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Home My WebLink About0082 FORTES WAY - Health 82 fortes Way OsteNille P A = 165 047 1 N III Commonwealth of Massachusetts lug. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Fortes Way c Property Address Timothy Buchanan 00 Owner Owner's Name/ information is Osterville �/ �$required for every Ma.- 02655 11/08/2016 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 0 on the computer, V a use only the tab 1. Inspector: key to move your cursor-do not Michael T Bisienere use the return key. Name of Inspector Cape Septic Inspections Company Name 624 Old Barnstable Road Company Address Mashpee Ma. 02649 Cltyrrown State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage-disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑- Fails ❑ Needs Further Evaluation by the Local Approving Authority ��11/11/201663 ' Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 - Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Fortes Way Property Address Timothy Buchanan Owner Owner's Name information is required for every Osterville Ma. 02655 11/08/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This home has a H-10 1000 gallon septic tank with two 1000 gallon leaching pits with appx. four feet of stone around them at the time of the insption there was appx. 3 feet of ponding water in the first leaching pit and the second leaching pit was dry the covers are raised on all of the componetes B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 r— Commonwealth of Massachusett s WU Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Fortes Wa y Property Address Timothy Buchanan Owner Owner's Name information is required for every Osterville Ma. 02655 11/08/2016 page. CI crown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if Pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board,of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y '❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health safety or the env ironment. n t. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Tithe 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments g` 82 Fo rtes Way Property Address Timothy Buchanan Owner information is Owner's Name required for every Osterville Ma. 02655 11/08/2016 page. City/Town State Zip Code Date of inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: " This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: { D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the round or❑ ® g surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 r r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 82 Fortes Way Property Address Timothy Buchanan Owner Owner's Name information is required for every Osterville Ma. 02655 11/08/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No } ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 _.1 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Fortes Way M , Property Address Timothy Buchanan Owner Owners Name information is required for every Osterville Ma. 02655 11/08/2016 page. Cityfrown State Zip Code ' Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ Pumping information'was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? - ® ❑ Were as built plans of the system obtained and examined? (if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® Were all system components, excluding the SAS, located on site? Z ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of,bedrooms): >330 t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 6 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 82 Fortes Way Property Address Timothy Buchanan Owner Owner's Name information is required for every Osterville Ma. 02655 11/08/2016 page. CitylTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Well Water 9 ( Y 9 (gp ))� Detail: The well is 100 plus feet from the s.a.s. Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 ' Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,.•`� 82 Fortes Wa Property Address Timothy Buchanan Owner Owner's Name information is required for every Osterville Ma. 02655 11/08/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: Z Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Fortes Way Property Address Timothy Buchanan Owner information is Owner's Name required for every Osterville Ma. 02655 11/08/2016 page. EVrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 33" 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.): Septic Tank(locate on site plan): Depth below grade: 24" feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: standard H-101000 gallon Sludge depth: 3„ t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 9 of 17 Commonwealth of Massachusetts A�. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments p 82 Fortes Way Property Address Timothy Buchanan Owner Owner's Name information is required for every Osterville Ma. 02655 11/08/2016 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle apx. 35" Scum thickness 1 Distance from top of scum to top of outlet tee or baffle apx. 5" Distance from bottom of scum to bottom of outlet tee or baffle apx. 12" How were dimensions determined? sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I would recommend the new owner put the tank on a maint. plan with a local septic pumping co. based on the future use of the home.The Barnstable Health Dept. has a list of local pumping co. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene y ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Fortes Way Property Address Timothy Buchanan Owner Owner's Name information is required for every Osterville Ma. 02655 11/08/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 • Commonwealth of Massachusetts _ m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 82 Fortes Way Property Address Timothy Buchanan Owner Owner's Name information is required for every Osterville Ma. 02655 11/08/2016 page. City/Town State' Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert N/A 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(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -' Not for Voluntary Assessments 82 Fortes Way Property Address Timothy Buchanan Owner Owners Name information is required for every Clsterville Ma. 02655 11/08/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: Two ❑ 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.): At the time of the inspection there was appx. 3 feet of ponding water in the first pit and the second pit was dry and there were no signs of past hydraulic failure Cesspools (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 ❑ No t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t 82 Fortes Way Property Address Timothy Buchanan Owner information is Owner's Name required for every Osterville Ma. 02655 11/08/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 f Commonwealth of Massachusetts Title 5 Offici:al Ins ect on 'Form Subsurface Sewage Disposal System Form -Not for VoluntaryAssessments menu 82 Fortes Way Property Address Timothy Buchanan Owner information is Owner's Name required for every Osterville Ma. 02666 11/08/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (Cont.) Sketch Of Sewage-Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately e e�l ?iv J 0 0 +Z At It .. go 1 11/11/2016 3:59 PM. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •�' 82 Fortes Way Property Address Timothy Buchanan Owner .Owners Name information is required for every Osterville Ma. 02655 11/08/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 15 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: • Date ® Observed site(abutting property/observation'hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: I augered a hole to 15 feet and found no H2O Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 official Inspection . p Form Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments 82 Fortes Way Property Address Timothy Buchanan Owner Owner's Name information is required for every Osterville Ma. 02655 11/08/2016 page. Ciry/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems)completed System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 11 of - I - L t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Fee--- ---------------- No.-- -- --- - BOARD OF HEALTH TOWN OF BARNSTABLE ApptitationArVell Con-Otruction Permit Application is hereby made for a permit to Construct K), Alter ( ), or Repair_S_ )an individual Well at: Location —f Address Assessors Map and Parcel /yfJyOJ'w/ner Address f� Installer — Driller Address — Type of Building Dwelling-- -- - -- -- --- - Other - Type of Building-------------- - No. of Persons- Type - ------------- q&q Type of Well— " Purpose of Well - !��------- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation i rt-ifis to of Compliance has been issued by the Board of Health. Signe _ #d. Application Approved By Application Disapproved for the following rea s:-------------------------— - --- - ----------- — - ---- ------------------- -- --- — date Permit No. -- Issued---- -- -� - - - - da BOARD OF HEALTH TOWN OF BARNSTA.BLE Certificate Of Compliance THIS IS T ERTI at the I ivi u Well Co t cted Altered ( ), or Repaired ( ) -1 O - - - - --- ---- - by-- - Ins er f _ --------- /I� A V ' ! I has been installed in accordance with the provisions of the Town of Barnstable Board of Health vate Well Pr ection �� Regulation as described in the application for Well Construction Permit No.1V&11 dated-- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE----- -—-- — - - Inspector-- ---— - -- - - -- li ' y `No.--------------9 Fee-7Z7--=------------- iE BOARD OF HEALTH s TOWN OF BARNSTABLE 0(pplicat ion,for lVell Con$truct ion 30ermit Application is her by made forq-a permit to Construct ( , Alter ( ), or Repair )an individual Well at: " - - ----------- --- — t . Locatio Address _ :Assessors:Asse Map and Parcel — r(A4 ,>0Ckf4AJAJ " — — �r�,�JS�_ /Z�� 1�.57�2�Jttt��9 6 Owner - Address r �, !(��r7t'�-_�1��-__fat�4.�-r� -Z,c.�c. t�i--- '-----�=-��•-�y/" -/1f,EA£'�c� , ��?�'l Installer — Driller Address Type of Building Dwelling --- -- — —-- - Other - Type of Building No, of Persons----------------------------- � t �---- Ca acit Type of Well---------------- P Y-----_---\169 -- Purpose of We1F2—)Q '�- Agreement: �� The undersigned agrees to install the aforedescribed individual well in accordance/with the provisions of.The Town of Barnstable Board of Health Private Well Protection Regulation The undersigned further agrees not to place the well in operation untila i to of Compliance has been issued by the Board of Health. t Sign- � _ Application Approved By _ _ — — / Application Disapproved for the following rea ns: ------------- -- r � ----- ----( �) /`� 1 r.+- — -------.--------- �------d— _ date Permit No.----- Issued ----�- - r t L dat S BOARD OF HEALTH TOWN OF BARNSTABLE Certificate (Of (Compliance THIS I T E TI1 , _t thel II I 'du 1 We Co t z�cteld Altered ( ), or Repaired ( ) by--- �'kt v '`' Instal er ro r6z WA VI at- -— -- --------- -- k :' x 'j has been installed in accordance with the proves ns of the Town o,Barnstable,Board of Health vate Well Pr ection 1a2-' Regulation as described in the application for Well Construction Permit No. ated—!-/ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS'A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. p k DATE----------- - - Inspector--- -- - - ------—- BOARD OF HEALTHY TOWN OF BARNSTABL,EY . well Con5tructionermt; _,: ;m � t rr t o Permission is hereby granted -to Cons �u��` (-�,�jlt�er ),vo • pa' " ndivid al =ea No. —( � r 1 4 l�� --- as sho on the apph ation for W 11 Construction irmit No.-- t t V,t, '(Dated .�---- - Board o 7A`alth� DATE � 'Map Page 1 of 1 Town of Barnstable Geographic Information System New Search Home I Help Parcel Viewer Custom Map Abutters ■ . Zoom Out Jill 1"'In 41 �, 1PT� Q LP Ej a=7PG Map: 165 Parcel: 047 Pro ert P Y 1ee014 Location: 82 FORTES WAY Info N 151 Owner: BUCHANAN,TIMOTHY 137 1ee100 t 168013 O N76 Map&Parcel 165047 Location 82 FORTES WAY Acreage 1.01 acres a ti a Current Owner Mailing Address BUCHANAN,TIMOTHY P 0 BOX 189 w. l OSTERVILLE,MA 02655 few I I N 9] 1e5101 — —---------- —— 0127 Appraised Value(FY 2012) Extra Features $30,700 Out Buildings $5,100 Land $160,700 Buildings $82,500 }�, `• Total Appraised $279,000 Assessed Value(FY 2012) 1 -102 Extra Features $30,700 r•� N75 '� - - °T17 Out Buildings $5,100 t 4 Land $160,700 .1 r: 9 Buildings $82,500 Total Assessed $279,000 Set Scale 1" = 64 April 2008 J I MAP DISCLAIMER Copyright 2005-2010 Town of Barnstable,MA All rights reserved.Send questions or comments to GIS http://66.203.95.236/arcims/appgeoapp/map.aspx?propertyID=165047 7/23/2012 0ofll OFFICIAL IINSPECTION FORM — NOT FOR VOLUNTARY ASSESSJNIENT SUBSURFACE SENVAGE DISPOSAL SYSTE:ti1 INSPECTION FORS] IF PART C SYSTEM INFOR-'MATI0N (continued) Property Address: — 0 /� `3�.��f Lc �� h.1TCc;�;//�_ j+►4 Owner: Date of Inspection: . SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks: Locate all wells within 100 feet. Locate where public water supply enters the buildine. j F i i •''�' ram'°- � � Moll. ;2 a ofie.. Way, o�stewill r xd r x � '�. �• h y4. y, i W n >♦t -y R�'^y� _ .t it _ �•� i "'�,�r!`:',, e G000le-eartk n20'2'Googie. / � 1 t< l Massachusetts-Department:of Conservation and._Recreation Office of Water Resources 164173 TYPE OR PRINT ONLY Well:COmpletiOln Report 1.WELL LOCATION' GPS (Required)° North -2a 3—62_'7 &- West _I s .' Address at Well-Location: _.�o2 t 5 +* Property Owner/Client: M/M O Ttt �6 t 4AA A " Subdivision-Name:. Mailing Address: 01. -Box 1.8 Cityfrown: City/Town: ,-r -evf -L MA Assessors Map 1 k5 Assessors Lot#: 047 NOTE: Assessors Map and Lot# mandatory rf no sU'.etaddt6ss available 2. 0 ul2�x � Board of Health permit obtained.. : Yes N.. Not Required ❑ Permit Number Date.,lssued 2.WORK-PERFORMED = 3 WELL,-TYPE _ a . 4:DRILLING METHOD 6 CASING '= Overburden Bedrock From(ft) To (ft) ,- Type ` Thickness Diameter 0 0 0000 ❑� -0 ❑ b C - oM sue .0 5.WELL LOG' OVERBURDEN Extra " ❑y❑ Water. Loss or Drop in LITHOLOGY Bearing Addition Drill Fast or Ell]❑ ow From(ft) To(ft) Code Coloe Comment Zone of Fluid Stem . D u Rate 7,°SCREEN From (ft):�To(ft)` ~'"` Type Slot Size .Diameter ,b 3W M$ W/ Z)c-K Y / N Y /-N F / S _61g 2 L�p 0 4` F a' 1 W A0 Y / N Y / N F / S ❑❑❑ _ - - - t �+ Y / N Y / N F / S ; S.' ANNULAR=SEAL/FILTER PACK/ABANDONMENT MTL (pc�,9 51 LA ND Y / N Y / N F / A From(fi) To`(ft) Material Description Purpose S (Al Y / N I Y./ N F / $� �QI �K 32 Y / N Y / N S'l ❑❑ . 2 17R I Wa- Y / N Y / N F,/ ❑❑ ❑❑ Y / N Y /, N- I `S 1111 ❑❑ WELL LOGY BEDROCK ExEia 9<SITE SKETCH-.r; ; . - ..-Water Drop in Fast—s Extra IS le Loss or #of, r LITHOLOGY Bearing Drill Large Slow 'Rust Addition Fracture From(ft) To (ft)- Code Comment Zone Stem Chips+06II Rate Staining of Fluid per foot i Y / NF / S Y / N Y / N Y / NY1) N F / S Y / N Y / N l / NYC/-N F / S Y / N Y ! N ✓cp' - +' ( �Y /"NY / N F / S Y / N Y / N trL'�- w Y�/�N jY / N F / S Y / N Y / NAt. r 1_- %IVY / N F./ S Y / N Y / N 4 % NY / N F / S Y / N Y / N c.< € `, - Y / NY / N F / S Y / N Y / N 2 s+ Y / N Y / N F / S Y / N Y / N a Y / N Y / N F / S Y / N Y / N .` t0:WEL TESTCF TA(A SECTIONS MANDATORY FOR PRODUCTtON.,WELLS) „E; 11.;STATIC'WATERtEVEL'(ALL WELLS) - Yield TAe Pumped Pumping Level Time to Recover Recovery Depth Below Date Method (GPM) (h►s&min)f (Ft. BGS) (hrs& min) (Ft. BGS) DateMeasured Ground Surface (ft) / 12. PERMANENT"PUMP(IF AVAILABLE) 13.ADDITIONAL WELL INFORMATION Pump Description Horsepower® ® Horsepower ®:S Developed .% N Fracture Enhancement Y / N Pump Intake Depth , (ft) Nominal Pump Capacity (9pm) Disinfected(o N Surface-Seal Type 14. COMMENTS 44 A L 1 Total Well Depth �2' Depth to.Bedrock 15. WELL DRILLER'S STATEMENT This well was drilled, altered, an�q abandoned under my supervision, according to applicable -.,. rules and regulations, and"tfiis ort i complete and correct to the best of my knowledge. Driller: Supervising Driller Signature: -- Registration #:1 1 / i g A Firm: AT-&4: ,7tc_ rye � (uc( r, Date Com fete: - 27 Z Rig Permit#: I I I I 61q Ii xWelL Pmpletion Reports,' st'be_filed by,the registered.well driller,wathin 30,days i'of well completion.,-, .. e Well Completion Report Codes 41 Section°2 , ' Section 3 Section 4 Work _ Well Drilling Work - Performed Type Method Performed .Code Well Type Code Drilling Method Code Decommission DC Cathodic Protection CTPR Air Hammer AH Deepen DP Domestic DMST Air Rotary AR Hydrofracture HF Geoconstruction GCON Auger AG, New Well NW Geothermal Closed Loop GTCL Cable Tool CT Repair RP t Geothermal Open Loop GTOL Casing Advancement CA Replacement RE Industrial INDS Core -CR Injection INJC Direct Push DP Irrigation IRRG Drive and Wash DW Monitoring MONT _r ' r Dug DG - _ +, Public Water Supply PBWS ; Mud Rotary MR Recovery RCVR Reverse Rotary RR Test Wells TSTW Sonic SN s Section 5. Section 6 Overburden i Casing Lithology Overburden Overburden Overburden Bedrock c Type t -Thickness Name (OB)Code Color Color Code Bedrock Name (BR Code) ',, - Casing Type Code Thickness_ (NO CODE) Artificial Fill AF Black BL Amphibolite AM Certa-Lok' CTL Schedule 5 Boulders B Bluish Gray BG Basalt BS , Fiberglass FBG Schedule 10 Clay CL Brown BR Conglomerate(Breccia CG/BR Galvanized Pipe GLP Schedule 40•' Coarse Sand CS ,. Dark Gray _ DG" Diorite DI HDPE HDP Schedule 80 Cobbles ' C r' Greenish Gray GG Gabbro GB. NSF Coated Steel NCS Schedule 160 Fine Sand FS Light Gray LG Gneiss GN PVC PVC SDR 13.5 Fine to Coarse Sand FCS Reddish Brown RB_ Granite GR Stainless.Steel SST SDR 17 Gravel G Yellowish Brown YB Limestone LS Steel STL- SDR 21 Medium Sand MS Marble MA SDR 26 Organics 0 Quartzite QZ SDR 32.5 Sand&Gravel SG Rhyolite RH SDR.40 Silt SI Sandstone SS 17# Silty Clay SICL Schist SC 19# Silty Sand SIS Shale . SH Silty Sand&Gravel SISG Slate/Phyllite SL/PH Till T Pegmatite PM Section 7 r� Section 8 Section 10 Annular Seal/Filter Screen-., Annular Seal/Filter _ Pack/Abandonment Purpose Method Screen Type Code Pack/Abandonment Material Code Purpose Code Method = Code Carbon Steel CST Bentonite Chips/Pellets BC Fill FL Air Blow with Drill Stem AB Continuous Wire PVC' CWP Bentonite Grout BG Filter FT Air Lift AL Galvanized Wire Wrapped GWW Cement/Bentonite Grout CB Seal AS Bailing BL Perforated Pipe PFP Concrete CT Constant Rate Pump CR Pre-pack PVC PPP - Sand SD Variable Rate Pump VR Pre-pack Stainless PPS 'Native Material NM - Slug SG Slotted PVC SLP- , Stainless Steel Vee Wire SSV _ Stainless Steel'Well Point SSP Section 12 Section 13 Pump = Description Well Seal Pump Description Code Horsepower. Surface Seal Type Type Code 3 Wire Variable Speed Submersible 3WVS 112 20 Cement,. CM 2 Wire Variable Speed Submersible 2WVS 3/4 25 - Cement/Bentonite CB 2 Wire Constant Speed Submersible 2WSS 1 30 Concrete CT 3 Wire Constant Speed Submersible 3WSS .. 1 1/2, 40 None- NO Constant Speed Submersible Turbine CSST j 2 50 Variable Speed Submersible Turbine -VSST_ 3 -60 yet JET 5 75 Line Shaft Turbine LST ' 7 1/2 100 _ Centrifical CENT 10 125 15 . 150 ENVIROTECII LABORATORIES,INC MA CERT NO.:M-MA 063 8 Jait Sebastian Drive Unit 12 Sandwich,MA 02563 (508)888-6460 1-800-339-6460 FAX(508)888-6446 Client Name Atlantic Well Drilling Location 82 Fortes Way Address PO Box 339 Osterville,MA No.Eastham MA 02651 Sample Date 07/25/12 Collected By Client Sample Time 14:45 Sample Type New Well Date Received 07/26/12 Lab Order Number DW-122101 Well Specs 4"PVC 72'Deep 46'Static LocatieraSotarce Bate Collected.- Time Collected - comments - "A '. , 07/25/12 14 45 Analysis Requested Units Recommended Limits Analysis Result `Method Date Analyzed Analyzed By Total Coliform 1100ml 0 0 SM9222B 7/25/2012 RS pH pH units 6.5-8.5 6.37 SM4500-H-B 7/26/2012 LL _--------- - - ---- -- --- --- --- - ---------- -- - - - ---- .. _ .. ----------- Specific Conductance= umhos/cm 500 3 145 *EPA 120.1 7/26/2012 LL Nitrite-N mg/L 1.00 <0.004 EPA 300.0 7/26/2012 LL Nitrate-N mg/L 10.0 0.10 EPA 300.0 7/26/2012 LL Sodium mg/L 20.0 29.9 EPA 200.7 7/27/2012 MC Total Irona mg/L 0.3 0.09 EPA 200.7 7/27/2012 MC - - ----- --- ------- ---_ --- ------- --- - ----- ----- -- - --------- -------- ---- - Manganese= m9/L 0.05 <0.008 EPA 200.7 7/27/2012 MC Location Source. -Date Collected Title Collected Comments B 07/25112 NA Analysis Requested Units Recommended Limits Analysis Result Method Date Analyzed Analyzed By Volatile Organic Compounds' ug/L See comment. EPA 524.2 8/1/2012 RS Comments: pH is below recommended limit and may have corrosive characteristics. - Sodium level is not a health hazard. Total Trihalomethanes can not exceed 80. ` Water meets EPA standards aid is suitable for drinking for parameters tested. - Date -- _ Ronald J a Laborato D rector • r BRL=Beloiv Reportable Limits ;See Attached Page 1 of 1 ❑Certification is not available for this analyte for non potable water samples.. New England ChromaChem 6 Nichols Street Salem,MA 01970 978-744-6600 Massachusetts DEP Lab.MA-072 Sample Information EPA Method 524.2 Rev 4.1 Volatile Organic Compounds in Water Lab ID: 208001 Client: Envirotech Laboratory,Inc. Client ID: DW-122101 82 Fortes Way,Osterville MA State: Liquid Date Sampled: 07/25/12 Date Received: 08/01/12 Date Analyzed: 08/01/12 MCL - ----- Regulated VOC's Results(uglL) (ugll) Unregulated V C's Results ug Benzene ND 5 Acetone ND Carbon Tetrachloride ND 5 Bromobenzene ND 1,1-Dichloroethene ND 7 Bromochloromethane ND 1,2-Dichloroethane ND 5 Bromodichloromethane ND 1,2-Dichlorobenzene ND 600 Bromoform 1.29 1,4-Dichlorobenzene ND 5 Bromomethane ND Trichloroethene ND 5 2-Butanone ND 1,1,1-Trchloroethane ND 200 N-Bu benzene ND Vinyl Chloride ND 2 Sec-Butylbenzene ND Chlorobenzene ND 100 Tert-Butylbenzene ND cis-1,2-dichloroethene ND 70 Chloroethane ND trans-1,2-dichloroethene ND E 100 Chloroform 1.71 1,2-Dichloro ro ane ND 5 Chloromethane ND Eth Ibenzene ND 700 2-Chlorotoluene ND Styrene ND 100 4-Chlorotoluene ND Tetrachloroethene ND 5 Dibromochloromethane 0.80 Toluene ND 1000 1,2-Dibromo-3-Chloro ro ane ND X lenes otal ND 10000 1,2-Dibromoethane ND Methvlene Chloride ND 5 Dibromomethane ND 1,2,4-Tdchlorobenzene ND 70 1,3-Dichlorobenzene ND 1,12-Tdchloroethane ND 5 Dichlorodifluoromethane ND 1,1-Dichloroethane IND 1,3-Dichloro ro ane ND 2,2-Dichloro ropane ND 1,1-Dichloro ro ene ND Hexachlorobutadiene ND Iso ro Ibenzene ND __.....-_ P-tso ro"ltoluene ---ND Methyl-tert-butyl ether ND Naphthalene ND N-Propylbenzene ND 1,1,1,2-Tetrachloroethane ND 1,1,2,2-Tetrachloroethane ND _ 1,2,3-Tdchlorobenzene ND Trichlorofluoromethane ND 1,2 3-Trichloro ro ane ND 1 2,4-Trimeth Ibenzene ND 1,3,5-Tdmeth Ibenzene ND Analysis Detection Limit=0.5 u /L Recoveries of Internal Standards % Benzene-d6 198 4-Bromofluorobenzene 1103 MCL TTHM's=80 ug/L 1,2-Dichlorobenzene-d4 106 Method Detection Limit=0.5 ug/L Analysis performed per 310CMR42 Electronically signed and approved by Mr.Bruce A.Bornstein,Lab Director Date: 8/2/2012 >�: s�. Page: 1 'M CERTIFICATE OF ANALYSIS g Barnstable County Health Laboratory Report Dated: 5/7/2004 RECEIVED Report Prepared For: Tim Buchanan Order No.: G042505 MAY 1 2: 2004 Buchanan,Tim P. O.Box,189 TOWN OF BARNSTABLE HEALTH DEPT. Osterville. MA 02665 Laboratory ID 0425059-01 Description: Water-Drinking Water Sample#: 25059 Sampling Location 82 Fortes Way Osterville MA Collected: 5/6/2004 Collected by: T Buchanan Received: 5/6/2004 Routine " ITEM RESULT UNITS RL MCL Method# Tested i LAB: IC Lab Nitrates 0.7 mg/L 0.1 l0 EPA 300.0 5/7/2004 LAB: Metals Copper 3.3 mg/L 0.1 1.3 SM 3111E 5/7/2004 Iron 0..1 mg/L 0.1 0.3 SM 3111 B 5/7/2004 Sodium 29 .'i mg/L 1.0 20 SM 311113 5/7/2004 LAB: Microbiology Total Coliform Absent P/A Absent Absent 309 5/6/2004 LAB: Physical Chemistry Conductance 211 umohs/cm l EPA 120.1 5/7/2004 pH 6.2 pH-units 0 EPA 150.1 5/7/2004 I 'Sodium level above the average.Those on a low sodium diet may wish to contact a_physicians - Approved By: Director) 1L •� }C.'i:. •v{c Ttr+. _r..,.`j ,,,.r ,4 ,�7fr_?,',)e '9vJ. ,._r,!ii'._, r1 ;T•; G jC • ;� •• _ ,..,,Y r s'.•`.j` ,..i k'-� ... `�i�1�sT' �'a.+t:.b l;ti i - Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 . e - - COMMWLTH OFMA 9� EXECUTIVE OFFICE 01, ENVIRONME NTAL AFF,.-u i),s DF-PART.NIENTOF E\"viRON.NIE' NTAL PR0TECTj(),N1 k.- F RECEIVED q . kP-vl U PARCEL MAR 10 2004 LOT TOWN OF BARNSTABLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM OT FOR VOLUNTARY Y ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION' Property Address: 8') FL,4 CV 53 Owner's Name: Address: _,,ry 6 Date of Inspection: ril, (jf Name of Inspector: (please print) Company Name: 4 4 AcTjo tj Mailing cil�wvv�— Address P 7 V. .Te lephone Numb CERTIFICATION STATENIENT I certify that I have ,,wrsonal!� if)sPecze.` the sewage disposal S�Stc!l� at (this address and,that the inform belov,� is true, accurate and c ' -ition repon�:-ci OMPjele as o(the time ot'the inspection. The inspection was performed based on t1l) training and experience in the proper function and maintenance ol'on site sewage disposal systems. I am a DE11 approved system inspector pursuant to section 15.340 of Title 5(310 C M R- 15.000).:The system..' Passes Conditionally Passes —c. Needs Further Eva lua t il_oc,li Falls approving Authority Inspector's Signature: A C- Date: G c-- The system inspector shall submit e Dy off this PY of inspection report to the Aing Authority (Board of Health of- DEP) within 30 days of completing this mspection. if pprov 1-ne sysiern is a sha'red system or has a design flow o l' i o,o(j;j gpd or greater, the inspector and the system owner shall submit the report tO the appropriate ree-jonal OPICC 01'the. DEP. The ol-jotila authority. should be sent to system.te owner vner and copies sent to the buyer, ii applicable, and tits approvit-It., • &N.145 Notes and Comments!`., ****This report only describes conditions at The time'of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5hispectionF'on-ri 6,15"21000 page 1 7 OFFICIXL INSPECTION FORM — N`OT SUBSURFACE SEWAGE DISPOS AL�R VOLUNT A�RY ASSESSMENTS STEM INSPECTI()!'� FORM PART .A CEkTIFIC'.-�TION (continued) Property Address:_�y Owner: ��1C, Z Date Orin sPection: lospection Summan: Check .-N,B,C,D or E ;A L;;',q yS complete all of A.�Ihave —�" P Section D asses: not found any information which indicates that a 15.303 or in 310 CMR 15.304 exist. Any fai!ure criteriaany of the failure criteria described in 3 10 CM not evaluated are indicated below. Comments: B• System,Conditionally Passes: _ One or mo vstem com repaired. The system,.0 ponents as described in the Conditional Pass" section need to be r-. completion ol'the re lacernent orC , as P cpiacra �:r repairapproved by the Board of Health, will pass. Answer yes, no or not determined (Y, ,�explain, ) in the for the following statements. If"not determined" __� The septic. tank is metal.and over 2 Please unsound, exhibits substantial inf 0 Years o • or the septic tank (`•�heu existing tank is replaced with a com tiv nor e)•. le metal or not I.r non r,tank failure Is Ic lank, asmminc;nC. S}'stern will `A metal septic tank will pass inspection ifsitpslswcturall s indicating that the tank is less than ?p roved by the Boiird of Health. pass ulspect,orl 11 u;, Years old is available. nd'.norleaking and if a Certificate of Cornp�ia,��.,, ND explain: i Observation ot'se,,ti-age b obstructed i e s «ckup or break out or high static �,aler ievc•! , P P O or due to a broken, settled or uneven distribution box. System approval 01 Board of Health): tale alsrrlbuuon oox uuc ,;; > 1 pass inspection if(with ,r broken Pipe(s)are replaced obstruction is removed distribution box is'leveled or replaced ND explain:,..-'" � __7Z'The system required pumping more than 4;times a piss inspection if(with approval of the Board of Health); }ear due to broken or obstructed pipe(s). The system w' ll III broken pipe(s) are replaced obstruction is removed ND explain: OFFICIAL, INSPECTION FORM - NOT FOR VOL SUBSURFACE SE«'A(;E DISPOSAL SYSTEM INSPECTION UNTARY ASSFSS�1E�'"l S PART A ION FOR(Yl CERTIFICATION (continued) Property Address: Owner: �.� C'�7 l c , Date of Inspection: �. �A �z y C. Further Evaluation is Required by the Board of Health: exist which Conditions public health,reqry or the environment. require further evaluation b Y the Board of Health in is failing rder to determine if the system 1• System will pass unless Board of Health determines in ordanc'e with 310 C'1 System is not functioning in a manner which will �� sect public health, safety and the e�>l�irlonmtenrtt: Fire _ Cesspool or privy is within 50 feet o _ Cesspool or privy is within 50 t of a bordering vegetated wetlan or a sa - marsh_._...__._..._ 2• :System will fail unless the Board of Health (and Public Water Supplier, if an system is functioning,in a manner that protects the public health, safety and envir -, y) determines that the• ` on�ment. _ The system has a``sePtic tank and soil absorption system (SAS) and the SAS 'is�vithi surface water supply or tributary to a surface water supply. n .00 i�.et of a The system has a septic tank and SAS and the SAS is w / tt•t.•� Lone I of a public water suppiv. _ The system has a septic �� P tank and SAS, d the SAS ithin 50 feet of a private water supply well. _ The system has a septic tank and SAS an private ce water Supply I •well•• e S is less than !00 feet but 50 feet or more from a PP y Method use o determine is less "This system passes if the ,a ' water analysis, error �r --_� ------- -bacteriaand volatile or�a P med at a ..�Lf certified laboratory• i coon and Indicates that the ��eli is tree From pollution from that tac:i!iry ;u:d the presence of am or col form to nitrogen and nitrate nitrogen is equal to or less than 5 failure criteria triggered. A copy of the analysis must be attached to this form,pprn, provided that no other 3. Other: Page 4 of I I ti OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK] PART A CERTIFICATION (continued) Property Address: 4 Owner:. Date of lnspection: D. System Failure Criteria applicable to all systems: You must indicate "yes" or"no" to each of the following for all inspections: Yes No ckup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ischarge or ponding of etlluent to the surface of the ground or surface waters due to an overlo;;dee r logged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS of esspool Liquid depth in cesspool is less than 6" below invert or available volume is less than '/ day flow �equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Nurnber of times pumped Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or pricy is within 100 feet of a surface water supply or tributan to a curia:;:, water supply. Any portion of a cesspool or privy is within a Zone I of a public well. _ 1 v portion of a cesspool or pr�ti is within 50 feet of a private water supply well, �y portion of a cesspool or privy is less than 100 feet but greater than 50 feet I7om a private ae supply well with no acceptable eater qualiry analysis. (This system passes if the well water anak,.is, 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 ammoni:i nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteri:, are triggered. A copy of the analysis must be attached to this form,) !L—=(Yes/No) The system fails, I have determined that one or more of the above failure criteria exist as described fn 310 CMR 15.303, therefore the system fails. The system owner should contact the Hoard o Health to determine �+hat will be necessary to correct the failure. E. Large Systems: ,To be considered a large ,stem the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes" o'r-"no" to each of the,following: (The following criteria apply to large' stems in addition to the criteria above) yes no the system is within 400 feet of a s e king water supply — _ the system is within 2 eet of a tributary to a surfac inking water supply — , the system ' ocated in a nitrogen sensitive area (Interim ','✓'ellhead Protection Area—IWPA) or a mapped Zone I fa public water supply well If you h answered"Yes" to am question in Section E the s\stcm, is considered a slunlflcant thi-eat, or ajis cj Cl: "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 3 10 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMFI ,'rS SUBSL RFACE SE\V-AGE DISPOS.AI_ SYSTFNI INSPECTION FORM PART 13 CHECKLIST Property Address: �VA,tTZ"jC.S t<u) J);4J,/ Owner: 'c,�irti t Date of Inspection: 1 Check if the following have been done. �'ou must indicate 'yes" or "no" as to each of the followin Yes Pumping information was provided by the 0ner. occupant. or Boar,! of Health Were any of the system components pumped out un the previous two �tieeks ? bZ Has the system received normal flows in the previous two week peri od od . Have large volumes of water been introduced tolthe system recently or as pan of this inspection '? u/ Were as built plans of the systenn ootatnd and e.rarntncd•' ('i t. ��er< riot available note asN;,\) 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 uncoverec. o ned. and the interior of ti e tank inspected for the condition of the baf,les or tees, material of construction, dimensions, depth of liquid, deput of sludge and depth of scum ? Was the facility owner(and occupants if different from owner maintenance of subsurface sewage disposal systems ° )provided with information on the proper The size and location of the Soil ,absorption System (SAS) on the stte has been determined based on: Yes o Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Pan C is at issue a proximation of is unacceptable) (310 CMR I .302(3)(b)) P. distan,< I'a,gc u ui I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM I:NFORIN'IATION Property Address: Owner: —' 6�r l7 �44 ram-; r Date of Inspection: <<1�,� J� FLOW' CONDITION'SRESIDENTIAL Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x # of bedrooms Number of current residents: `?— ) yL' C 2D Does residence have a garbage grinder J(yes or no): 1v' Is laundry on a separate sewage system (yes or no): f'U'j [if Yes separate inspection required] Laundry system inspected (yes or no): Seasonal use: (yes or no): _pLJ �f Water meter readings, if available (last 2 years usage► (gpd)); �l Sump pump (yes or no): d -- Pr Last date of occupancy: 70 Ake-A-0 p I COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 C-,'YiR 15.203): d Basis of design flow (seatsipersons/sgn,etc.):---� Grease trap p nt(yes or no): — — —--- Industrial waste holding _. Non-sanitary waste discharged to the e 5 system (yes or no): Water meter readings, if avail — Last date of occupancy,' OTHER ( ribe): Pumping Records GENERAL INFORMATION , Source of information: Was system pumped as part of the inspection (yes or no): :�' If yes, volume pumped: ,ice �Y 2allons •- Hoy'. was Quantity pumped cieierr.l;r r+' Reason for pumping: ti;J�k TYP OF SYSTEM ---------��__ Septic tank, distribution box, soil absorption system _Single cesspool _Overflow cesspool — Privv _ Shared system (yes or no) (if ves, anach previous inspection records, ii ;!nv) — Innovative/AltematiAtechnOlogv. .Attach a copl Of tf e CU rel;t �1)er3110n U fll a11alntenanCe CUlllraCl ((U be obtained from system owner) Tight tank _Aaach a copy of the DEP approval —Other(describe): Approximate age ofall components, date installed (if known ) and sourer o;'inio!mation: .J- j f i') / �� e l . _e!r�r_J rJ �' ;) J ,1 17 c Were sewage odors detected when arriving at the site (yes or,no): .10� I 6 Pagc 7 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTE%,1 INSPEC•TIO!N F0101 PART C SYSTEM INFORMATION (continued) Property Address: kJ� _ �) Owner: V"', Date of Inspection:tt i- BUILDING SEWER (locate on site plan) Depth below grade: Materials of construction: _cast iron 40 PVC ocher (explain): Distance from private water supple yell or suction !ine Comments (on condition of joints, venting, evidence of ieakage, etc.l: SEPTIC TANK: (locate on site plan) 1 Depth below glade:;3 Material orconsrruction: concrete meta! nberglass _pol}ethylene other(explain) _ — If_tank is metal list age: — Is age confirmed by a Certificate of Compliance (yes or no): certificate) -(attach a copy of Dimensions: ( c}f; y i w— Sludge depth: _ y Distance from top of,sludee to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or bathe: '= Distance from bottom of scum to bottom of outlet tee or baCTie: How were dimensions determined: f°1r_!t �'u r tt 1 Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as`rel ted to outlet invert, evidence of-leakage, etc.): C-z C. :t f t .f} !I i41 E 1 e I < .. lTii � Lrv�:iil oc. � GREASE TRAP: _(locate on site plan) Depth below grade:_ Material of construction:_concrete metal fiberglass__polyethylene other (explain): _ — — Dimensions: Scum thickness: - Distance from top of scum.(o 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 I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSME..N'pS SUBSURFACE SEWAGE DISPOSAL S)i'STF:N7 I N`SPEC'TION F0101 P.-ILRT C SYSTEM INFORMATION (continued) Property Address: 1-1 w , a Si Ct'Jr)/j0 rr,4. Owner: I ' Date of Inspection: p TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of c.o.nstruction: concrete metal fiberglass_poiyethylene _ o,ther(explain) Dimensions: ---- - Capacity: eal!ons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in w g order (yes or no): Date of last pumping: Comments (conditio a arm and float switches, etc.): DISTRIBUTION BOX: (if present must be opened catersite plan) Depth of liqui e outlet invert: Comments (note ifbox is le hri �L� of solids carryover, any evidenci of leakage into or out € x, etc.) v, PUMP CHAMBER: n site plan) -----_--.-._..............._._... Pumps in working order(yes or no): - Alarms in working order(yes o). Comments (note cond of pump chamber, condition of pumps and appurtenances, etc.): 'Page 9 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESStNJj-N,I' SUBSURFACE SE�1 AGE DISPOSAL SYSTEM INSPECTION F0101 PART C SYSTEM INFORMATION (continued) Property Address: 7-1c'I /-� Owner: Date of inspection: /�'2 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: leaching chambers,number: leaching galleries, number: leaching trenches, number, lenzth: leaching fields, number, dimensions overflow cesspool, number: Ln.novative/a item 2live s\-stem T�pe,,name of technology: Comments (note condition or soil, signs of hydraulic failure, level of ponding, damp soil, co ndition ondition of vegetation, etc.): A CESSPOOLS: (cesspool must be Pumped as pail of Lnspec[ion)(Joc�it- on site Number and configurgiQn: Depth-top of liquid to in e --7 Depth of solids layer: Depth of scum layer: Dimensions ot'cesspool-:------- Materials of construction: Indication of groundwater (yeS in 111 Comments (note condition of. 5 igns of hydraulic failure, level of poriding, condition of vegetation, etc. ............ PRIVY: ......... (locate on site plan)) Materials of construction: Dimensions: -------- Depth of solids: Comments (note condition o signs of hydraulic failure, level of ponding, condition of vegetation, etc el- Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORS.] PART C SYSTEM INFOR:'NIATION (continued) Property Address: �� )�,i rf �.�� d,Jl"Cr_�.; Owner; el-yc'T; Date of Inspection; 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 tite building. `r n P \ ,yam r ram/ v\ I ! I Page 1 1 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water� 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: cked with local excavators, installers- (attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Lull t.. 11 Commonwealth of Massachusetts' Executive Office of Environmental Affairs Dept. of Environmental Protection, One winter Street,Boston,Ma. 02108 John Grad D.I .P. Title V Septic Inspector P.O. Box 2119 Teaticket, MA 02536 WILLIAM F.WELD (508)564-6813 Governor 2 ARGEO PAUL CELLUCCI NV Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �) 'PART A 9 �,r+ R ft CERTIFICATION GC `,r � r Property Address: 82 Fortes Way Osterville Map 165 Par 047 Lot 3 Address o Owner: R r Q f .. Date of Inspection: 8112198 (If different) , 1`9, Name of Inspector: John Graci . Valerie Wright-Seay ; }°� & f ' I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) �J F Company Name,Address and Telephone Number: B +t� CERTIFICATION STATEMENT I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. -The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: r X Passes This Inspection Is based on criteria dented InTRIe V COnd1110 all P855e5 code 310 CMR 16303.My findings are ofhow the system is performing at the time of the Inspection.My inspection does _ Needs ur er Evaluation By the Local Approving Authority; not impyany warrontyor guarantee of the longevity ofthe Fails septic system and any of its components useful lire. Inspector's Signature: Date: 8112198 The System Inspector shall ubmit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. i INSPECTION SUMMARY: Check A, B,C,or Do- A] SYSTEM PASSES: u x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303.,Any failure criteria not evaluated are indicated below.' COMMENTS: B] SYSTEM CONDITIONALLY PASSES: - One or more system components need to be replaced or repaired. The system,upon completion " of the replacement or repair,passes inspection. Indicate yes, no, or not determined(Y, N, or ND): Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Co7hpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection or the septic tank,whether or not metal, is cracked; structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is.replaced with a conforming septic tank as approved by the Board of Health. (revised 04127)97) s One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 0 Telephone(617)292-5500 r - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 82 Fortes Way Osterville liap"105 Par 047 Lot 3 Owner: ValerieWrright-Seay „ Date of Inspection:8112198 - _ Sewane backup or.hreakout or hiah.static water level observed.in.the distribution box is due to a broken. r or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced _The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water,. Cesspool or privy is within 50 feet of a bordering vegetated wetland or a'salt marsh. ' 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNEWTHAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform,bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must Indicate either"Yes"or"No"'as to each of the following: _ I.have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. - _ Discharge or ponding of effluent to the surface of the®round or surface waters due to an overloaded or clogged " cesspool. SAS is in hydraulic failure. (rsv19ed04127197). SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued)' Property Address: 92 Fortes Way Osterville Map 165 Par047 Lot 3' Owner: Valerie Wright-Seay Date of Inspection:9112198 D]SYSTEM FAILS(continued) __ y Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less'than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4.times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy,is below the high groundwater elevation. Any portion of a cesspool or privy is within.100 feet of a surface water,supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool oe privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: ' The following criteria apply to large systems in addition to the criteria: is _ The system.serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following-conditions exist: Yes No 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(1WPA)or,a mapped Zone II of a public water supply well) ' The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local,regional office of the Department for further information. (revised 04127)87) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST - Property Address: 82 Fortes Way Osterville Map 165 Par047 Lot 3 Owner: Valerie Wright•Seat' Date of Inspection:911219& ` Check if the following have been done;You must indicate either"Yes"or"No".as to each of the following: _c_ — Pumping information was requested of the owner,occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal — flow rates during that period. Large volumes of water have not been Introduced into the system recently or as part of this inspection. x — As built plans have been obtained and examined. Note if they are not available with N/A. -. x — The facility or dwelling was inspected.for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow.' _x_ — The site was inspected for signs of breakout. x All system components, excluding the Soil Absorption System,have been located on the site: x The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge,depth of scum. x The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, If different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex.,Plan at B.O.H' Determined in the field(if any failure criteria related to Part C is at issue,approximation of distance is x x — unacceptable)[15.302(3)(b)] - (revlsed=7197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION,PE FORM M PART C SYSTEM INFORMATION Property Address: 82 Fortes Way Osterville Map 165 Par 047 Lot 3 r Owner: Valerie Wright•8eay Date of Inspection:8112198 FLOW CONDITIONS RESIDENTIAL:TIAL: .d./bedroom for S.A.S.aao 9P Design flow. ,• . Number of bedrooms: a Number of current residents: 1 r Garbage grinder(yes or no): No Laundry connected to system(yes or no)' yes Seasonal use(yes or no): No Water meter readings,if available:(last two(2)year usage(gpd): rda Sump Pump(yes or no): No Last date of occupancy: nla a COMMERCIAL/INDUSTRIAL:' y Type of establishment: nla Design flow:g gallons/day Grease trap present: (yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings,if available: nre Last date of occupancy: n<a OTHER:(Describe) nra Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Na 4 System pumped as part of inspection:(yes or no)No n If yes,volume pumped:u gallons ` Reason for pumping: nra TYPE OF SYSTEM x Septic tank/distribution,box/soil absorptions system Single cesspool P. t . Overflow cesspool , Privy Shared system(yes or no)'( if yes,attach previous inspection records, if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components, date installed(if known)and source information: Original system Installed In 1971 with new pit Installed 1n April 1990 - Sewage odors detected when arriving at the site: (yes or no) No ` (revised OWD97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) _ Property Address: 92 Fortes Way Osterville Map 165 Par 047 Lot 3 Owner Valerie Wright-Healy Date of Inspection:9r12f98 SEPTIC TANK:x (locate on site plan) Depth below grade: 3' Material of construction:x concreate_metal_FRP_POlyethylene—other(explain) If tank is metal, list age nla . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: Lee"h5'7^w4•t0^ Sludge depth:4" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness:2" Distance from top of scum to top'of outlet tee or baffle:6 Distance form bottom of scum to bottom of outlet tee or baffle: 16" How dimensions were determined: Measured Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) Septic tank and all components are structurally sound and functloning properly.Recommend pumping every two years. GREASE TRAP: (locate on site plan) Depth below grade:ola ,ti` .r Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Y Dimensions: nla Scum thickness:rug, Distance from top of scum to top of outlet tee or baffle:rda " Distance from bottom of scum to bottom of outlet tee or baffle:rva Date of last pumping;�a Comments: ` (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) We BUILDING SEWER: (Locate on site plan) Depth below grade: 3-6-- Material of construction: cast iron x 40 PVC_other(explain) Distance from private water supply well or suction linetown ' Diameter: nia Qmments: (conditions of joints,venting,evidence of leakage,etc.) -2. - (revised 04127197) a _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART'C SYSTEM INFORMATION (continued) Property Address: 82 Fortes Way Osterville Map 165 Par 047 Lot 3 Owner: Valerie Wright-Seay Date of Inspection:8112199 TIGHT OR HOLDING TANK'. Y (locate on site plan) Depth below grade: rda Material of construction:_concrete_metal_FRP_Polyethylene'_other(explain) Dimensions: We Capacity: rda gallons �'• Design flow: rda gallons/day Alarm level:_nra Alarm in working order?—Yes—No T Date of previous pumping:-. Comments: (condition of inlet tee,condition of alarm and float switches,etc.), - rda DISTRIBUTION BOX: Y (locate on site plan) Depth of liquid level above outlet invert: nla " Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.) Na PUMP CHAMBER: (locate on site plan) Pumps in working order.(yes or no)rid a Alarms in working order(yes or no)_ve: Comments; (note condition of pump chamber, condition of'pumps and appurtenances, etc) rda ..-', (revised 0427)811 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C a SYSTEM INFORMATION (continued) Property Address: 82 Fortes Way Osterville Map 165 Par 047 Lot 3 , ti Owner: Valerie Wright-Seay Date of Inspection:9112199 SOIL ABSORPTION SYSTEM (SAS):x (locate on site plan, if possible;excavation not required,but may be approximated by non intrusive methods) If not determined to be present,explain: Type leaching pits, number: 2-1000 gallon leach pits leaching chambers,number:Ne leaching galleries, number: Na ' Y leaching trenches,number,length: Na leaching fields.number, dimensions:rda overflow cesspool, number:Na Alternate system: Na Name of Technology:_Na Comments. (note condition of soil, signs of hydraulic failure,level'of ponding,condition of vegetation, etc.) The leach pits ere structurally sound and functioning properly.The old leach pit was full and the new p@ was empty. CESSPOOLS: , (locate on site plan) _ ° Number and configuration: Na Depth-top of liquid to inlet invert: Na Depth of solids layer: Na I r Depth of scum layer: Na r Dimensions of cesspool: Na Materials of construction: - Na Indication of groundwater: Na _ inflow(cesspool must be pumped as part of inspection) Na Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) Na PRIVY y (locate on site plan) y' Materials of construction: Na Dimensions -Na Depth of solids: Na Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Na (revised 04127)97) f V SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ` SYSTEM INFORMATION(continued) 82 Fortes Way 0sterville Map 165 Par 047 Lot 3" Valerie Wright-Seay 8112198 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) lJ°1 WA.. J : ID,Al�b pevmed04R7187) Paya,f o! 10' s , 'SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 82 Fortes Way Osterviile Map 186 Par 047 Lot Valerie Wright-Seay r. ` 8112198 , Depth of groundwater 12 Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting-property,observation hole, basement sump etc.). Determine it from local conditions Check with local Board of Health - Check FEMA Maps Check pumping records - Check local excavators, installers F x Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) . USGS Maps and charts Y .. • .fit.• - (revised0027197) J lags.30 0['30 TOWN OF BARNSTABLE We LOCAiJN SEWAGE# VILA,AGE ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. J ,.SEPTIC TANK CAPACITY 1000 LEACHING FACILITY: (type) ��C�� (size) ( a0 U ,;,NO.OF BEDROOMS (( nn 11 BUILDER OR OWNER PERMTTDATE: 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 '"` � w AC ® AO 6� qa TOWN OF BARNSTABLE j LOCATiON r'.2- Foat"e,5 UJA v SEWAGE # j VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO.7 1f M AGO A40f F;,X Tia 77r-9337 E EPTIC TANK CAPACITY z LEACHING FACILITYAtype_�/ 1. (size)f o„� ►. NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: L% - DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No J Wit' � Sh i ci i � � a I} r No.._..9b C b l Fss. ...30.00 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliratiun for Uiupuuttl Works Tonutrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair '(XX) an Individual Sewage Disposal System at: 82 Fortes Way-_Osterville ........___--__.•---• -••---------•--------•-• -•-•-....•--------------•-----•----•----•----•-------••-•----•---•--•----••-•--••.........._•----- Location-Address or Lot No. Charles Seay .... __ -- ---- ............................................... .................................................................................................. Owner Address W J.P.Macomber Jr. ,-1 --------- ........ Installer Address Type of Building Size Lot----------------------------Sq. feet U DwellingX—No. of Bedrooms............ -Expansion Attic ( ) Garbage Grinder ( ) pa-, Other—Type of Building ............................ No. of persons--.------..-----.------.---- Showers ( ) — Cafeteria ( ) PL Other fixtures ------------------------------- - ... W Design Flow............................................gallons per person per day. Total daily flow.............................................gallons. WSeptic Tank—Liquid capacity............gallons Length--------------- Width................ Diameter--........--.... Depth................ x Disposal Trench—No..................... Width................... Total Length.................... Total leaching area-----.-----..-------sq. ft. Seepage Pit No--------------------- Diameter----.---.--------.-- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........---............. Test Pit No. 2................minutes per inch Depth of Test Pit--.---.------------- Depth to ground water........................ ---•------------------------------------•-------............---•--•---------------•----------.-•-•--......................................................... 0 Description of Soil-----------------------------------------------------................................................................................................................... v ..................................................Sand...&._Gr_aye_1•••---•------••---•----------•------•-----•---------•------------•------•-----....._..........------------------. W ------------------------------------------------------------------------------------------------------------------------------------------------------------------•---------------------------------•-- V Nature of Repairs or Alterations—Answer when applicable............................................................................................... 1-1000 gallon leaching pit. ................................. •------------•-•-- ---•---------•-----------•--••----•--•----•-----------------------------------------•-••------------------------------•-•----•--................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b edn ssued by the oar of health. Signed -- ----j -- .. .� - ------------------------------- ....4Z3 9Q--_--------- Date Application Approved By .........................................---------------- e Application Disapproved for the following reasons: .. --------------------------------------------------------------- --------------.......................................... ----------- ------ ------------------------ ----- --------- -------- ---- ---- --------------------------...-----------------------------------------------------------------. ...------.........- ------------------ n Dace PermitNo. ..... ��. f- ............................... Issued ............................................................. Date 1_ t a S�� NO.._...!. ...�� Fiml...a i.00... THE COMMONWEALTH OF MASSACHUSETTS 4BOARD OF HEALTH . TOWN OF BARNSTABLE l Apphratiun for Diuvuual Warkii Tonstrudion ranfit Application is hereby made for a Permit to Construct ( ) or Repair (XX) an Individual Sewage Disposal System at: ---82 Fortes Wav Osterville.-----------•--••--------- ---------------------•----•---•-•-------------• ---------_._---------•------------------------ Charles. - ...... -••------•--•-•-----------------•-------------- •••-•-••••--...................................................................................... Owner Address w J.P.Macomber Jr. Installer Address Type of Building Size Lot............................Sq. feet U DwellingX—No. of Bedrooms............ .............................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ------------------------------------------•--- =....-•---- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No.-------------------- Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No____________________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test 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........................ �+ ------------------------------------- ---•-----------------... --•------•-------•--------------------------- •........ --------•-----------------_----- 0 Description of.Soil--------------------•.........--------•-----------------•---........----•--•----------------------------------••---•---------------------••-••-•----•-----•••--•-•••--•- U •-•••-•--•_.........•.... ..,t. =s--- .....----•-........'............................................................................................. W i. t . . -----•---•--••---------•-•....-•-••-•-----•------------------------------------•---•---------------------------------------•-•.._......•... U Nature of Repairs or Alterations—Answer when applicable.............................•............_.._._._._......._._......._......_...............__. 1-1000 Gallon leaching pit. -----------------------•----•--•----------------------•---••-•-•--••----------------•-•-----•--••--------....---------------------------------•------.................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been 'ssued by the board of health. Signed ' 3.100 Application Approved By ........................................ ----- ---- ---- -------------------1%....----..........----..... ....-- --------------------------------------------------....---------- ....................................... Date Application Disapproved for the following reasons- ............................................................... -------------------------------------------------- ---- - -- -- ------------------------------ --- ---------------------------------------------------------------------------------------------------------------------------------------- ............................. ........................................ Permit No. 9r! -/�- ------------------------------- Issued ......................................................... Dare............ are ---- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF' HEALTH, TOWN OF BARNSTABLE Cezttftrate of C�ontlatiaure THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XX ) by......J.-P.,Macomb.er Jr. Installer at ......82...Faxtes-...WAY---Oste............................ .............. has been installed in accordance with,the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No.��...1..-'�l.�l...�7--'...............�.--1 dated _ '--4�FJ................-----.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT I E CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION;SATISFACTORY. DATE..--- Y... l'��..------......................................................... Inspector ....�....q?h it . ---------------........................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH nn TOWN OF BARNSTABLE No. .-...61.... FEE ... :gip.... Rupoual Workg dun rttr Uan �ernti# Permission is hereby granted-- e.r i................ to Construct ( ) or R��eppairX( ) an Individual Sewage Disposal System at No...82.:Fortes Way 6sterville...... ....................... :. Street //ll as shown on the application for Disposal Works Construction Permit No.. .:l.C�..r/. Dated....3�71a._f.�............. ................................... w � .�:..................._ L/ /� ,�b Board of Health DATE.... -••-•...............•-•--•--••----............--••--•--... FORM 36508 HOBBS&WARREN,INC..PUBLISHERS