The URL can be used to link to this page

Home My WebLink About0025 HICKORY HILL CIRCLE - Health 2 [hickory Hill Circle Osterville A= 120-066 f 09--16-2010 a 1 O Z 20aa DEED RESTRICTION °1 WHEREAS,David Brito,of 25 Hickory Hill Circle,.Osterville,MA 02655,is the owner - - of 25 Hickory Hill Circle located in Osterville,MA 02655 (herein after referred to as Lot 25 on a plan of"Hickory Hill Subdivision of Land in Barnstable(Osterville),Barnstable County,Massachusetts duly recorded in the Barnstable County Registry of Deeds in Plan p Book 199,Page 31,as amended by Re-division of Hickory Hill, Osterville,Barnstable County,Massachusetts,duly recorded in the Barnstable County Registry of Deeds in Plan Book 211,Page 135. UWHEREAS,David Brito,as the owner of said lot has agreed with the Town of Barnstable Board of Health to a restriction as to the number of bedrooms which can be �- included in any home built on said lot as a pre-condition to obtaining a disposal works construction permit in compliance with 310 CMR 15.000 State Environmental Code, . �— Title V,Minimum Requirements for the Subsurface Disposal of Sanitary Sewage; WHEREAS,the Town of Barnstable Board of Health, as a pre-condition to granting a C disposal works construction permit for a septic system in compliance with 310 CMR 15.200, State Environmental Code,Title V,Minimum Requirements for the Subsurface J Disposal of Sanitary Sewage and authorizing the issuance of a building permit for the G construction of a single family home on this property,is requiring that the agreement for —�— the restriction on the number of bedrooms in any house constructed on the lot to be put on record with the Barnstable County Registry of Deeds by recording this document, N Bk. 24832 Pg 2 #46625 NOW,THEREFORE,David Brito,does hereby place the following restriction on his above-referenced land in accordance with his agreement with the Town of Barnstable Board of Health,which restriction shall run with the land and be binding upon all successors in title: 1. David Brito may have constructed upon the lot a house containing no more than three(3)bedrooms. David Brito agrees that this shall be permanent deed restriction affecting the property located at 25 Hickory Hill Circle,Osterville,MA 02655 and being shown on the plan recorded in Plan Book 199,Page 31 and amended in Plan Book 211,Page 135. INTENTIONALLY LEFT BLANK , . Bk 24832 Pg 3 #46625 Executed as a seal ent jqV1 day of September,2010. avid Brito COMMONWEALTH OF MASSACHUSETTS Barnstable,ss. fqdOn this ay of September,2010,before me,the undersigned notary public, personally appeared David B 'to,proved to me through satisfactory evidence of identification,which was I�� I- i LP 11 to be the person whose name is signed on the preceding or attached document,and acknowledged to me that he signed it voluntarily for its stated purpose. � = LORA E.TEDEMAN NOTARY PUBLIC commonwealth of Massachusetts Notary Public Logk E, J 2e12mapi commission Expires October 4,2014 My Commission Expires: �q SAMSTABL E REGISTRY OF DEEDS , r TOWN OF BARNSTABLE LOCATION GIeCLE- SEWAGi'#!2�K- CFO VILLAGE 0�%E�l�/L L � I Vp 0 , ASSESSOR'S MAP 6� LOT r -/ � INSTALLER'S NAME 6z.PHONE NO. , _ � 11/L �C a L/ SEPTIC TANK CAPACITY�j L) Y t. LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR UBLIC WATER BUILDER OR OWNER?`'' e-7f-) --e' h�G ffr DATE PERMIT ISSUED: '� � DATE ..COMPLIANCE ISSUED: .`" �' VARIAiVCE GRANTED:, Yes No ,. S 7li D � b 6 aa , o s r 13 D �s� No-so THE COMMONWEALTH OF MASSACHUSETTS rnst le Consery BOARD OF HEALTH S' TOWN OF BARNSTABLE +gned Date Appliratiun for Dirivitual Nurki Tomitrnrtiun remit Application is hereby made for a Permit to Construct ( ) or Repair ( ) .an Individual Sewage Disposal System at: .. -... .?4Location-Address or Lot No.:C: '--------------------------------------------------- ................................................ .....----...........-----..........------ Owner Address a •-....L....- .�..._!tt_�'i�i �tJ?�-•------��E ................................... ......---^...............•..... Installer Address Type of Building Size Lot............................Sq. feet �.� Dwelling—No. of Bedrooms----------- ------------------------------Expansion Attic ( ) Garbage Grinder ( ) PL4 Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) WOther fixtures ------------------------------------------------------------------------- W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length----__--___-_- Width---------------- Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date-....................................... a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Li, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ----•--•---•---••-----------•------•---•--•------•-•--•-----•....•----•-•-•-._.......•-••-•••-•...............•-•----•----•-•-•--.........._........._.....•. 0 Description of Soil........................................................................................................................................................................ W ----- •----------------------------•-----------•----------------------------._.......•-•---....--------------------- U Nature of Repairs or Alterations—Answer w ap ' able..- � ` - •.. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is ed by the board of health. Signed ......................... ---- Application Approved By ------------ U... .. .. .._.... - ... .. Dare Application Disapproved for the following reasons: ................. .. . ................................................ . ....--................................... .................. ..... ........--...................... ........... .. .................................................................................................... ... ............................... p Dace PermitNo. ..... ............................ Issued ..................................--. ............................ Date ----------------------------- yNo..l_ 0.-••---•- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �/TOWN OF BARNSTABLE Appliratinit for Diripwial Works Tomitrurtiun rrntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: tV '7�``�r_11 Location-:address or Lot No. 1 ._ l V re owner � Installer Address----�..................................... Type of Building Size Lot............................Sq. feet L-I Dwelling— No. of Bedrooms----------- ----------------------"--------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures --------------------------------- ---------------------------------------------------- W Design Flow.........................................--..gallons per person per day. Total daily flow............................................gallons. x Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter.-.------------- Depth................ Disposal Trench--No. .................... Width.................... Total Length.................... Total leac_hing,area_..........._.......sq. ft. Seepage Pit No--------------------- Diameter.......:------------ Depth below inlet.................... Total leachifig area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per Inch Depth of Test Pit...--------.-..----- Depth to ground water........................ fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 0 Description of Soil......--••---------------------------------------------------------------------•------------------------...----•------------•-----------•---------------••-............. x W ---------------------------------------------------------------------------------------••-----...-------------- ---------- ----- ......................=•-•••••• ••-- U Nature of Repairs or Alterations—Answer when applicable.-----, C .r `�'`� i - ----------------------------•-------------------...------------------...: .........44-'v............ j -°`��'---------------...----------------....-----------------..-----------..-.----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is ed by the board of health. I / Signed ........ ..... -- ------------------------------------------------- --_f /...' .... a re Application Approved By -------------- ` .1...�. . . A .................... t�...-.�.c?....-.(?.L1.. re I Application Disapproved for the following reasons: .... .................... ' ..... ..................---..................................................... ... .. ........`...... ........... '' ' ........ qare PermitNo. l f......te----------------------------- Issued .. ............................................................... are THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE CTPz#tfirate of Cotuptian e THIS IS T,Q CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired O by ......' ................. _-. ..Q . .......................................................................................................................................................................... at .............�...�... . j..,....�.......- .....- ...� �`�( (" ;r - .. c.. f.......... .............. ..................._...... .......... has been.installed in accordance with the provisions of TITLE 5q of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .._/-.` ._f.....aC............ dated ..........................................._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE... S ..... - `- ....C�...-....-................... Inspector= . -Y�1 - .. . .... ... .. -- ------- -®d><_,_-___ -._v_,_---- --------,--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � TOWN OF BARNSTABLE -No----- ----------•--••. FEE.... ...I..?........ Uispviial WorkB Tunitrutinn Wrmit Permissionis hereby granted------------- - -- - -- ---- ------------------------------------------------......--------------••------------•--- to Construct ( ) or Repair (>�-) an Individual Sewage Disposal System at No.----•-----•-•---Z---15� " ------..G�/ 'f1 ----�� _�,�_��? Street qq as shown on the application for Disposal Works Construction Permit No._!'L :7 2--- Dated........ _------.- .-�.�.r •---•-•.................•--•-..._---•--. t\I-. ................................................ Board of Health DATE................... 7 .............................. FORM 36508 HOBBS 6 WARREN.INC.,PUBLISHERS COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS � d DEPARTMENT OF ENVIRONMENTAL PROTECTION ,.. Ricky L.Wright- Certified Title V Inspector,508-477-0653 TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTSS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 25 Hickory Circle Ostervilie,MA Owner's: Nancy a cy&..Joe Lane Owner's Address: 25 Hickory Circle Osterville,MA Date of Inspection: September 28,2009 Name of Inspector:Ricky Wright -License#S14595 Company Name:B&B Excavation,Inc. Mailing Address: 14 Teaberry Lane Forestdale,MA 02644 Telephone Number: 508-477-0653 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 performedbased on nvy-t Q training and experience in the proper function and maintenance of on site sewage disposal s stems: am a DEPI -n approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system _X Passes _Conditionally Passes N _ Needs Further Evaluation by the Local Approving Authori m _ Fails Inspector's Signature: Date: �e 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. Notes and Comments: The information as identified represents only the condition of the system on September 28, 2009 at 10:00 a.m. ****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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) A Property Address: 25 Hickory Circle Osterville,MA r Owner's: Nancy&Joe Lane Owner's Address: 25 Hickory Circle Osterville,NIA Date of Inspection: September 28,2009 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 which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static.water level in the distribution box due to broken or . obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced (THIS IS REQUIRED TO BE COMPLETED) ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s):The system will- pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 25 Hickory Circle Osterville,MA Owner's: Nancy&Joe Lane Owner's Address: 25 Hickory Circle Osterville,MA Date of Inspection: September 28,2009 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 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**.Method used to determine distance **This system passes if the well water analysis;performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 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: 25 Hickory Circle Osterville,MA Owner's: Nancy&Joe Lane Owner's Address: 25 Hickory Circle Osterville,MA Date of Inspection: September 28,2009 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''/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 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 4 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 "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. Page 5 of 11 a OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 25 Hickory Circle Osterville,MA Owner's: Nancy&Joe Lane Owner's Address: 25 Hickory Circle Osterville,MA Date of Inspection:September 28,2009 Check if the following have been done.You must indicate"ves"or"no"as to each of the following: 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? _X_ _ Were all system components,excluding the SAS,located on site. 5: I _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? _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Existing information.For example,a plan at the Board of Health. _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 I5.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-,NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 25 Hickory Circle Osterville,MA Owner's: Nancy&Joe Lane Owner's Address: 25 Hickory Circle Osterville,MA Date of Inspection: September 28,2009 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_Number of bedrooms(actual):3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x 3-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]NO Laundry system inspected(yes or no):NO Seasonal use: (yes or no): Water meter readings,if available. Sump Pump(yes or no):NO Last date of occupancy: CURRENT COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Lpd Basis of design flow(seats/persons/sgft,etc.): r G ease trapes present(Y 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): 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(6' pit with 2'stone) _Single cesspool Overflow cesspool t ' —_privy -Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) - Tight tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information:Approx. Were sewage odors detected when arriving at the site(yes or 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: 25 Hickory Circle Osterville,MA Owner's: Nancy&Joe Lane Owner's Address: 25 Hickory Circle Osterville,MA Date of Inspection: September 28,2009 BUILDING SEWER(locate on site plan) Depth below grade:Approximate;36 Inches Materials of construction:_cast iron X- 40 PVC other(explain): Distance from private water supply well or suction line:_NA Comments(on condition of joints,venting,evidence of leakage,etc.):at time of inspection,pipes and joints appear to be in good condition SEPTIC TANK: (locate on site plan) Depth below grade:2.5' Material of construction:—X—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: 5.5'X 5.3'X 8' Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle: 3.5' Scum thickness:0 Distance from top of scum to top of outlet tee or baffle:N/A Distance from bottom of scum to bottom of outlet tee or baffle:N/A How were dimensions determined: Actual measurements with tape and scour stick. Condition of tank(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,septic tank was in good condition -baffles were present and liquid level was equal with outlet invert GREASE TRAP: N.A. 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.): f Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 Hickory Circle Osterville,MA Owner's: Nancy&Joe Lane Owner's Address: 25 Hickory Circle Osterville,MA Date of Inspection: September 28,2009' TIGHT or HOLDING TANK: N.A.—(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no)-' Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:_X_(if present must be opened)(locate on site plan) Depth of liquid level even with outlet invert: liquid level is above the outlet invert. ' Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.):at time of inspection,D-Box was structurally sound-no signs of carryover or backup—water level was equal with outlet invert M 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.): I Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 Hickory Circle Osterville,MA Owner's: Nancy&Joe Lane Owner's Address: 25 Hickory Circle Osterville,MA Date of Inspection: September 28,2009 SOIL ABSORPTION SYSTEM(SAS):—(locate on site plan,excavation not required) If SAS not located explain why: Type —X_leaching pits,number 1 _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, etch No ponding on ground. No excessive growth of vegetation. At time of inspection 1'water in bottom of pit 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: 25 Hickory Circle Osterville,M-A Owner's: Nancy&Joe Lane Owner's Address: 25 Hickory Circle F Osterville,MA Date of Inspection: September 28,2009 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. a. AL 6 Z% 8 " Ao -(Aa '' AE BD- 3d' 1�" K- (3 - -3 9 ' 5 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 Hickory Circle Osterville,MA Owner's: Nancy&Joe Lane Owner's Address: 25 Hickory Circle Osterville,MA Date of Inspection: September 28,2009 SITE EXAM Slope 2% Surface water NONE Check cellar (crawl space) YES Shallow wells NONE Estimated depth to ground water_15_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: _X_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: Based on information in the Board of Health the ground water in the area appears to be approx. 10'below grade. 4 I