HomeMy WebLinkAbout0023 JANES WAY - Health 23 Jones Way
Osterville P
A = 146 048 _
TOWN OF BARNSTABLE
LOCATION -3 A Al £ 'J SEWAGE'# "
VILLAGE J ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. 1 -6 A4/UCO 5110 P 79-r
SEPTIC TANK CAPACITY £. '471 c / £c fi_-A�,
l LEACHING FACILTTy: (type) (size)
NWOF'BEDROOMS
BUILDER OR OWNER 9✓ / ie a`;`4 y' i ""�
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
t
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by.
y i
5
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071
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SENDER:'coMPLETE-THIS SECTION, '.
v Complete items 1,2,and 3.Also complete signature
item 4 if';Restricted Delivery is desired. X ❑Agent
■ Print your name and address on the reverse ❑Addressee
so that we can return the card toyou. c d by(Printed Name) C. Date o Delivery
® Attach this card to the back of the mailpiece,
or on the front if space permits.
D. Is delivery address different from item 1. Yes
If YES,enter delivery address below:- ❑No
I Karen,.,C:. t
L23 .Panes
Osterville, MA 0?65
1 3. Service Type
`$Lertified Mail ❑Express Mail
O Registered ❑Return Receipt for Merchandise,
❑Insured Mail ❑C.O.D.,
t 4. Restricted Delivery?(Extra Fee) p.Yes
2. Article Number 012 1010 `0 0`0 0` 2 8 5 0`"8 5°1,T ' ' ��C
'(transfer from service label
PS Form 3$11:February 2004.. Domestic Return Receipt +.02595-02-W54
UNITED STATES POSTAL SERVICE First-Class Mail
Postage&Fees Paid
USPS
Permit No.G-10
M Sender: Please print your name, address, and ZIP+4 in this box •
I � �
Town of B.
arnstable
a e Health Division
200 Main Street
Hyannis, MA 02601
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Request Information
Request ID: 49455 Created: 5/28/2014 3:17:57 PM
Status: Assigned To Staff Assigned To: O'Connell,Timothy
Health Office
Anonymous: Yes Request Category: Chapter II : Housing Substandard edit
Routine work: No Estimate: No jeditDate scheduled:
Estimated 6/11/2014 Change EstimatedMay June 2014 Jul
Completion Completion Date:
Date: Sun Mon Tue Wed Thu Fri Sat
25 26 27 28 29 30 31
1 2 3 4 5 6 7
8 9 10 11 12 13 14
15 16 17 18 19 20 21
22 23 24 25 26 27 28
29 30 1 1 2 3 4 5
Created By: Crocker, Sharon Priority: Medium edit
Health Office
Citation Numbers: edit
Requestor Information
Requestor Request
DETAILS: LOCATION: 23 JANES WAY
Osterville, Ma 02655
Regaesf Parcel
Caller said the property is Number Map: 146 !Block: 048 !Lot: 000
' regualarly rented out in the summer.
It is currently listed on a Webslte" Parcel Lookup
myrealestate.nytimes.com\rentals\d eta ils\10208
-1009-14578. $1800/mo or weekly.
Unregistered.
Email:
Edit Requestor Information
http://issgl2/intemalwrs/WRequest.aspx?ID=49455 5/29/2014
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Request Work History: Internal Note History:
Entered on 5/28/2014 3:46:06 PM System entry on 5/28/2014 3:17:57 PM:
by Crocker, Sharon
Assigned to O'Connell,Timothy
Owner's phone listed in ad: K.J. (owner=Karen),
'T'= gentleman who lives there whenever not
renting out. Phone 617-462-4843
Enter work progress: Enter internal note:
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*Time entries are in hours. Examples of time entries: 1.25, 0.5, 0.75, 1, 3.5, 0.25, 0.10
* Response time: Measured from the creation date to your first actions on the request.
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Application Center Parcel Lookup Selection Items
Parcel Septic Perc Well Fuel Tank
Parcel: 146-048 Location: 23 7ANES WAY, OSTERVILLE Owner: CARLINO, KAREN A
Business name: Business phone:
Rental property: r Deed restricted: r Number of bedrooms : 0'
Contaminant released: r Fuel storage tank permit: r
je Parcel Changes a Return o Lookup g
Parcel Info Parcel ID: 146-048 Developer lot:LOT 25
Location:23 JANES WAY Primary frontage: 110
Secondary road: Secondary frontage:
village:OSTERVILLE Fire district:C-O-MM
Town sewer exists at this address:No Road index:0790
Asbuilt Septic Scan: 146048_1 Interactive map ,;
GP (Groundwater Protection Overlay
Town zone of contribution:District) State zone of contribution;IN
Owner Info Owner: CARLINO, KAREN A Co-Owner:
Streets:23 JANES WAY Street2:
City:OSTERVILLE State:MA Zip: 02655
Country:
Deed date:6/29/2007 Deed reference:C183532
Land Info Acres: 0.39 use: Single Fam MDL-01 Zoning:RC Neighborhood: 0105
Topography:Level Road:Paved
Utilities:Public Water,Gas,Septic Location:
Construction Info Building No ear Built Gross Area Living Area Bedrooms Bathrooms
1 1976 3492 1544 2 Bedroom 2 Full
Buildings value:$111,800.00 Extra features: $36,800.00 Land value: $106,700.00
http://issgl2/intranet/healthMaster/HealthMasterDetail.aspx?ID=146048 6/3/2014
s S
1
Town of Barnstable
°Ft"E ram, Public Health Division
'Thomas McKean, Director
BAMSCABLE, `MAss. 200 Main Street
1639• a``� Hyannis, MA 02601
ATED MA'S
Fax: 508-790-6304
June 3, 2014
Karen Carlino
23 Janes Way
Osterville, MA 02655
As of October 1, 2006 a new rental registration ordinance was put into affect requiring
all property owners of rental units to register their rental units with the Town of Barnstable
Health Division. Once registered all rental properties will receive a yearly inspection to insure
no Massachusetts State Sanitary Code or Town of Barnstable Ordinance violations exist.
According to our records, you own the rental property at 23 Janes Way Osterville, MA
Enclosed is an application. If dwelling.is occupied, you must provide occupants name(s): Also
provide the occupant's contact phone number for inspection scheduling purposes. Please use
a separate application for each rental unit you own. Should you need more applications, they are
available online at www.town.barnstable.ma.us. Go to the Health Division page by looking in
the Department Menu. There is a link to the Rental `Registration information on the Health
Division page. You may print out as many as you need,.and return them to the Health Division .. .
with the appropriate 2010 fees included. This must be completed within (14) fourteen days
of your receipt of this letter.
Failure to comply with this ordinance will result in the issuance of a non-criminal ticket
citation in the amount of$100. Each day of,non-compliance is considered a separate offense.
Should you have any questions, please feel free to call 508-862-4644. Thank you in
advance for your cooperation.
Timothy B. O'Connell, R.S.
Health Inspector
Health Division
Direct#508-862-4646
COMMONWEALTH OF MASSACHUSETTS
w EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
m + d DEPARTMENT OF ENVIRONMENTAL PROTECTION
IoqM SJ 1b
350 MAIN STREET MAP/& �p WEST YARMOUTH,MA n ®C} U
508-775-2800 PARCEL ;
LOT 25 —
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
MAP 146 PAR 047
Property Address: 23 JANE'S WAY
OSTERVILLE,MA 02655
Owner's Name: VIATOR,LYDIA
Owner's Address: 23 JANE'S WAY
OSTERVILLE,MA 02655 RECEIVED
Date of Inspection MARCH 2,2004
Name of Inspector:(please print) 'JAMES D. SEARS MAR 15 2004
Company Name: A&B Canco
Mailing Address: 350 Main Street TOWN OF BARNSTABLE
West Yannouth,MA 02673 HEALTH DEPT.
Telephone Number: 508-775-2800
CERTIFICATION STATEMENT
1 certify that I have personally inspected the sewage disposal systern 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:
fs. ✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date:
The system inspector shall su mit 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 tot he 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 1
Page
a e 2 of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 23 JANE'S WAY
OSTERVILLE,MA 02655
Owner: VIATOR,LYDIA
Date of Inspection: MARCH 2,2004
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: N/A
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 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
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:
Title 5 Inspection Form 6/15/2000 .2
Page 3 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 23 JANE'S WAY
OSTERVILLE,MA 02655
Owner: VIATOR,LYDIA
Date of Inspection: MARCH 2,2004
C. Further Evaluation is Required by the Board of Health: N/A
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 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 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:
Title 5 Inspection Form 6/15/2000 3
Page 4 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 23 JANE'S WAY
OSTERVILLE,MA 02655 ,
Owner: VIATOR,LYDIA
Date of Inspection: MARCH 2,2004
D. System Failure Criteria applicable to all systems: N/A
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 pit 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
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply
N/A Any portion of a cesspool or privy is within a Zone 1 of a public well
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well
N/A 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 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 detenmined 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: N/A
To be considered a large system the system must service 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 is 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.
Title 5 Inspection Form 6/15/2000 4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 32 JANE'S WAY
OSTERVILLE,MA 02655
Owner: VIATOR,LYDIA
Date of Inspection: MARCH 2,2004
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 infonnation on the
proper maintenance of subsurface sewage disposal systeins?
The size and location of the Soil Absorption System(SAS)has been determined'based on:.
Yes No "
✓ Existing infonnation. 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)]
c
T
Title 5 Inspection Form 6/15/2000 5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 32 JANE'S WAY
OSTERVILLE,MA 02655
Owner: VIATOR,LYDIA
Date of Inspection: MARCH 2,2004
FLOW CONDITIONS
RESIDENTIAL
Number of Bedrooms(design): 2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 220
Number of current residents: 1
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): YES
Seasonal use(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)): 2002 21,000 l2002 20,000
Sump pump(yes or no) NO
Last date of occupancy: PRESENT
**NOTE: MOP SINK IN BASEMENT NO DISCHARGE PUMP,NOT IN USE.
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): `
Basis of design flow(seats/persons/sqft,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 infon-nation: 2002 r
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
./ Septic tank,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 copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
1976 PERMIT#311
Were sewage odors detected when arriving at the site(yes or no): NO
Title 5 Inspection Form 6/15/2000 6
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 32 JANE'S WAY
OSTERVILLE,MA 02655 '
Owner: VIATOR,LYDIA
Date of Inspection: MARCH 2,2004
BUILDING SEWER(locate on site plan): ✓
Depth below grade: 18"
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 onsite plan): ./
Depth below grade: 26"
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: 1,000 GALLON PRE CAST
Sludge depth: 1"
Distance from top of sludge to the bottom of outlet tee or baffle: 29"
Scum thickness: 0"
Distance from top of scum to top of outlet tee or baffle: 12" t
Distance from bottom of scum to bottom of outlet tee or,baffle: 18"
How were dimensions detennined: ASBUILT AND TAPE
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as r
related to outlet invert,evidence of leakage,etc.):
MAIN TANK AT WORKING LEVEL. INLET OLD TYPE BAFFLE,OUTLET BAFFLE.TANK 26"BELOW
GRADE WITH INLET COVER AT 6".NO SIGN OF OVERLOADING OR LEAKAGE.
g 4
GREASE TRAP(located on site plan) N/A -
Depth below grade:
Material of construction: concrete u`metal fiberglass , ' polyethylene4 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.):
r
Title 5 Inspection Form 6/15/2000 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: 32 JANE'S WAY
OSTERVILLE,MA 02655
Owner: VIATOR,LYDIA
Date of Inspection: MARCH 2,2004
F
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: N/A (if present must be opened)(locate on site plan)
Depth of liquid level above 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.,):
PUMP CHAMBER: N/A (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.):
Title 5 Inspection Form 6/15/2000 8
Page 9 of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 32 JANE'S WAY
OSTERVILLE,MA 02655
Owner: VIATOR,LYDIA
Date of Inspection: MARCH 2,2004
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
./ 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,etc.)
LEACHING IS ONE 1,000 GALLON PRE CAST PIT.PIT IS 40"BELOW GRADE WITH COVER AT 8".20"
WATER IN PIT.NO HIGH STAIN LINE.NO SOLID CARRYOVER.NO SIGN OF OVERLOADING.
CESSPOOLS: N/A (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: N/A (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.)
Title 5 Inspection Form 6/15/2000 9
PaL,e q of 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property.Address: 32.IANE'S WAY
OSTERViLLE,MA 02655
Owner: VIATOR,LYDIA
Date of Inspection: MARCH 2,2004
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two:pennanent.reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
Li - -
Title 5 Inspection FormA6/15/2000 10
Page 1 1 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS '
SUBSURFACE SE«TAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 32 JANE'S WAY
OSTERVILLE,MA 02655
Owner: VIATOR,LYDIA
Date of Inspection: MARCH 2,2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater feet
Please indicate(check)all methods used to detennine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observation 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:
USGS WELL DATA WELL SDW 253 47.2 ZONE C 1.7
Cf
-`
Title 5 Inspection Form 6/15/2000 I l
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THE COMMONWEALTH orMussAc*uesrre
U����� l�K�
°^" ~�°
H E!!A LL T1 IHI
--'OF-. .......................
�
App4ioatmwn -for UbipwiaK� Works Toxvfitrurtmwn Vautw �
Application is hereby*made for a Permit to Construct (e--Tor Repair an Individual
' ^�""�"u", ~ Aaa,,""
Type of Building Size Lot-/f-.�u'��...Sq. feet
� Dwelling-No. of Be6nuomx--------------------------------------------Expansion Attic ( ) Garbage Grinder
Other-Type of Building ............................ No. of yrrsoos-------.-- Sbo`vcr» ( ) -- Cafeteria ( )
Other Di^��uboubox ( ) tank ( ) ���` ���°%�~ J�u� . ^�«u�~w��
~~ Percolation Test Dcauito Performed by-------------------------------------------------------------------------- Date--------------
Tes Pit No. l----------------minmtoxperinc6 Depth of Test Pit.................... Depth to ground vnter--------
rX4 Test Pit No. 2................minutes per inch Depth of Test Pb_................. Depth to ground
P4 -----.. -''' ----
[) �� Sod '-^-^����-` ��� ��_ �� ��'- ^ '' � ' ^
/ � --~-'- ='� .-----__-__-.�-__�.-_---'_-. -_���� �����__-��-_ ����� -
/ ------------------------------------- ...........................................................................................................................................................-------
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations-Answerwhen upyica6le. ...................................................................... ----------------------
------------------------------------------'-----'--''----------'--------'------'--'---'--'''----
Agrccozooc:
The undersigned agrees to install the afomdescribed Individual Sewage Disposal System in accordance with
the provisions of Article XIof the State Sanitary Code-The undersigned further agrees not m place the system in
operation until uCertificate of Compliance cd
-'"---�r----------------- ---------- -'---'---'---
� �y �� u*"
ApplicationApproved By-------------------------------------------------------------------------------------------------- -------'---.---
u*e
� Application Disapproved for the following reasons:------------------------------------------------------------------------------------------------------------------
---'-----------'-------------'---------------'-------'----------'-------'-'--
� Date
PermitNn......................................................... Issued........................................................
~.~
----~-'-'--''-'''''-''''------------------------------------------------------ -------''-'----
f........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O?-f HEAL H�t e- -........OF.......:`. �� ?:? ........
Appliration -fur Uiapoiiaf Works Tonstrurtion Pprutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System-at: al
;cation-Address or Lot No.
l_... --
Installer
U % S Address
Type of Building ize Lot....��.__�OU S e q. fet.
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
In-I Other—Type of Building ---------------------------- No, of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ------------------------------- --
W Design Flow...........................................gallons per person per day. Total daily flow......... ----------------.----gallons,
WSeptic Tank—Liquid capacity------------gallons Length---------------- Width................ Diameter................ Depth.--.___-._----
x Disposal Trench—No. ..................... Widtl ---------- Tot, gth-------- T 1 le ing area......?a
.._sq. ft.
3 Seepage Pit No....... Dia ..__ �' -De o 'nlet_-.../. ��__._ ' : eacl ing area------__--.._--_-sq. ft.
z Other Distribution box Dosing tank
a .Percolation Test Results Performed bY--------- ------------------------------------------------ --- Date---------------------------------------
Test Pit No. 1................minutes per inch Depth of Test Pit_.._.__--_________-- Depth to ground water_..--____-_.--.-..-. -
LT, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
R+
--- ---------
G Description of Soil------------�� ` � ��__.�:.�l�r= '� f ✓: e :r
x
W
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 Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed....`"/'`�''.....�......-- � �
—/•-•-•-•-•------ Date
Application Approved By-------------------------------------------------------------------------------------------------- ........................................
Date
Application Disapproved for the following reasons------------------------------------------------------------------------------------•-------...•-•...........---
-•---•-•-••-•-•••-----------•----•--•------------•------------------------------•-••-••-••----••-•••••-------------------------------- ---------------------------------------------...................
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
-��• BOARD O,� HEALTH ,,
............ ...(f'. ..OF.......... ,.�f/t/n%
...............................
%Untifirate of fI',amphaurr
THIS IS 0 CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
b °------------------------------------------•-•-----•----
Installer
has been installed in a ccordance with the provisions of Ar)Qe XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.--- ��.�..- �1--------------- dated......�'_ll%....7�,_,...............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARAphTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE---- - -?y Inspector f � "`� _
- ,
THE COMMONWEALTH OF MASSACHUSETTS
Y`
BOARD OF HEALT_,H /
............. ...4 OF.... ,- /�......r '.
.i
FEE_.....................
�trti xr rrmit
Permission is rTeby granted f E `
................. ------•------•------------------------------------------------
to �Repair ( ) an Individyal Sewage Disposal Sys —�
at None ;; r - /for
�r (.�2 G`Euction
----------------- '--------------------------------------------
Street
as shown on the applicatiosposal Works C PermitNc __._ Dated_,____ .`_- -...- 7G-••._•-
Board of Health
DATE........ ' „ -------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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