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Home My WebLink About0044 HOLLINGSWORTH ROAD - Health q 44 Hollingsworth Road, Osterville `A=140-074 1 n i . I o I i f I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ti T�TLE 5 OFFICIAL INSPECTION FORM=�OT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM FART A CERTIFICATION Property Address: Yk �,� m � Owner's Name. Owner's Address: rJU o 5 T J�N 13 ? Date of Inspection: ' ( *OWIV P (P print) tiFq�"oFpTAerF Name of Inspector: lease rint t-i 'T Company Name — � tG Mailing Address: l ; A C)0(aVe Telephone Number: (Qe)ff 7'7/ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage d''sposal 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.tooSSection 15.540 of Title 5(310 CMR 15.000). The system: �' Passes - Vai ly Passes er Evaluation by the Local Approving Authority 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 shalt 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 I � time.This inspection does not address how the system will perform in the future under the same or different conditions of use. I Title 5 Inspection Form 6/15/2000 page 1 f Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Addressc ae/ WA Owner. Date of Inspection:. 1('1 / /p/ 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. 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 backu or break out or high static wa b p b ter level n 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(§)are replaced obstruction is removed distribution.box is leveled or replaced 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 ND explain: 2 Page 3 of 1'1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: VVi(l Ow A(, lr?��ticw�J-n_ Date of Inspection: C. Further Evaluation is Required by the Board o Health: Conditio ns exist which require further evaluation by the Board of Health in order to determine tf the system is failing to protect public health, safety or the environ lent. 1. System will pass unless Board of Health Bete; mmes'm accordance with 310 CMR i5.303 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 bol dering 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 aseptic 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 o-rga'niccompounds indicates that the well is free ftom 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: i 3 Page 4 of 11 OFFICIAL,INSPECTION FORM—NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owne Date of Inspection: (a /44 Zn / 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 V 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 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number ' of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. ] Any portion of a cesspool or privy is within 50.feet of.a private water supply well. Any portion of a cesspool or privy is less than,]00 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 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 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. 4 Page 5 of 1.1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECICL,IST Property Address: VV A Ovine • Date of Inspection: Check if the following have been.done.You must indicate"yes"or."no"as to.each of.the.fol lowing; _ Yes o _ Pumping.information.was provided by the owner, occupant,or.Board of Health . A t/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 ? t/ Have large.volumes of water been introduced to the system recently or as part of this inspection-? tr/_ Were as built plans of the system.obtained and examined?(If they were not available note as N/A) 1/ Was the facility.or dwelling inspected for signs of sewage back up Was the site inspected for signs of breakout? 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 m'Sintenance.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 / t . t�Existing information.For example,a plan.at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance' is unacceptable)[310 CMR 15.302(3)(b)] 5 Page 6 of 1 l OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SE WAGE, SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 4 Owner: Date of Inspection: (o/[o Za/ FLOW CONDITIONS RESIDENTIAL V' Number of bedrooms(:design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 11.0 gpd x#6I bedrooms): —�3'3 Number of current residents:.aC&,ac� CtA*- t xi>— Z Does residence have.a ga,bage grinder(yes or notlale-- Is laundry on a separate sewage system(yes or no) [if yes separate inspection required] Laundry system inspected(yes or no Seasonal use: (yes or no. Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no)• Last date of occupancy:" L ✓�� COMMERCIAL/INDUSTRIA✓X Type of establishment:. Design flow(based on 310 CMR.15.203): gpd Basis of design flow(§eats%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 i spection(yes or no If yes,volume pumped: gallons--How was quantity pumped determined? Reason'for pumping: T E OF SYSTEM Septic tank, distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy —Shared system.(yes or no)(if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) —Tight tank _Attach a copy'of the DEP.approval —Other(describe): Approximate age of all components,date installed(if known)and.source of information. Were sewage odors detected when arriving.at the site(yes or no) 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) t Property Address Owne V Date of Inspection: /0 %D / 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: g " Comments(on condition of joints,venting,evidence of leakage,etc.): M SEPTIC TANK: 1�(locate on site plan) Depth below grade:_ 'r Material of construction: ✓t'oncrete metal_fiberglass_polyethylene other(explain) 1f tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no)'._(attach a copy of certificate) Dimensions:lo.'-C.- x � S Sludge depth: '�3 f! 9� Distance from top of sludge to bottom of outlet tee or baffle: 3 25 Scum thickness: 0 Distance from top of scum to top of outlet tee or baffle:i Distance from bottom of scum to bottom of outlet tee or baffle: 17- How were dimensions determined: t,(7e� A.Comments(on pumping recommendd ts, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet inve , evidence of leakage,a .) "� x,. GREASE TRA�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.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY,.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 6d-mChae!� Date of Inspection: 6,,&2 TIGHT or HOLDING.TAN✓,,ff&(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(expia.in): 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:—Z(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_agrj / &4qj 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.): si Vv PUMP CHAMBER:J&-(locate on site plan) Pumps in working order(yes or no):. Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances;etc.): 8 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: VV Owner. Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): ovate on site plan,excavation~not required) If SAS not located explain why: Type leaching pits,number: J leaching chambers,number: leaching galleries,number: _j�eaching trenches,number, length: 2 'X X J 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.): ) CESSPOOLS: /M- esspool 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/.,V&(locate on site plan) ' Materials of"construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.): 9 Page 10.of 11 OFFICIAL-INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SE WAGE DISPOSAL:SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION(continued) Pr.operty.Address: 7`yW, ��//yjyj,�,t1!'j11}ZtC�r�G� Owner.��g�eyy�yt� Date of Inspection: C12 /C 161 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. C C? J � I 10 I Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: L �CU Owner Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water ! G/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: hecked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: 11 ` rG� TOWN OF BARNSTABLE L.GC�CATION w Aff 91—WQ661 Pcl SEWAGE# viLLAGE �5� � Il l^l( 2 T ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. V I l SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 2— NO.OF BEDROOMS / BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation.Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet ofjl aching facility) Feet Furnished by JU 1 ✓� /i!'G�2��/ :6 Y: 4 o07y No. IF I Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0ppYication for Mi!5pooal bpotem Construction Permit Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: LocaWddress or No. Owner's Name,Address and Tel.No. 0 AssessMap/Parcel 6�� Installer's Name,Address,•andT 1.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flower gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Na re of Re airs orAltera ' ns(Answer when applicable) x �2_ Date last inspected: —� Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system -in accordance with the provisions o 'tle 5 of the Environm Code and not to place the system in operation-until a Certifi- cate of Compliance has been i ued by this oard th. Signed � Date Application Approved by Date nC V - Application Disapproved for the following reSsons Permit No. r s 7 / Date Issued No. ` / V / /! Fee THE-COMMONWEALTH OF MASSACHUSETTS . PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ' 01ppYication for Migpogal *pMem Congtruction Permit Application-is-hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System"at: 3 i Locatio daress or o No. 41 Q Owner's Name,Address and Tel.No. Assessors Map/Parcel Installer's Name,Address,-and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures / Design Flow ?6 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date '7* Title y Description of Soil +°� Na re of Repairs orAltera ' ns(Answer when applicable) l SUS _.. x 2— Date last inspected: , Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system -,`..in accordance with the provisions jtle 5 of the Environme t Code and not to place the system in operation until a Certifi- cate of Compliance has been i u� ed by this oard offQthS. Signed �,.'^' ?o Date Application Approved by _ Date ' s Application Disapproved for the following reAsons ,Permit No. (� :.�`I x �..�° « « Date Issued ———— ———————— t-w ---THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE MASSACHUSETTS (Certificate of Compriance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( ' )or repaired/replaced(d—)-Tn by All R Installer at W 61deeg-A has been constructed in accordance with the provisions of Title and the for Disposal System Cons tructio ermit No. g lY l dated J?--��- ., Date Inspector 1 a t THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THA , THE SYS- TEM WILL FUNCTION SATISFACTORY.- 4 No. �/ice— �� --------------------------Fees �. / THE COMMONWEALTH OF MASSACHUSETTS a PUBLIC HEALTH DIVISION BARNSTABLE., MASSACHUSETTS Migpogai *pgtem Congtruction Permit Permission is hereby granted to to construct( )rep (C4-aff'On-site Sewage System located at No.# kStmet - and as described in the above Application for Disposal System Construction Permit. No. Date The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed/within three years of the date below. Date: — '�f7 Approved by Board of Health t_ .s • :, CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) j, hereby certify that the application for disposal works construction permit signed by me dated 9 —Y ' 6 , concerning the property located at �� meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED : DATE: LICENSED SEP/1CSYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUM3ER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. a. i$ J �� O "fw � � � 1 i 4 1 � �I ��J � ( + � ( I I � I � � � � j � '_ I ,� � _ � � r� Jo_ Pop -s -. t �J 1Af i - � I i PfJPP� .. r -- f�+,,; TOWN OF BARNSTABLE r LOCATION ° SEWAGE # VII.LAGE__ 5��2 l / ll2 n ASSESSOR'S MAP &LOT D. d Z INSTALLER'S NAME&PHONE NO. �1_ /� SEPTIC TANK CAPACITY LEACHING FACILITY: (type) x `f, � �� 1 lstze NO. OF BEDROOMS_ M1 BUILDER OR OWNER ,P / PERMITDATE: COMPLIANCE DATE: Separation.Distance Between the: Maximum Ad justed Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility� PP Y g .(If any wells exist r on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of aching facility) Furnished by Feet n :r