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HomeMy WebLinkAbout0018 FOX HOLLOW LANE - Health 18 Fox Hollow Lane Osterville P M `A = 145 006004 e ,. N o a Flynn, Judith From: richandersonfire@gmail.com Sent: Wednesday, May 04, 2016 5:12 PM To: McKean, Thomas Cc: Flynn, Judith Subject: RE: Distribution Box Issue Attachments: 20160503_114051jpg; 20160503_113928jpg; 20160503_113952jpg; 20160503_ 114006jpg; 20160503_114044jpg Hi Mr. McKean, Thank you for getting back to me. As I stated on the phone this morning I'm going to skip spending the extra money to have Tom Roux do an inspection and 12 page report as it-will cost me an additional $300+to have that done. I'm simply moving forward with having the new D Box installed next week and will be filing a small claim at the Barnstable Country Court with Dave Mason. I have attached some pictures of the D-Box so you can view yourself the condition of it. I will have Tom Roux revise the letter he wrote to me. Thank you! Richard Anderson From: McKean, Thomas [mailto:Thomas.McKeanC�)town.barnstable.ma.us] Sent: Wednesday, May 04, 2016 4:46 PM To: richandersonfireCa)gmail.com Cc: Flynn, Judith Subject: RE: Distribution Box Issue Good Afternoon Mr. Anderson, Unfortunately, the attached note contains some misinformation. On the telephone, I recall Mr. Roux stated one of the walls was disintegrated and had fallen off. However, his letter does not indicate this. Also this note states that 1 (Mr. McKean)verbally stated the distribution box needs to be replaced right away. However, I specifically remember stating to Mr. Roux that his verbal telephone call is not sufficient in order for me to make any findings or suggestions. I informed Mr. Roux that I need a completed septic system inspection report.To date I have not received a completed inspection report. In addition. on the telephone yesterday, Mr. Roux informed me that the septage pumper uncovered the distribution box. However, during the telephone conversation this morning,you informed me that you uncovered the distribution box accidentally while attempting to find the septic tank cover. Please submit an inspection report(at a minimum pages 1-5, and page 12 regarding the distribution box)for my staff to review, as we discussed this morning on the telephone. Sincerely, Thomas McKean From: richandersonfire@gmaii.com [mailto:richandersonfire@9mail.com] Sent: Wednesday, May 04, 2016 12:34 PM To: McKean, Thomas Subject: RE:,Distribution Box Issue ` 'Hi Tom, Thanks for your phone call. Attached is the letter Tom Roux put together for me. Go ahead and send out the letter stating I have a year to get it replaced. Let me know when,I can expect it. Thank you Tom! Richard Anderson 508-685-1106 _ 4 From: McKean,Thomas [mailto:Thomas.McKean@town.barnstable.ma.us] Sent: Wednesday, May 04, 2016 11:59 AM To: richandersonfire(&gmail.com Subject: Distribution Box Issue , Here is our e-mail address. x 2 - Y f V Commonwealth #110 ���_xl -�! of Massachusetts / Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Fox Hollow Lane s Property Address 1 =- Richard Anderson Owner Owner's Name gal information is required for every osterville Ma. 02655 October 9, 2015 page. Cityrrown State Zip Code Date of Inspection t 2 r�3 Inspection results must be submitted on this form.Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information h � on the computer, f 1 21D use only the tab 1. Inspector: key to move your cursor•do not Thomas Roux use the return Name of Inspector key. Company Name 89 Mayflower Lane Company Address East Wareham Ma 02538 City/Town State Zip Code 774-678-9066 S14531 Telephone Number License Number , B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340.of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority ®h 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 Disp �•Page 1 of 17 r Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Fox Hollow Lane Property Address Richard Anderson Owner Owner's Name information is required for every Osterville Ma. 02655 October 9, 2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E 1 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: 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 exfrltration 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): r r t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 18 Fox Hollow Lane Property Address Richard Anderson Owner Owner's Name information is required for every Osterville Ma.. 02655 October 9,2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) . ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y 0 N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N' ❑, ND (Explain below): ❑ obstruction-is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113_ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �. 18 Fox Hollow Lane Property Address Richard Anderson Owner Owner's Name information is required for every Osterville Ma. 02655 October 9,2015 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: t D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑_ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than Y2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal S g pose System Page 4 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Fox Hollow Lane ' Property Address Richard Anderson . Owner Owner's Name information is required for every OstefViNe Ma 02655 October 9,2015 page. Cfty/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 1the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply 0 ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone Il 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 Insp ection Form:Subsurface Sewage Disposal System•Page 5 of 17 r Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M s 18 Fox Hollow Lane Property Address Richard Anderson Owner Owner's Name information is required for every Osterville Ma. 02655 October 9,2015 page. City/Town state Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health f ❑ ® Were-any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example,a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: . i Number of bedrooms(design): 492 gpd Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 492 gpd t5ins•3/13 Title 5 Official Ins pection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Fox Hollow Lane Property Address Richard Anderson Owner Owner's Name information is required for every Osterville Ma. 02655 October 9 2015 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? - ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑' Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ 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? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 18 Fox Hollow Lane Property Address Richard Anderson Owner Owner's Name information is Osterville Ma. 02655 October 9,2015 required for every j page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): - General Information Pumping Records: Source of information: owner Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons y How was quantity pumped determined? ' Reason for pumping: r Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy . ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3t13 Title 5 Official Inspection Form:Subsurface Sewage Disposal g pose System•Page 8 of 17 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments yam. 18 Fox Hollow Lane Property Address Richard Anderson Owner Owner's Name information is required for every Osterville Ma. 02655 October 9 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (f known) and source of information: 29years, Design plan on file is dated 8/28/86. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5' feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line. feet feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 5' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a'copy of certificate) ❑ Yes ❑.}No Dimensions: 8'L x 5.2'W x 5ZH Sludge depth: <1" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Fox Hollow Lane " Property Address Richard Anderson Owner Owner's Name information is required for every Osterville Ma. 02655 October 9 2015 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cost.) Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness <111 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The septic tank does not need to be pumped out at this time. • y r. - Grease Trap (locate on site`plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Official Inspecton Forth:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official I nspection- Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 18 Fox Hollow Lane Property Address Richard Anderson . Owner Owner's Name information is required for every Osteryille Ma. 02655 October 9 2015 page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑' Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Fox Hollow Lane Property Address Richard Anderson Owner Owner's Name information is required for every Osterville Ma: 02655 October 9, 2015 page. CitylTown 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 0" 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.): The D-Box is in good condition. Pump Chamber(locate on site plan): s Pumps in working order: ❑ Yes . ❑ No* Alarms in working order: ❑ Yes ❑ No* v 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: The septic tank and d-box are functioning correctly.Therefore,the SAS is draining properly. I t5ins-3f13 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 18 Fox Hollow Lane Property Address Richard Anderson Owner Owner's Name information is required for every Osterville Ma. 02655 October 9,2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ 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.): No evidence of 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•3113 Title 5 Official Insp ection Form: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 wM Sve,� 18 Fox Hollow Lane Property Address Richard Anderson Owner Owner's Name information is required for every Osterville Ma. ..02655 October 9, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) 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 Disp osal pawl System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 18 Fox Hollow Lane - Property Address Richard Anderson Owner Owner's Name information is ruir d for every Osterville Ma. 02655 October 9,2015 page, ry Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 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 � l 1 Y t5ft W3 Title 5Offuaal hmpecbon Form,Subsurface Sewage DspoW System-Page 15 of 17 i r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Fox Hollow Lane Property Address Richard Anderson Owner Owner's Name information is required for every Osterville Ma. 02655 October 9,2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.)" 4 r Site Exam: ® Check Slope Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 10, feet f. 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: 8/28/86 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) 'F ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: From the septic system design plan on file. 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 Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Fox Hollow Lane T Property Address Richard Anderson Owner Owner's Name information is required for every Osterville Ma. 02655 October 9,2015 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D,or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal posy System•Page 17 of 17 Commonwealth of Massachusetts' W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 18 Fox Hollow Property Address All LBB Realty Trust Owner Owner's Name information is required for every Osterville MA 02655 5/6%10 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: 02Z key to move your cursor-do not Ricky L. Wright use the return Name of Inspector key. B & B Excavation, Inc. Company Name 14 Teaberry Lane Company Address Forestdale MA 02644 City/Town State Zip Code 508-477-0653 S 14595 Telephone Number License Number B. Certification L��r � J —e i 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 one ite sewage disposal systems. I am a DEP approved system inspector pursuant to Section R340 of Title 5(310 CMR 15.000).The system: M ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further.Evaluation by the Local Approving Authority 5/6/10 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. 2Systemt5ins 09/08 Title 5 Official Inspection Form:Subsurface Se a isag 40f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Fox Hollow Property Address LBB Realty Trust Owner Owner's Name information is required for every Osterville MA 02655 5/6/10 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: 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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Fox Hollow Property Address LBB Realty Trust Owner Owner's Name information is required for every Osterville MA 02655 5/6/10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y -❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y . ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑. ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 18 Fox Hollow Property Address LBB Realty Trust Owner Owner's Name information is required for every Osterville MA .02655 5/6/10 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: . Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® 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 '/z day flow t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Fox Hollow Property Address LBB Realty Trust Owner Owner's Name information is required for every Osterville MA 02655 5/6/10 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ 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 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I Commonwealth of Massachusetts Alffim Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 18 Fox Hollow M Property Address LBB Realty Trust Owner Owner's Name information is required for every Osterville MA 02655 5/6/10 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 18 Fox Hollow Property Address LBB Realty Trust Owner Owner's Name information is Osterville MA 02655 5/6/10 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes E No Water meter readings, if available (last 2 years usage(gpd)): Detail Sump pump? ❑ Yes ® No Last date of occupancy: 12/09 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Fox Hollow Property Address LBB Realty Trust Owner Owner's Name information is required for every Osterville MA 02655 5/6/10 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: ® 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): l5ins•09l08 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 °M 18 Fox Hollow Property Address LBB Realty Trust Owner Owner's Name information is Osterville MA 02655 5/6/10 required for every - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1988 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 11 Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: > 60'feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appears to be in good condition- no signs of leakage Septic Tank(locate on site plan): 811 Depth below grade: feet Material of construction: ® concrete ❑ metal.. ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ® No Dimensions: 8,6"X 5'2"X 5'3" Sludge depth: 2" t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 18 Fox Hollow Property Address LBB Realty Trust Owner Owner's Name information is required for every Osterville MA 02655 516/10 page. Cityrrown State' Zip Code -Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 32„ Scum thickness 4„ Distance from top of scum to top of outlet tee or baffle 511 Distance from bottom of scum to bottom of outlet tee or baffle 8" How were dimensions determined? scour stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection tank appeared to be in good condition Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 18 Fox Hollow Property Address LBB Realty Trust Owner Owner's Name information is required for every Osterville MA 02655 5/6/10 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene . ❑ other(explain): Dimensions: a 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.): j *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 18 Fox Hollow Property Address LBB Realty Trust Owner Owner's Name information is required for every Osterville MA 02655 5/6/10 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 0 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.): At time of inspection d-box appears in good shape-no signs of carryover or leakage 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•09/08 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 18 Fox Hollow .,M Property Address LBB Realty Trust Owner Owner's Name information is required for every Osterville MA 02655 5/6/10' page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: (3)flow diffusers ❑ 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 time of inspection leaching appears in good shape- no signs of ponding or damp soils 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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 18 Fox Hollow Property Address LBB Realty Trust Owner Owner's Name information is psterville MA 02655 5/6/10 required for every page. City/Town 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Fox Hollow Property Address LBB Realty Trust Owner Owners Name information is OSterville required for every MA 02655 5/6/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately a � 0 Al = 25 ' A2= 9z' C7 a2= 21 ' A3 = GO �8 3 = 2-9 ' i i l5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^M 18 Fox Hollow Property Address LBB Realty Trust Owner Owner's Name information is required for every Osterville MA 02655 5/6/10 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: 9'2"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: hand augered hole-GW @ 97' - bottom of field 37' -seperation 65" (GW ADJ. 05) Distance between adj. gw and bottom of leach field = 5' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION r i• TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM 0,0ig 001 PART A CERTIFICATION Property Address: 18 FOX HOLLOW LN ss 33o�-�i OSTERVILLE Owners Name: DOURETE COSTA Owner's Address: Date of Inspection: 10/24/05 Name of Inspector: (please print) Douglas A.Brown Company Name: Douglas A.Brown Septic Inspections Mailing Address:P.0 Box 145 Centerville,MA 02632 Telephone Number: 508-420-4534 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system - Yam) X Passes ' Conditionally Passes <i rL "n Needs Further Evaluation by the Local Approving Authority =a Fails Inspector's Signature: _ �' � Date: 10/24/05 ;w The system inspector shall submit a copy of this inspection report to the Approving Auth rity(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving, authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different Conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Revised on 10/31/2000 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 18 FOX HOLLOW LN OSTERVILLE Owner's Name: DOURETE COSTA Owner's Address: Date of Inspection: 10/24/05 inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information winch indicates that any of the failure criteria described in 3 10 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: at this time system MEETS IyflNIMUM PASSING REQU RMENTS B. System Conditionally Passes: one or more system components as described in the"Conditional Pase' section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or-the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health, *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed t Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 18 FOX HOLLOW LN OSTERVILLE Owner's Name: DOURETE COSTA Owner's Address: Date of Inspection: 10/24/05 C.Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2.System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the 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 1b0 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 I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 18 FOX HOLLOW LN OSTERVILLE Owner's Name: DOURETE COSTA Owner's Address: Date of Inspection: 10/24/05 D. System Failure Criteria applicable to all systems: You must indicate"yes or no to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 3 10 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure, E. Large Systems: To be considered a large system the system must serve a facility with a design flow of.10,000 gpd to 15,000 gpd• You must indicate either"yes"or no to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ _ the system is within 400 feet of a surface drinking water supply — _ 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 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered ytg m 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 undeuSection D shall upgrade the system in accordance with 310 CMR Page 5 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 18 FOX HOLLOW LN OSTERVILLE Owner: DOURETE COSTA Date of Inspection: 10/24/05 Check if the following have been done. You must indicate"yes"or"no" as to each of.the following: i Yes No X 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 ? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? _ _ Were all system components,excluding,the SAS,located 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? _ X Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X i Existing information. For example, a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3 ))(b)] 5 Page 6 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 18 FOX HOLLOW LN OSTERVILLE Owner's Name: DOURETE COSTA Owner's Address: Date of Inspection. 10/24/05 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN How based on 3 10 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): NO F�"3 - 1,C3 Cac� s C. Water meter readings,if available(last 2 years usage(gpd)):6 ci - f1V5',0M ��1 Sump pump(yes or no):_ Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): _ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy Shared system(yes or no)(f 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 awner) —Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components, date installed(if known)and source of information: INSTALLED 2-2-88 Were sewage odors detected when arriving at the site(yes or no)? NO Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 18 FOX HOLLOW LN OSTERVILLE Owner's Name: DOURETE COSTA Owner's Address: Date of Inspection: 10/24/05 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_ (locate on site plan) Depth below grade: 12" Material of construction: _concrete_metal_fiberglass _polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): _(attach a copy of certificate) Dimensions: 1000 gal Sludge depth: 0 Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 0 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.)- TANK LOOKS STRUCTUALLY SOUND AT THIS TIME PUMPED BY PINA SANITATION AS PART OF INSP 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 to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 18 FOX HOLLOW LN OSTERVILLE Owner's Name: DOURETE COSTA Owner's Address: Date of Inspection: 10/24/05 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: eallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 18 FOX HOLLOW LN OSTERVILLE Owner's Name: DOURETE COSTA Owner's Address: Date of Inspection: 10/24/05 SOIL ABSORPTION SYSTEM(SAS): _(locate on site plan,excavation not required) If SAS not located explain why: SAS LOCATED BUT NOT OPENED DUE TO DEPTH Type leaching pits,number: X leaching chambers,number: 3 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.): 16 X 20 SAS 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`or no): 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.): Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 18 FOX HOLLOW LN OSTERVILLE Owner's Name: DOURETE COSTA Owner's Address: Date of Inspection: 10/24/05 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. t� 1_ 4 % 3— �O 1� I— 34 Page 11 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM ] INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 18 FOX HOLLOW LN OSTERVILLE Owner's Name: DOURETE COSTA Owner's Address: Date of Inspection: 10/24/05 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: Checked with local excavators,installers-(attach documentation) _ Accessed USGS database-explain: You must describe how you established the high ground water elevation: I 1 f COMMONWEALTH OF MMSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTE �1-- % I I S(� Z- SEP 0 -3 2003 TOWN OF BARNSTABLE HEALTH DEPT. 'TITLE 5 _- OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FOR PART A rvl$ CERTIFICATION PARCEL , �o �i LOT Property Address: 18 Fox Hollow Lane Osterville Owner's Name: George RusGPI Owner's Address: Date of Inspection: Name of Inspector:(please print) W i 11 i am E_ •Robinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA Telephone Number: ( 508) 775-8776 CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Se ton 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 0 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health of DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the .DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments .t ****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. s Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: _- 18 Fox Hollow Lane Osterville Owner: George Russel Date of inspection; 4c= 5�--a Inspection Summary: Check A,B,C,D or E I ALWAYS complete all of Section D r A. Syst Passes: . ( 'I have noffound any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B' System Conditionally Passes: One or more system components as described in the"Conditional Pass.'section need to be replaced or repaire .The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer y s,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The eptic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,a ibits substantial infiltration or exfiltration or tank failure is imminent_System will pass inspection if the existing is replaced with a complying septic tank as approved by the Board of Health. •A metal se tic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating 'at the tank is less than 20 years old is available. ND explain Observation of sewage backup or break out or high static water level in the distribution box due to-broken or obstruct pipes)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approv of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND expl in: e system required pumping more than 4 times a year due to broken or obstrtxud pipe(s).The system will pass ins,ection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is I=Ycd ND c plain: r Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION'(continued) Property Address: 18 Fox Hollow Lane Osterville Owner: George- Russel Date of Inspection: C. Further Evaluation is Required by the Board of Health: 12. ystem ditions exist which require further evaluation by the Board of Health in order to determine if the system protect public health,safety or the environment. tem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the em 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 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 ` urface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I 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 frond a private water supply well" Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other ilure criteria are triggered.A copy of the analysis must be attached to this form. 3. Ot er: 3 Page 4 of 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 18 Fox Hollow Lane Osterville Owner: George Russel Date of Inspection: D. System Failure Criteria applicable to all systems: You ri st indicate"yes"or"no"to each of the following for all inspections: Yes N Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow Required pumping more titan 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 100,15eet of a surface water supply or tributary to a surface water supply. _ Any portion of a cesspool or privy is within a Zone 1 of a public well. _ .Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E: arge Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You m st indicate either"yes"or"no"to each of the following: (The fo lowing criteria apply to large systems in addition to die criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a sm-face drinking water supply — _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you ve answered"yes"to any question in Section E die system is considered a significant threat,or answered "yes"i Section D above the large system has failed.The u%mer or operator of airy large system considered a signif ant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.3 The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 18 Fox Hollow Lane Osterville Owner: George_Ri]GRPI Date of Inspection: Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes No / umpi information was provided by the owner,occupant,or Board of Health �/WPcre any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? _ 3/ 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? 1/ Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? _% _ Were the septic tanl:manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? �I Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: . Yes YE isting information.For example,a plan at the Board of Health. _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 18 Fox Hollow Vane Osterville Owner: George R r--s -1 Date of Inspection:„ "—�;� FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design)::2 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): ? Number of current residents:_ Does residence have a garbage grinder(yes or no): A o Is laundry on a separate sewage system(yes or no):/L0[if yes separate inspection required] Laundry system inspected(yes or no): �> Seasonal use:(yes or no): LL-V Water meter readings,if available(last 2 years usage(gpd)): 2 0 01 -5 7 ,0 0 0 Sump pump(yes or no): 10- 2 0 0 2—9 0,0 0 0 Last date of occupancy: COMMER IAL/INDUSTRIAL Type of estab -shmcnt: Design flow( ased on 310 CMR 15.203): gpd Basis of des i i flow(seats/persons/sgft,etc.): Grease trap p esent(yes or no):_ Industrial wa to holding tank present(yes or no):_ Non-sani waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date o occupancy/use: OTHER escribe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as pint f the inspection(yes or no): If yes,volume pumped:_gallons--How was quantity pumped deteruiined? Reason for pumping: TYtpli F SYSTEM c 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 contact(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): L 6 I'agc 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 R Fox Hol 1 c)w La.he Osterville Owner: _George Russel Date of Inspection: '�� BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron 40 PVC_other(explain): Distance from private water supply welFor—suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK., �(Iocateon site plan) Depth below grade: Material of construction: �-- rete_metal_fiberglass__polyethylene —other(explain) If tank is metal list age:— Is age confirmed-by a Certificate of Compliance(yes or no):_(attach a copy of certificate) d p Dimensions:_- (a V 4' Sludge depth:_ / 7l' i v Distance Gom top of sludge to bottom of outlet tee or baffler Scum thickness:-Z—� . Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum(o bottom of outlet tee or battle: How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle conditicn,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.)-. GREASE TRAN,,_(locate on site plan) Depth below grade't_ b Material of construction:_concrete. metal fiberglass_polyethylene_other (explain): C Dimensions: Scum thickness: Distance from topaof scum.to top of outlet tee or baffle: Distance from boom of scum to bottom of outlet tee or baffle: Date of last pumps g: Comments(on punt ing recommendations, inlet and outlet Ice or baffle condition,structural integrity,liquid levels as related to outlet in rt,evidence of leakage,etc.): Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropertyAddress:18 Fox Hollow Lane C1stPryi 1 1 P Owner: el Date of Inspection: A3 TIGHT or HOLD[N TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of constructio concrete metal fiberglass Polyethylene other(explain): Dimensions: Capacity: allons Design Flow: rf allons/day Alarm present(yes or Alarm level: rking order(yes or no): Date of last pumping: Comments(condition float switches,etc.): DISTRIBUTION BOX: VZ f present must be opened)(locate on site plan) Depth of liquid level above outlet invert: D 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.): ,r PUMP CHAMBER: (locate on site plan) Pumps in working or r(yes or no): Alarms in working or cr(yes or no): Comments (note con ition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 18 Fox Hollow ow Lane Osterville owner: George Russel ' Date of Inspection: L- = SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type aching pits,number:_ r/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.): CESSPO/na (cessp of must be pumped as part of inspection)(locate on site plan) Number figurati Depth— iquid to let invert: Depth oflayer: Depth ofayerDimensie pool:Materialtraction:Indicatiotutdwater inflow(yes or no):Commen condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate site plan) Materials of cons tion: Dimensions: Depth of soliKotecondition Comments of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLU NTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 18 Fox Hol 1 nw T,ane Osterville Owner: George Russel Date of Inspection: '25—Z, � SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 18 Fox He I 1 nw r.ane Osterville Owner. George Russel . Date of Inspection: 5.— ` e 0 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water j'' feet Please indicate(check)all methods used to determine the high ground water elevation: Ob fined from system design plans on record-If checked,date of design plan reviewed: served site(abutting property/observation hole within 150 feet of SAS_) hecked with local Board of Health-explain: to 1 14 - i Checked with local excavators,installers-(attach documentat' n) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Z� `✓' v 11 . Coml ionweio tth of M0.SSoChusettS John Grad Executive Office Of ErMronnwrrtOi Aflodr5 D.E.P. Title V Septic Inspector Dlepartmeant of P.O. Box 2119 EnAron mental .Protection Teaticket,MA 02536 ' (508),564F,6K 1-3 �T �? SUBSURFACE SEWAGE DISPOSAL ASYSTEM INSPECTION FORM 010,P1 � CERTIFICATION , w6� ,>P 19 Property Address: 18 FOX Hollow Lane Osterville Lot 4 Address of Owner: ��ti�VSlA9 9? Date of Inspection;7131197 (if different) PT (F N Name of Inspector:John Gracl Mr.&Mrs.Edward Brith Company Name,Address and Telephone Number: E Z CERTIFICATION STATEMENT i certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X Passes This inspection is based on criteria defined in Title V Condi/bmit Passes code 310 CMR 15.303.My findings are of how the system is performing at the time of the Inspection.My Inspection does NeedFur er valuation By the Local Approving Authority not Imply any warranty or guarantee of the longevlly of the - Fails septic system-and any of its components useful life. Inspector's Signature: Date: 7131197 The System Inspector shall s 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. INSPECTION SUMMARY: Check A, B,C, or D: r , A] SYSTEM PASSES: 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., , 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,cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is R. 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 11115195) One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 9 Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued)` Property Address: 18 Fox Hollow Lane Osterville Lot 4 ' Owner: Mr.&Mrs.Edward Brith Date of Inspection:7131197 _ Sewage backup or breakout or high static water level observed in the distribution box is due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ry 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 Cl 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 MANNER THAT 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 water supply 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 is less than 100 feet but 50 feet or more from a private water supply well, unless a well water,analysis for coliform bacteria volatile organic compounds indicates that the well is free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm. 3) OTHER +- D] SYSTEM FAILS: _ 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, contactedto determine what will be necessary to correct the failure. Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to tho surfoce of the ground or surface waters due to nn overloadPd or clogged cesspool. _ SAS is in hydraulic failure. (revised 11115195) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 18 Fox Hollow Lane Osterville Lot Owner: Mr.&Mrs.Edward Brtth Date of Inspection:7131197 D] SYSTEM FAILS(continued) 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 or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria: _ 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: 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) 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. i (revised 11115195) 3 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: IS Fox Hollow Lane Ostervllle Lot 4 Owner: Mr.&Mrs.Edward BHth Date of Inspection:7131197 Check if the following have been done: X 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 existing information or approximated by non-intrusive methods. X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. s s r: (revised 11115195) 4 ` ' 4 _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 18 Fox Hollow Lane Ostervllle Lot 4 Owner: Mr.&Mrs.Edward Brith Date of Inspection:7131197 FLOW CONDITIONS RESIDENTIAL: Design flow: 330 gallons Number of bedrooms: 3 Number of current residents: 2 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: nla Last date of occupancy: nla COMMERCIAL/INDUSTRIAL: Type of establishment: nla Design flow:0 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: n1a Last date of occupancy: nla OTHER:(Describe) n1a Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System has not been pumped In the last year. System pumped as part of inspection: (yes or no)Yes If yes,volume pumped: 1000 gallons Reason for pumping: Maintenance TYPE OF SYSTEM X Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source information: 1987 Sewage odors detected when arriving at the site: (yes or no) No (revised 11115195) 5 • P t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 18 Fox Hollow Lane 0sterville Lot Owner: Mr.&Mrs.Edward Brlth Date of Inspection:7131197 SEPTIC TANK: X (locate on site plan) Depth below grade: 3' Material of construction:X concreate_metal_FRP_other(explain) Dimensions: L 8'6'H 5-T W 4-110- Sludge depth:3" Distance from top of sludge to bottom of outlet tee or baffle: 24" Scum thickness:3' 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: 15• 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.Recommend pumping septic system every two years for maintenance. GREASE TRAP:_ (locate on site plan) Depth below grade: n1a Material of construction: _concrete_metal_FRP_other(explain) Dimensions: n1a Scum thickness:n/a Distance from top of scum to top of outlet tee or baffle:n1a Distance from bottom of scum to bottom of outlet tee or baffle: n1a 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.) n1a (revised 11/15195) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) .Property Address: 18 Fox Hollow Lane Osterville Lot 4 Owner: Mr.&Mrs.Edward Brith Date of Inspection:7131/97 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: n1a Material of con struction:_concrete_metal_FRP_other(explain) t Dimensions: n1a Capacity: n1a gallons Design flow: nfa gallons/day Alarm level: rda Comments: (condition of inlet tee, condition of alarm and float switches, etc.) n1a DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: n1a Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.) n/a PUMP CHAMBER: (locate on site plan) Pumps in working order.(yes or no) Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) n1a (revised 11115195) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 18 Fox Hollow Lane 0sterv111e Lot 4 Owner: Mr.&Mrs.Edward Brtth Date of Inspection:7131197 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: n1a Type. r leaching pits, number: n1a leaching chambers,number:3-flowdilfusers leaching galleries, number: n1a leaching trenches°number, length: n1a leaching fields,number, dimensions:n1a overflow cesspool,number:n1a Comments:(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) $as is functioning properly and is structurally sound. CESSPOOLS:_ (locate on site plan) Number and configuration: n1a Depth-top of liquid to inlet invert: n1a Depth of solids layer: n1a Depth of scum layer: n1a Dimensions of cesspool: n1a Materials of construction: nfa Indication of groundwater: n1a 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.) n1a PRIVY:_ (locate on site plan) Materials of construction: n1a Dimensions: n1a Depth of solids: n1a Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Na (revised 11115195) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 18 Fox Hollow Lane Osterville Lot Owner: Mr.&Mrs.Edward Brith Date of Inspection:7131197 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' P p 6A 3! BB �� DEPTH TO GROUNDWATER Depth to groundwater:12 feet method of determination or approximation: USGS Maps and Charts 12 Feet (revised 11115/95) . 9 f :r -, t of THE ro DEQE File No. Sr 3-1570 j d 4� rro be provided by DGC1Ei1 to Commonwealth - )ARISTlu'iLL 1 City/Town: Barnstable of Massachusetts rsc -� 7�0 t639.�\ A Applicant Roberts Realty Order of Conditions MASSACHUSETTS WETLANDS PROTECTION ACT G.L. c. 131, § 40 TOWN OF BARNSTABLE WETLANDS PROTECTION BY-LAW, Ch. 3, Article XXVII FROM: BARNSTABLE CONSERVATION COMMISSION To Roberts Realty Robert Burpee & Robert Cunningham (Name of Applicant) (Name of property owner) P.O. Box 954 P.O. Box 954 Address Duxbury, mA 02332 Address Duxbury, !.IA 02332 This Order is issued and delivered as follows: 10 by hand delivery to applicant or representative on (date) - KI by certified mail, return receipt requested on March 23 1987 (date) This project is located at Lot 4 Fox ;-;ollow T,ane, O terville Barnstable Assessor's Map # 145 Lot 6-4 The property is recorded at the Registry of Deeds in Barnstable Book 3454 Page 264 Notice of Intent dated Jan 20, 1987 Date of Hearing Oarc_n 3 1987 This Order is issued on march 23 1987 Findings The Barnstable Conservation Commission has reviewed the above-referenced Notice of Intent and plans and has held a public hearing on the project. Based on the information available to the Barnstable Conservation Com- mission at this time, the Barnstable Conservation Commission has determined that the area on which the proposed work is to be done is significant to the following interests in accordance N�,zth the Presumptions of Significance set forth in the regulations for each Area Subject to Protection Under the Act (check as appropriate): 27 ONLY Public water supply Storm damage prevention = Erosion Control Private water supply _X Prevention of pollution Wildlife Ground water supply �1 Land,containing shellfish _ Recreational. Flood control ❑ Fisheries aesthetic hyV, Therefore, the Barnstable Conservation Committee hereby finds that the following conditions are necessary, in accordance with the Performance Standards set forth in the regulations, to protect those interests checked above. The Barnstable Conservation Committee orders that all work shall be performed in accordance with said conditions and with the Notice of Intent referenced above. To the extent that the following conditions modify or differ from the plans, specifications or other proposals submitted with the Notice of Intent, the conditions shall control. GENERAL CONDITIONS 1. Failure to comply with all conditions stated herein,and with all related statutes and other regulator,measures, shall be deemed cause to revoke or modify this Order. 2. This Order does not grant any property rights or any exclusive privileges; it does not authorize any injury to private property or invasion of private rights. • 3. This Order does not relieve the permittee or any other person of the necessity of complying with all other applicable federal, state or local statutes, ordinances, by-laws or regulations. 4.—The work authorized hereunder shall be completed within three years from the date of this Order unless either of the following apply: (a) the work is a maintenance dredging project as provided for in the Act; or (b) the time for completion has been extended to a specified date more than three years, but less than five years,from the date of issuance and both that date and the special circumstances warranting the extended time period are set forth in this Order. 5. This Order may be extended by the issuing authority for one or more periods of up to three years each upon application to the issuing authority at least 30 days prior to the expiration date of the Order. 6. Any fill used in connection with this project shall be clean fill, containing no trash, refuse, rubbish or debris, including but not limited to lumber,bricks,plaster,wire,lath,paper,cardboard,pipe,tires, ashes,refrigerators, motor vehicles or parts of any of the foregoing. 7. No work shall be undertaken until all administrative appeal periods from this Order have elapsed or, if such an appeal has been filed, until all proceedings before the Department have been completed. 8. No work shall be undertaken until the Final Order has been recorded in the Registry of Deeds or the Land Court for the district in which the land is located, within the chain of title of the affected property. In the case of recorded land, the Final Order shall also be noted in the Registry's Grantor Index under the name of the owner of the land upon which the proposed work is to be done. In the case of registered land, the Final Order shall also be noted on the Land Court Certificate of Title of the owner of the land upon which the proposed work is to be done. The recording information shall be submitted to the Barnstaple Conservation Cor:uu scion on the form at the end of this Order prior to commencement of the work. 9. A sign shall be displayed at the site not less than two square feet or more than three square feet in size bear ing the words, "Massachusetts Department of Environmental Quality Engineering.' File iv uiubc, STI - - 10. Where the Department of Environmental Quality Engineering is requested to make a determination and to issue a Superseding Order, the Conservation Commission shall be a party to all agency proceedings and hear- ings before the Department. 11. Immediately following completion, the project shall be certified to be as per these conditions and plans, in writing, to the Barnstable Conservation Commission by the project engineer who shall be registered in the state of Mass. 12. Upon certification by the project engineer the applicant shall forthwith request, in writing, that a Certificate of Compliance be issued stating that the work has been satisfactorily completed. 13. Prior to any work being done at the site, all legal advertising.bills incurred by the petitioner in relation to the Wetlands Hearing held on this project shall be paid. 14. This Order is issued under Article XXVII of the Town of Barnstable By-Laws as well as under 1XIass. G.L. Ch. 131, sec. 40. The Barnstable Conservation Commission or Conservation Officer shall be notified no more than two weeks nor less than two days prior to the commencement of work, and have the authority to issue an Enforcement Order if the terms or intent of this Order are not complied NN ith. 15. It is the applicant's responsibility to provide all contractors with a copy of this Order and to ensure that all workers are informed of the conditions of this Order before they begin \ ork at the site. 16. The work shall conform to the following plans and special conditions: PLANS: Title Dated Signed and Stamped by: On File with: Rev. March 3 & 4, 1987 Richard Baxter, R.L.S. Commission Plot Plan Aug. 28, 1986 Peter Sullivan, P.E. Barnstable Conservation i y Special Conditions (Use additional paper if necessary) 1. All areas disturbed during construction shall be revegetated immediately following completion of work at the site. No areas shall be left unvegetated or unmulched for more than 60 days. 2. This approval is contingent upon approval by the Board of Health of the subsurface sewage disposal system. 3. Dry wells shall be installed to handle roof runoff. 4. The driveway shall be constructed of pervious material. 5. The work limit shall be established as shown on the approved plan. Staked hay bales shall be set at the work limit prior to the start of work at the site and maintained throughout construction. 6. All wooden portions of the deck shall be CCA-treated or the equivalent. No creosote-treated material may be used. 7. A 10' X 10' deck may be constructed to the side of the house. 8. There shall be no disturbance beyond the work limit line, including the cutting of trees and clearing of brush without prior approval of the Conservation Commission. 9. Where possible, trees of significant size (6" diameter or greater) shall be preserved. 10. Approval shall be contingent upon receipt of a revised plan indicating the footprint of the approved deck. ...................................................................................................................................................................................... (Leave Space Blank) y Ow J Issued By Barnstable Conservation Commission Signaturels AVat, Orer signed by a majority;of(+theonservation Commission. On this 23rd day of March 19 87 before me personally appeared Thomas Cambareri to me known to be the person described in and who executed the foregoing instrument and acknowledged that he/she executed the same as his/her fr e act and deed. I November 28, 1991 to ary Pub c My commission expires The applicant,the owner,any person aggrieved by this Order,any owner of land abutting the land upon which the proposed work is to be done or any ten residents of the city or town in which such land is located are hereby notified of their right to request the Department of Environmental Quality Engineering to issue a Superseding Order, providing the request is made by certified mail or hand delivery to the Department within ten days from the date of issuance of this Order. A copy of the request shall at the same time be sent by certified mail or hand delivery to the Conservation Commission and the applicant. ...................................................._................_.................................................................................................................................... Detach on Dotted Line and Submit to the Issuer of this Order Prior to Commencement of Work. To Barnstable Conservation Commission (Issuing Authority) PLEASE BE ADVISED THAT THE ORDER OF CONDITIONS FOR THE PROJECT AT FILE NUMBER HAS BEEN RECORDED AT THE REGISTRY OF ON (DATE) If recorded land, the instrument number which identifies this transaction is If registered land, the document number which identifies this transaction is Signed Applicant TOWN OF BARNSTABLE A 1 �- D64 rJO LOCATION q /may s,/l�.a j SEWAGE # PZ- 7,61 VILLAGE /YT,��e ASSESSOR'S MAP & LOT r INSTALLER'S NAME PHONE NO. --� SEPTIC TANK CAPACITY lD,:)y LEACHING FACILITY:(type) ��.'¢ ����� (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER.w BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No I ' � I .. _ � � � � � r .•. ry vf/ � i r � i _ ' R '...�' .. a Fns..... - THE COMMONWEALTH FUAS^;HTu TS D4 BOAR® ®r HEALTH H 1 �. . .11.................OF..- �-K15._1 S .................................... Applira#ion for Disposal Works Tonstrurtturt Frrmit Application is hereby made for a Permit to Construct (Y ) or Repair ( ) an Individual Sewage Disposal v SS stem at: ocatio �r of No. Owner Ad ess K ....F, .C:P� �. -c � r!�s s--------- -�------------------------------------------- ,d• Installer Address Type of Building Size LotZr-A .......Sq. feet Dwelling—No. of Bedrooms...... ----------------------------------Expansion Attic 44b Garbage Grinder ] P4 Other—Type of Building No. of persons____________________________ Showers — Cafeteria ' Q' Other fixtures -------•---••---•--------------•----------------------.-•••••••••--••••••-•-••-•-•-•-••--•---•--•••-••-•••-••-••.........••••--•---•-•-•••--••••_._... d W Design Flow......... 51_______________________gallons per person per day. Total daily flow.___.��..'S .......................___gallon P W Sept- Tank�LLi id cctpacityl_G .gallons LengthB.-k _ WidthA!_J �_. Diameter___-.=...... DepthS._:_,Q-: Disp"o`sa ienc�i=�Go..................... Width___ {P_�_______ Total Length..___®_..j.___. Total leaching area ......sq. ft. Seepage Pit No..................... Diameter.................... De th below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box de$ Dosin nk ( ''"' Percolation Test Results� Performed by-_ ��c __A`3`l. _I_U .................... Date.....5h.�/_S�_�__...__. aTest Pit No. 1...____ ______minutes per inch Depth of Test Pit___l.�............. Depth to ground water....)______r.______...__. Test Pit No. 2................minutes per inch Depth of,Test Pit.................... Depth to ground water......................... a •-••••-••-•••••••--•-••-••--••••••---•-•..............••••••••••••••---•-•-----.........:--•....•••-----••••-•--•-•••-•-•---••-•-•-•-•••-••...•-•....._------ O Description of Soil_... ^2. op�uv� ..�a� l C� 2-. .. ---•--•------•----•--------•-------------- V •••••-•------------ •••-----------•- ------•-••-- W -•--••••-•--•---••----------••-••••••-•••••-•••••••••-••••-•-------••-•-•-•-••-•••••-•-...--••-•-•--------•••••---------••••--•-••-•-•••-•-•-•••••••-•-•-••••----•••-•-••-•••-•.................••_••••- VNature of Repairs or Alterations—Answer when applicable............................................................................................... ..--••••-•••-•••••-•••••••-••--••-•..._..-•••••-•-•-•-•••••••-•-••---••-••••-••••••••-•.................•-•-••-•---•-----•-•----•-•-•-•-•••--••-••••---••-•••••••••••-•••-•--•-•-••--••••••--•-••-_••••• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT E- 5 of the State Sanitary Code— The undersigned rther agrees not to place the system in operation until a Certificate of Compliance has b e issued by he b and of 1 Zgned... DaA lication A roved B __ t` J �� Date Application Disapproved for the following reasons_______________________________________________________________________________________________________________ ....................•-•-•.-...-•••••-•-•-.....-•- -- ----•-- ----•------•-•--____------__-_-------------------•-----•-----------•--•----•--Date---------•-- PermitNo---- . /...... ............. Issued....................................................... Date n.... No �ir. . FEs....71.... __... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................OF... �Zh.�S.� C�`L c._.................................., App irFation for Disposal Works Tonstrnrtiun Prrmit Application is hereby made for a Permit to Construct (k) or Repair ( ) an Individual Sewage Disposal Sy,�em a _ -�-_C)K_.. LCO� 1.�--4r i c tit ;?Y � - --- •.................. ....----.. ........ _....... .... ._.. ........ ........ ..... .._ cation- e o t No. ...................... _......� .....................................�-....------------..... _ - a ✓ �K �L�V�� t� tt C"�ret L.C-S ........................................ .......................................... ..................................................`.....--•--.............._.......--•------••--- Installer Address Type of Building Size Lot Z� ,Z�Q.......Sq. eet Dwelling—No. of Bedrooms______..................................Expansion Attic ( Cv Garbage Grinder '4 Other—T e of Building No. of persons............................ Showers — Cafeteria Ga Other factures ____________________________ _ d -- -----------•••--•-------•-----•---------------------------------------------�-•^-•�1-----------------•-•-----•------_------ W Design Flow........ ............................gallons per person per day. Total daily flow-_.-_-3.�Jv..........................gallons. R: Sepytic Ta k)—L q id;c�apacity� �--gallons Length_ ._.__ Width I__..1G;�_... Diameter________________ Depthe�_-8. Disposal Trench-�.T o .................... Width.. _�_....._. Total Length_Z�., g q.Total area?7 ___..____...s ft. Seepage Pit No---------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box Dosing-tank Nq, aPercolation Test Results- Performed by.-..TTj-A)t.DQ __ _:__._•y_�___ ______________________________ Date.___ __l_? ._ _�._____... ,.,,1 Test Pit No. 1----------------minutes per inch Depth of Test Pit..A.�..._______..._ Depth to ground water_-_ v.............. Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ --------------------------- - - - -------••--•-----•-- ------------------•......------------------•-----•--- O Description of Soil...' Lc>A .�n.�_�v.'v ` !a.. � '° t I._-�c t ?t►y ���` U ---------------•------------------••-----------------------------------_______-----•-------------••-----•-•-•---••---- =' ----------------------------------------------------------------- ---------------------•--------•- •-------------------------------------------------------•---------........-------•--•-•--._...... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... .-•-----------------------------••----------------•--------•----------------------.....----.......-----------------------------------------•--•----•--•------------------•------------......---•_-••--• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT1Z 5 of the State Sanitary Code—The undersigne :rther agrees not to place the system in operation until a Certificate of Compliance has issued b the ard�jo hh& " eYl_...._ .._ - � Date Application Approved BY %%O � "f) to _. . 9 Application Disapproved for the following reasons-.................................................. ----•-----•---............................................. ..................QQ-._.._..--'------------.........-•------...-------•---------•---'--........---------•--.....-------------••---------------•---•----------'-Date•----•-•••--- Permit No...v_._�- _..� "► . ...._.... --- Issued ---------•...__-•-••........._-•---- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........OF.....V.J.k. i . .)./...d`�E1,r ...................... (IntifirFatr of ToutpfiFanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (y) or Repaired J ) bY....................�� ..�t,� }( ��``/;�,���� r-----•--•--------•-••--------....---._...----•----•--------.....----:..------.....-------•---...---....._ Installer 'aPF0.X: �.f ... _ . has been installed in accordance with the provisions of TITIE 5 of The State Sanitary Code s d scribed in the application for Disposal Works Construction Permit No. ..... dated__..---/� �..�__ZHAT ---------------- THE ISSUANCE OF THIS CERTIFICATE SHALL AL NOT BE CONSTRUE® AS A GUARA TEE THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.................:o�" .- .* ..................................... Inspector.................. .......Z............................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No. .......70. . .. ...........O F..' /.{� c� �3 ..................... FEE...72J'� Disposal Works Tuntrn4Uan Vrrmit Permission is hereby granted..... ..... . ." � �? ._... to Construct or Repair ( ) an Individual Sewage Disposal System b/ ! at No.._._. :�+Q.J i �)_ 1 -...��� � •��-�_4 �Street ;1 14 .- -- ------------------ ----•----------•-- F.Ox - - . as shown on the application for Disposal Works Construction Per 't No _�.�`�_.� Dated...... .�. . -7-------------- .................. ',� '` ................................... . Board of Health . DATE............ / 7� ...................................... <, FORM 1255 HOBBS & WARREN. INC., PUBLISHERS � L E Q i►F Y I�T "I'N-� '�c'c�a..�,v�-n4�►.i, s N oi...i�1 /jLJT� 2 -'er1AA o _ , 1:1J1�'F �,cJ 1,'T1k�►dl;1'T'r'�` "�c,c�ctx�.e�t.�[� F. t M PC 0 ►oo7n� _./ -7t1TdL ZG�2So (,1 r i A ' t BAXIIFI . F SUG�DS Z Z j v. I o; -����- ►" No.210.48 C. vD P'�N S f!/ OF hj�s Za l 7 •Z , ���01Zp �-��-�'�IGA I_. ' �� �• rya f�ap�;< /: -O' � PETER c� fJat29 33 2 S' / U \— r $ ""� ��v • v - ��F �GtST& 97 Ir o 14 Af 7777777 le ,. : ' I c I , ff , ��- _ 1 i , �j t { �__. i � i ram./!' / •(� y • _ •. ^ f . ` _ �� -_ , .. 4; : J c t s f' x