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0004 JASON'S LANE - Health (2)
4 aso,a'47-Tane sits rvi.11e: m A 1.2,1..E 132 o ° o a , ° ¢ m- ° c ° ° . _ ° , a Y i u ° ° ° a r ° eoki m N n ° R a . r a is n a nr op by .. m lo r a M ° y d y v ¢ . . a . w r 0 0 y < v. TOWN OF BARNSTABLE LOCATION q TaSon S Lang. SEWAGE# Z0l7 - 0 9 4 VILLAGE O`�+c r%i I I t- ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. QJ� Q rC cck cal%©r, SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ,*T) - (size) NO. OF BEDROOMS OWNER 11u!�r►o-c+L L nic PERMIT DATE: y' 17 COMPLIANCE DATE: y '7- 1 7 Separation Distance Between the: 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 A V 30, No. Fee ;7 S THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 0(ppfiration for Misposai *pstem Construrtion i3ermit d boy Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. a50ns Lata 0 nner's Name,Address,and Tel.,[N�o. Assessor's Map/Parcel �-�3 � "" '""y'�na`"�� ` T J��5 Ian 0,5 Installer's Name,Address,and Tel.No. Desi er's Name,Address,and Tel.No. _13t/3 �Xt4V .fra'� 407 J"3 . /k Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 2,o d bax with p I SU 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 of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Boar of Si d Date ��'�� Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued I No. c/ " 7 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2ppfication for ]Disposal 6pstem Construction permit d by j Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. axons 1 Otter's Name,Address,and Tel.No.Assessor's Map/Parcel ny/YJnL � T� so-o5 /att OS Installer's Name,Address,and Tel.No. Desi er's Name,Address,and Tel.No. 81/3 �xCnuvllon SOk_ - 177-v1"53 A Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd l Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) OX (,U j t , 1 I `7 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 of Title 5 of a Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Bo of `t Si Date Application Approved by Date lxll Application Disapproved by Date for the following reasons Permit No. C ? / V Date Issued 411116 -------------------------------------------------------------------------------------------------------------------------------------- _ HE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( �) Upgraded( ) Abandoned( )by 1�i 3 k(-n\)a{ o n at LI o 5 o i is � a M_- 5 P \�( < < has been constructed in accordance with the vi 'ons of Title 5 and thp for Disposal System Construction Permit No.( 17-c 9�/dated /c Installer fl(� �t C1 LU`/ Designer #bedrooms Approved design flow gpd The issuance of this pefmjt shall 60 e construed as a guarantee that the system itt ftmgto6 a�designed. Date LL // Inspecto I ,� ------------------- ------ •------ --- - - -- - - - - ---�s _ - - - — --tea No. )' -- 7L/ Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction Permit Permission is hereby granted to Co�struct( ) Repair( V) Upgrade( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be cot leted ithin three years of the date of this pen it. / -/7 ` Date �� ( / Approved by i Commonwealth of Massachusetts -y. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 Jason's Lane � Property Address Raymond Lang Owner Owner's Name -n information is required for every Osterville Ma _ 02655 4-6-17 I 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:out forms A. General Information filling out forms on the computer. use only the tab 1. Inspector: key to move your cursor-do not Matthew Gilfoy use the return Name of Inspector key. B&B Excavation Company Name 374 Route 130 Company Address eta Sandwich_ Ma 02563 City/Town State Zip Code (508)477-0653 S113640 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 4-6-17 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. t51ns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 ,C o j�d VS i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M "r 4_Jason's Lane Property Address Raymond Lang Owner Owner's Name information is Osterville Ma 02655 4-6-17 _ required for every __— page. Cityrrown State Zip Code Date of Inspection B. Certification (cost.) 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: System was in working order and d-box was replaced at time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 Jason's Lane Property Address Raymond Lang Owner Owner's Name information is required for every _Osterville Ma 02655 4-6-17 _ _ _ 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 ❑ 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 tS,ns•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I i Commonwealth of Massachusetts JD W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 Jason's Lane Property Address Raymond Lang Owner Owner's Name information is Osterville Ma 02655 4-6-17 required for every page. Citylrown State Zip Code Date of Inspection B. Certification (cunt.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well"*. Method used to determine distance. ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the 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 t5ins•3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 4 Jason's Lane _ Property Address Raymond Lang Owner Owner's Name information is required for every Osterville Ma 02655 4-6-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304 The system owner should contact the appropriate regional office of the Department. t5ms•3113 Title 5 Official Inspection Form-Subsurface Sewage Disposal System•Page 5 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .� 4 Jason's Lane Property Address Raymond Lang Owner Owner's Name information is required for every Cisterville _ Ma 02655 4-6-17 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): 330gpd t51ns•3/13 Title 5 Official Inspection Form'Subsurface Sewage Disposal System•Page 6 of 17 P 9 P Y 9 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .° 4 Jason's Lane - - ---- - Property Address Raymond Lang Owner Owner's Name information is Osteryille Ma 02655 4-6-17 required for every - _ - — page. CitylTown 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? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d See below 9 ( Y 9 (gP )) Detail: 2016-62,000gallons 2015-64,000gallons Sump pump? ❑ Yes ® No Last date of occupancy: Dec'16 Date Commercial/Industrial Flow Conditions: Type of Establishment: NA 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: - - - - - - - t51ns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 Jason's Lane Property Address Raymond Lang Owner Owner's Name information is required for every Osterville Ma 02655 4-6-17 page. CitylTown 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: Date of last pump unknown 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): t5ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 8 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'M 4 Jason's Lane Property Address Raymond Lang Owner Owner's Name information is required for every Osterville Ma 02655 4-6-17 - --_ - - 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: Newest portion of SAS added to existing system in 1992 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1110" feet Material of construction: ❑ cast iron ❑ 40 PVC ❑ other(explain): - - -- - - - - Distance from private water supply well or suction line: Town feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 10'' 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: 1000gallons " Sludge depth: 7 7 l51ns•3113 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 ,M 4 Jason's Lane Property Address Raymond Lang Owner Owner's Name information is Osterville Ma 02655 4-6-17 required for every page. City/Town 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 29" - - - - Scum thickness 3 - 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 14" 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.): Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank is in need of pumping at this time and should be pumped every two years for maintenance. Grease Trap (locate on site plan): Depth below grade: NAfeet 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•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 4 Jason's Lane Property Address Raymond Lang Owner Owner's Name information is Osteryille Ma 02655 4-6-17 required for every _ 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: NA - 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 t5,ns•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth fM h o Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 4 Jason's Lane Property Address Raymond Lang Owner Owner's Name information is required for every Osterville - - Ma _02655 _ 4-6-17 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 oil -- - - 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.): D-box was replaced when inspected. 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.): NA 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: t5,ns•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �a 4 Jason's Lane Property Address Raymond Lang Owner Owner's Name information is required for every Osterville Ma 02655 4-6-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: (1) ® leaching chambers number: 2 stone pack infiltrators ❑ 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 was in working order and dry at time of inspection. Infiltrators are in series with leach pit. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA 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 t51ns•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form /o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 Jason's Lane Property Address Raymond Lang Owner Owner's Name information is Osterville Ma 02655 4-6-17 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: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5ns•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts — — W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 Jason's Lane Property Address Raymond Lang Owner Owner's Name information is required for every Osterv_ille _ Ma 02655 4-6-17 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 Rear C 3 A1. 14'6" 81.19' A2.187' 82-246' A3-26' 83-25"6" A4-29' g Front 84.30' t51ns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 l i Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 Jason's Lane Property Address Raymond Lang Owner Owner's Name information is required for every Osterville _ _ Ma_ 02655 4-6-17 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: >12 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: pate ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Perk logs for neighboring lots show no high ground water in area ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Information on file with BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ms•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 16 of 17 i I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 Jason's Lane Property Address Raymond Lang Owner Owner's Name information is Osterville Ma 02655 4-6-17 required for every _— _ page. Citylfown 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 t5,ns•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Town of Barnstable oFIKE T Regulatory Services Thomas F. Geiler, Director Public Health Division * BARNSTABLE, * Thomas McKean, Director MASS. �04 9� 1639, 200 Main Street, Hyannis, MA 02601 A Phone: 508-862-4644 t Email: health ,town.barnstable.ma.us D Fax: 508-790-6304 �a:zlO Office Hours: M-F 8:00—4:30 u May 12,2009 Robin Legere Trust RE: Underground Storage Tank Removal 4 Jason's Lane Order,4 Jason's Lane,Osterville,MA Osterville,MA 02655 Map Parcel 121132 Tank# 1,Tag#01229 To Whom It May Concern: The Barnstable Public Health Division is in receipt of a copy of the tank removal Application and Permit #001511 issued by the Centerville-Osterville-Marstons Mills Fire Department demonstrating that the above referenced underground storage tank had been removed in November of 2008 The Public Health Division appreciates your attention to this matter and has updated its data base to reflect this fuel tank status change. Should you have any further questions please contact Cynthia Martin of this office at 508-826-4645. 111�crh Aean. CHO Director of Public Health ` * Barnstable Town of Barnstable , Regulatory Services Department 2007 Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO Date: April 1, 2009 TO: Robin Legere Trust 4 Jason's Lane Osterville, MA 02655 RD �0111111 V RE: Underground Storage Tank at: 4 Jason's Lane Osterville, MA Map Parcel: 121132 Tank NO: 1 Tag NO: 01229 Our records indicate that your underground fuel (or chemical) storage tank is over 20 years old, and has not been removed as required by section 326-3: subsection 2 of the Town of Barnstable Code regarding fuel and chemical storage systems. You are directed to remove this tank within sixty(60) days from the date of this notice. After your tank is removed, please furnish this office evidence in the form of a permit from your local Fire Department within ninety(90) days of the receipt of this notice. You may request a hearing provided a written petition requesting same is received by the Board of Health within ten (10) days after this order is served. Per Order of the Board of Health Thomas A. McKean, RS, CHO Health Agent I 2r/APR/2009/TUE 15: 26 C-0—MM FIRE DEPT FAX No, 5087902385 P, 002� Make application to local Fire Department. Fire Department retains original application and issues duplicate as,P ` 66WPON 8 FEEL CO. 45 FREIGHT ST. -9-OCKTON,MA02302 r*' iM,tia,�e� t' , APPLICATION and PERMF jFees .2,Z�.00 for storage tank removal and transportation to approved tank disposal yard in accordance with the provisions of M.G.L. Chapter 148, Section 38A, 527 CIVIR 9.00, application is hereby made by: Tank Owner Name (please print) 1� `�'� X rDnerura fit op Plying to,pcmrn) Address srraar Clq. sratr uP J Company Nam�-�L � V✓IC�//1< S�lCu1C�7AcdidressCo' ividual Prim Address �� �y1�C)Vl � SicZnature(if applyin for perms PrInt /[/1�! Signatu�lying for pemlt) v IFCI' Certified Other _ L 4 Other Tank Location , _ — St•m Aoerrs Crq• Tank Capacity(gallons) Substance Last Stored Ql Tank Dimensions (diameter x length) Remarks: Firm Mlransporting waste 41�� 'r�sUC,1 �yZr�T State L Hazardous waste manifest` E.P.A,4i Approved tank disposal yard Tank yard W Type of inert gas Tank yard address I City or Town Centerville FDID# 01920 Permit# 001511 Date of issue November 3, 2008 Date of expiration Dig safe approval number S J /��"' Dig Safe Toll Free Tel. Number-800-322-4844 Signature/Tltle of Officer granting permit � i �►L� �`R� ��+ ��r� After removal(s) ("Consumptive Use"fuel oil tanks exempted)send Form FP-29OR signed by Local Fire Dept. to UST Regulatory Compliance Unit, Department of Fire Services_P.O. Box. 1025, State Road, Stow,MA 01775. 'International Fire Code Instllute FP-292(revised 4/97) rl/APR72009/TUE 15: 26 C-0—MM FIRE DEPT FAX No, 5087902385 P, 001 s ;r :L CENTERVILLE-OSTERVILLE-MARSTONS MILLS FIRE DISTRICT DEPARTMENT OF FIRE-RESCUE & EMERGENCY SERVICES 1875 Falmouth Road, Rte. 28 Emergency Number: Centerville, MA 02632-3117 Business: (508)790-2375 John M. Farrington Facsimile: (508) 790-2385 Fire Prevention/Administration Chief of Department Facsimile: (508) 957-8239 Dispatch Center FAX COMMUNICATION MESSAGE DATE: TO - tee - ATTN: FROM: WE ARE SENDING ( � ) PAGES, INCLUDING THIS COVER SHEET. PLEASE CALL (508) 790-2375 IF YOU DO NOT RECEIVE THE TOTAL NUMBER OF PAGES. CONFIDENTIALITY NOTICE: This fax transmission may contain confidential information belonging to the sender and such Information is legally privileged and Is intended only for the use of the individual or entity named above. Any copying, disclosure, distribution or dissemination of this information or the taking of any,actlon based.on the contents of this communication is strictly prohibited. If you have received this transmission in error, please notify us Immediately by telephone and return the original transmission to us by mail or delivery at our address above. We shall cover the cost of return mail. Thank you! e. 02 1%A-rR%2009/TUE 17: 24 C-0—MM FIRE DEPT FAX No. 5087902385 P. 005 , r gsr. COMM Fire District a3 1875 Route 28 4� CENTERVILLE, MA 02632 1926 INSPECTION REPORT Tueaday November 4, 2006 LANG, RAYMOND B 4 JASON'S LN OSTERVILLE, MA 02655 Occupancy ID: LANG09 Date Completed: 11/04/2008 Inspection Type: INSPECTION - UST Removal Arrived on location to meet with tank removal contractors. Tank is un-earthed and located on the A/D corner of the building. Tank was recently in service and was holding liquid. Tank is being removed for homeowner who converted to gas equipment. Fank, fill and vent are in good condition. Tank removed from grave. No abnormal odor present from the grave, soil is dry to the sides and under the tank. Tank integrity is good all sides. 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['_}l. .t:.,tl:+r(..,� :e 7,,.•1: .,.+<._•,.1.{ .p �o. ,.� .:,al..: L_���11.r.,.,: "t.r,^r u,,,gn ;at .. ,t, ;';Y ,•t-.. 'L"3; .pW 1-' �.t... ,,,.,.P,.. ,..ud.,,i..,.. t..,,,,.;r„f�,• '1r � !r,,"flr._ 9I:`4C,:�b.,�3i�a iR. I.!„71•T�, b,h•4r�f r,,7�,',t�c.•,�t��3"�.�,�da6+,'�L �V.It..tr�,,.,1r:4:.:1'�y,t.S •.�:. �tl r�'I`;F•'1,:.:;r:': ;:fair?\.,.,1 ;i 'r 1, �)„2 . ]37,..,.T�t,af ty.cJ'-�� .11a{T;�'�i •t.gin..,+..✓s.rJ�•rtf�,..i,.. ....�.,v. _..,...�,�..r..�a..J.,}a; ,. ,..'i�iFP.`r:;: _.].•s:. ),:we' �J�-f�Ja,` s ^ ly`..r .V,,y. ASSESSOR'S MAP f NO. PARCEL LOCATION SEWAGE PERMIT NO. VILLAGE INSTALLER'S NAME A ADDRESS (�' • R �<> i � S U I L D E R� OR OWNER DA T E P ERMIT ISSUED DATE COMPLIANCE ISSUED I - ` q, rLr\ . 1 G� W ( VTHE COMMONWEALTH OF MASSACHUSETT APPROM S BOARD OF HEALTH g.rpK TOWN OF BARNSTABLE - r 'f Appliration for Biopoottl Works TvmArUrit#TVrntit Aption is hereby ma Construct ( ) or Repair ( X) an Individual Sewage Disposal System a l-" C.9 : a ......: .... .. .............•-••----..........------... ---------..............................._. John Carpenter ko��tprl_Ilddress or Lot No. ......................_._...._...._._..t.------•-----•----................._............._._...... ......---.................._................_.........._..---•-•--................................ Owner Address W W.E. Robinson Septic•Service P O Box 1089 Centerville MA 02632 ,a -•--------•------•-•-•........ .......................••----------•-----------•--•.....•-••-•--•----••---•-•--.....0........•-- Installer Address Type of Building Size Lot............................S feet Dwelling—No. of Bedrooms....3......................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e 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..................... Width..............._.... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--_---------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit..............---... Depth to ground water........................ Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �+ -•-•-----•-----------------------•-------•------..........-•-•-••--......---••--•--•......------........_.._._..-----•------•---•-.............---.....------ ODescription of Soil..........s�id.................................................................................................................................................... x V .....-•-•----••--••---....-••-------------•-•------•---••-----•-•---•--•--••-•-••----••••-•-••-------.........---------------------------•---•-..............---••-•••-•.._..-----•---••-•-------•-••---- W --------------------------•------------------•--------•-------------•-------•-•--------•-•--•.....------------------------------------------------........------.................-----•------•----•--- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ..2.-stmepacked--infiltxaters........................-............................................................................................................... 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 iss by e board of health. v Signed board Ll..............1 Date o Application Approved By --------------- ) ..... ;•-e7 =; L" / a Application Disapproved for the following reasons- -------------------------------------------------------------------------------------------------------------------te.----------------- ----------------------------------------- --------- ------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------........... -- Date PermitNo. �,a�........-...y-.............................. Issued ------..............................----------.......---------...... Date L V. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE `? ppliration for Disposal Works Tonstrudbon 1rrutt# _,,,Application is hereby made for.-a.Per6it to Construct ( ) or Repair (X) an Individual Sewage Disposal System at• A YN s Y .._4 _ - c11. - ------- --- ----------- John Carpenter I,oecaSti1n�Address or Lot No. - - - —-_.....__.....tc.... .................................. ......................................................—.......................... Owner Address a W.E._Robinson_SelDtic Service P O.Box 1089 Centerville MA 02632 Installer Address Type of Building Size Lot____ ___-_._-_Sq. feet �-t Dwelling—No. of Bedrooms.___j2......................................Expansion Attic ( ) Garbage Grinder ( ) `PL44 Other—T e of Building No. of persons............................ Showers — Cafeteria POther fixtures ------------------------------------------------------.--•----•••-•---•---------•---•-------------•----....._........---------...-•••---•--------•---- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width...._........... Diameter................ Depth-•_-__-_.__--•.- x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by........................................................................... Date---------------------------------------- Test Pit No. 1................minutes per inch. Depih of Test Fit.................... Depth to ground water--_-_-__-•_-_-___-__.-_. 44 Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water............:---__•_--__ a --•-•---•----•--•-----••-------•--••---•-•-•----••••---•-•-•---.....•-•--•--•-••-••----•----•--•••--......................................................... O Description of Soil--........g * ---------------------------•--•----------------------- x w UNature 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 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 iss eVbyt board of health. Signed U- ---- are _ A IifItion'A`�" roved B �s+�.+ P ` pp y ------------------U .................. --- --------------- --- �y' Application Disapproved for the following reasons- ----------------------------- ......................--------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------- -- ate Permit No. 1-/ Issued ------------------ Date Y THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ger#tfirate of Cfumylianxe THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired( X ) bya.F R�It� np�nti 4c�rt�i Cc� Installer at --4..-Jasmine Lane Ostervil�.e..................: ------------------------------- --- ------------------------------------------------------------------------------------------------------------------------------------ has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. --------?�-1---------Y--1`--7----- dated .-------------------------.._.-_.---------..-. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...................... r `-1--; Inspector ---------•-------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH C� TOWN OF BARNSTABLE No.....[..:.1Y/7 FEE..T, -DO....... Disposal Works Tuns#rudilan Prrutit Permission is hereby granted 'oav�q.. = m................................................................. - to Construct ( ) or Repair (X ) an Individual Sewage Disposal System I at No.- 4.�T miz� _•I�ne_Ost v le.............................................................. --------•---•-•--------------------------•---------...---- Street Q�_ as shown on the application for Disposal Works Construction Permit No, ................. Dated.......................................... -------------------------- -----------•-----------•----._...._..-------------. DATE.................. �l Board of Health -•---a-y-••-- ..............•••••--•---•-•-• FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS r ASSESSOR'S MAP NO. PARCEL LOCATION � �11 W AG�IP E RMIT NO, VILLAGE �vt. � �� - I N S T A LLER'S RE7 Z NAME A ADDSS S UILDER OR OWNER DATE PERMIT ISSUED S"Jz,3 DATE C 0 M P L I A N C E ISSUED o I - - #' TCJWN OF BARNSTABLE - UNDERGROUND FUEL AND CHEMICAL STORAGFr REGISTRATION MAP NO. _ PARCEL NO. ADDRESS OF TANKt. `s LA ffF y VILLAGE �d/ /!✓'��' MAILING ADDRESS ( IF DIFFERENTMOO AM BOV�E/) : OWNER NAME: l� p h l J y A (--r PHONE: INSTALLATION DATE: CUI Q l BY: INSTALLER ADDRESS: 'CERT. JO. *TANK LOCATION: (D000PQ I OC TANNK LOCATION W Z TH RQOPQCT TO mU Z L_D I NO) r f D CAPACITY IUl/C� TYPE OF TANK1/ AGE YRS. FUEL/CHEMICAL VbL Q/L TESTING CERTIFICATION C ] PASS C ] FAIL DATE "LEAK DETECTION C ] CHECK IF N/A TYPE/BRAND 111?q t ZONE OF CONTRIBUTION r' .] YES C ] NO DATE TO BE 'REMOVED FIRE DEPT. PERMIT ISSUED C ] YES C ] NO DATE o1V //r3 .t00g, C-o F,�� CONSERVATION C ] CHECK IF N/A� DATE PM t�,r 10- oI6 . BOARD OF HEALTH TAG NO. C ] DATE . PLEASE PROVIDE SKETCH SHOWING THE TANK LOCATION .ON THE BACK OF THIS CARD - .. -T> r `h �j;Xti^.lY'wt"'ie�."r°6dy°".`vr"..5�-siw.•r-.nti"'t`r:�;y,rf...... . .:-,�. ,•r.-.,.. -r..,..-. -. ..-. ._. ... .: _.- , TGi+VN OF BARNSTABLE - UNDERGROUND FUEL AND CHEMICAL STORAGF;�REG,_I STRAT�N MAP NO. I PARCEL NO. ADDRESS OF TANK: ` '' LA,1 V I L L A G E r-`kl U' rl I NuMb40r r404m MAILING ADDRESS ( IF VIFFERENT FROM ABOVE) : , � f OWNER NAME: 1 t �fI PHONE: INSTALLATION DATE: dod f'' BY: INSTALLER ADDRESS: -CERT.iJO. *TANK LOCATION: (DGOOR=Z DG TANK f`OOAT I ON W S TH RQOPQOT TO mu S LD Z NO)) r CAPACITY 1 000 TYPE OF TANK AGE YRS. FUEL/CHEMICAL f ' � `%w- TESTING CERTIFICATION [ ] PASS [ ] FAIL DATE LEAK DETECTION C ] CHECK IF N/A TYPE/BRAND [ . ZONE OF CONTRIBUTION C ] YES [ ] NO DATE TO BE REMOVED f PA , � � FIRE DEPT. PERMIT ISSUED C ] YES C ] NO DATE S _ 76, 1, T/1"N" ��'��fU VE�' CONSERVATION [ ] CHECK IF-� N/A* DATE BOARD OF HEALTH TAG NO. C ] DATE * ,PLEASE .PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD ,r n. TOWN OF BARNSTABLE r A t V� �� UNDERGROUND.FUEL AND CHEMICAL STORAGE SYSTEMS t.. 4' n • ASSESSORS MAP .NO. PARCEL N0. 13 15 -, / — VILLAGE, . ADDRESS?" NAME - -�A Z . _ . _ C CONTACT PERSON ' "' PHONE NUMBER( (./ . LOCATION OF TANKS:. CAPACITY: ;.TYPE OF FUEL. AGE: TYPE: LEAK OR CHEMICAL: DETECTION SYSTEM! �:itil. DATE OF PURCHASE OF. EACH: 1. / 2. 3. 4. 5. _ DATE' OF .FIRE DEPARTMENT PERMIT: TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS 'PLEASI PROVIDE. A SKETCH 'SHOWING.THE LOCATION OF TANKS ON THE BACK OR THIS CARD. i o�j 0 f �j/� C 7� From Wovs5 [��Oloo �f