with increased levels of nitrate and other ntaminants in.groundwater. In recognition of 4 and 5 above, DEP has determined per 310 CMR 15.2.14(I),.that no serving new construction in a nitrogen sensitive area designated in 310 CMR 15.215 shall ' '3' i be designed to receive or shall receive more than 440 gallons of design flow per day per acre except as set forth at 310 CMR 15.216 (aggregate flows) or 15.217 (enhanced nitrogen removal). 7. All lots in the subdivision are less than an acre in size. Further, all lots,.except lots 23 and 21, are less than one-half acre (20,000 sf). Under the nitrogen loading requirements of 310 CMR 15.214, the half-acre lots would be entitled to a 220 design flow, the lots less than one-half acre would be entitled to a 110 gpd design flow: 8. Under the Title 5 transition rules, 310 CMR 15.005, the owner-of a lot on which 4 construction of a septic system in full compliance with 310 CMR 15.000 is.not feasible.is entitled to construct a system with,a cumulative design flow of up to 330 gpd provided that the system is constructed in compliance with 310 CMR 1.5.000 to the maximum extent feasible as determined by the local approving authority pursuant to 310 CMR 15.404 and 15.405. 9. 310 CMR 15.404 (maximum°feasible compliance) states that a non-conforming system may be brought into compliance through the installation of an alternative. system (i.e. a nitrogen removal system with associated design flow credit may be used to bring a system into compliance with the requirements of 310 CMR15.214). 10. The Board is in receipt of a letter from DEP to William Nye (one of the applicants)dated February 4, 1997 stating that"the department interprets compliance with the requirements of 310 - l CMR 15.005 (3)(a) through (c) to require, pursuant;to 310 CMR 15.005(c), a considered assessment by the proponent of approved nitrogen removal technologies when site limitations prevent attainment of the 440 gallon per acre design flow standard set for new construction under 310 CMR 15.215(1)..." ,< . 4 11. The applicant is entitled to 'pursue an aggregate determination of p. nitrogen loading per 310 CMR 15.216 and DEP guidelines. It is this board's belief that the cumulative acreage in the subdivision, minus the acreage devoted to roads, when considered,in the aggregate is sufficient to allow the construction of 2-bedroom homes (220 gpd design flow) on twenty of the lots and this will be in general compliance with the nitrogen loading requireriients of 310 CMR 15.214. 12. The applicant has acknowledged that lot 15 will be used for drainage and is not to be considered buildable: 13. At the hearings held on August 19, 1997 and September 3, 1997, the applicants proposed to the Board that dwellings located on 20 of the lots, which specific lots they identified, would be limited to 2 bedrooms unless the system(s) are modified to include enhanced nutrient removal as approved by the Board of Health in which case.a dwelling served by a modified system may be permitted to have not more than 3 bedrooms. The remaining four lots would be limited to not more than 3 bedrooms and said system(s) must be modified to include enhanced nutrient removal as approved by the Board of Health. 14. Based upon the evidence presented, the Board finds that the applicants can achieve maximum feasible compliance with 310 CMR 15.000 through either 1) the construction of 2- bedroom homes on twenty of the lots with the remaining four lots provided with nitrogen removal technology; the twenty lots must have appropriate restrictions placed upon their deeds to indicate that only 2 bedrooms are allowed, or 2) the installation of nitrogen removal technology on any lot will entitle the owner to a design flow of 330 gpd. - . 5 I ` 15. The applicant may choose in the future to present to this board an aggregate nitrogen loading which complies with 310 CMR 15.216; this plan, if approved by the board, will negate the restrictions in 14 above. ACTION TAKEN BY BOARD OF HEALTH Based upon the Board's unanimous approval of the proposed findings, the Board of Health voted to take the following action regarding the pending twenty-four applications for..disposal system construction permits submitted by the applicants, Osterville Highland Trust, John Alger, Trustee and ORE Associates, Inc.: A) Disposal System Construction Permits shall issue to ORE Associates, Inc. for lots 3, 5, 7, 9, 11, 13, 17, 19, 21, 25 and to Osterville Highland Trust, John Alger, Trustee for lots 2, 4, 6, 8, 10, 14, 16, 18, 20, 24, as designed, said issuance subject to compliance with the following conditions: 1. All dwellings shall be limited to 2 bedrooms unless the system(s) is modified to include enhanced nutrient removal.as approved by the Board of Health in which case a dwelling served by a modified system may be permitted to have not more than 3 bedrooms. 2. Each plan.shall be modified by the applicants to include a notation containing the full text of the language recited in paragraph (A)(1) above. 3. Deed restrictions, approved as to form by the Town Attorney, limiting the use of the •ellings,to-two bedrooms on each of the above-referenced lots shall be recorded at the stable Registry of Deeds. A copy of the recorded deed restriction for the particular lot for 6 which a Disposal System Construction Permit is°sought shall be provided to the Barnstable Board of Health prior to the issuance'of a Disposal System Construction Permit. (B) Disposal System Construction Permits shall issue to ORE Associates, Inc. for lots I and 23 and to Osterville Highland Trust,'John Alger, Trustee for lots 12 and 22, as designed, subject • k to compliance with the following conditions: . 1. All dwellings shall be limited to not more than 3 bedrooms and said systems) must be modified to include enhanced nutrient removal as approved by the Board of Health. 2. Each plan shall be modified by the applicants to include a,notation' containing the full text of the language recited in paragraph (B)(1) above. ,.., (C) No permit shall issue for;lot 15 which has been designated,,pursuant to the initial subdivision approval by the Planning Board, as a lot reserved.for drainage. (D) The issuance of the permits, as restricted, shall not prejudice or otherwise limit the right of both applicants, jointly or severally, to file with the Board of Health and the.DEP a plan pursuant to the provisions of 310 CMR 15.216(2), nor shall,the mere filing of such a plan obligate the Board of Health to approve same. VOTE: IN FAVOR OF DECISION : 'RASK, GRADY, MURPHY OPPOSED: NONE Dated: October 7, 1997 ° Susan Rask, Chair Barnstable Board of Health `i ,