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HomeMy WebLinkAbout0034 JASON'S LANE - Health 34 Jason's Lane Osterville A= 121 — 127 Commonwealth of Massachusetts Title 5 Official , lnspecfidh Forhi' iI Subsurface Sewage Disposal System Form -Not'for,Voluntary Assessments ;,v, .,,; 34 Jason's Ln Property Address � ,, .• ,, , Bear Fisher Owner Owner's Name information is required for every Osterville• t, rs MA 02655 5-6-21',ns' 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. $ '.'r ', , . '. ,- , .a,i A. Inspector Information ._,3a-y.. ,W Shawn Mcelroy tr, -'Name of Inspector, 7 ::J `{,, r ,rU 16 1>. :if ra "4 /t:Ur.::;:,a. r'r.} ,.u,.,•,,:: ' 1L a ,t..:i i , - bap s ! +stK:. e`t'r ft. ._ '^�i 7 1�'�,- 1'.i t '�i iS' :fir• �'tEt..J tF�'t fib Upper ape Septic Services Company Name , .,_,.: ::,.•..r„ P.O. Box 73 Company Address �::,+ tat flf,l• East Falmouth.- ,, e, it, ri'rfro.'tr 'MA; .fsiy f . .1a�rfr r rFtrlt;'02536 City/Town , , •3 t:�'• '1"11 .1(, if3..1$tate 7i:!ifi .r�,.Zip Code 508-495-0905 S13971 Telephone Number License Number B. Certification I certify that:l am a DEP approved system inspector,in,full compliance with Section 15.340 of Title 5 (310 CMR 15.000);l have personally inspected the sewage disposal system at theproperty address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on'my:training and expen6nce,in the proper function and •maintenance of on-site sewage`disposal systems:After conductirig this inspection I have determined that the system: ��.rt :i . °;° t► ;.� f -:1' ® Passess' ' Y,, ,�:_ t1', << ; fr,;r�'', !r. +"'•rg '4f+~ lri}"' rr .,y:- -2;f ❑..Conditionally Passes 3 r Cat •� • `' tq,t �''... f�,�*a, +t.,'� - '?�t�G a i`, r ?`.. . t, • 3.. ❑ ,Needs Further,Evaluation,by the,Local4Approving Authority. 4. ❑ Fails !-t •1 q -t, ' - ilrlkfl"�:.iae %{r i i1 .1 1i. :,gzjii !:n- .3 fqx' p; �,r •,�� .�r:Nt;r :f tf ;E ''^x hRJ r,f:� c{t'.7ilr`f� "^;4tsc'ii�'. .. 5-6-21 Inspector's Signature - Date ` The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of - 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future,under the same or different conditions of use. t5insp.doc•reW7/26/2018 a-_ ..•a.i' *•. •.,n ,.r - .• - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of.18+ r s Commonwealth of Massachusetts P Title 5 Official - Inapec$ion 'Form ' Y i Subsurface Sewage Disposal System'Form Not for Voluntary Assessments � 4 34 Jason's Ln " Property Address Bear Fisher Owner Owner's Name information is Osteryille MA 02655 5-6-21" - required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 4 1) Systern 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 is in good working order with no sign of failure. System has moderate tree root intrusion into septic tank. Recommend regular pumpings to keep roots under control. s 2)"'System Conditionally Passes: One or more system components as described in the"Conditional Pass",section need to be ti 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 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): ` t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts ; t, }, ,_ •h ,, y, �, at,t-.r ,. Title 5 Official Inspection orryi, I, Subsurface Sewage Disposal System Form,-Not for Voluntary,Assessments,,•.;.+';:,;= 9 p Y 34 Jason's Ln Property Address Bear Fisher Owner Owner's Name information is required for every Ostetville MA 02655 5-6-21'cr• :j. page. City/Town . State Zip Code Date of Inspection C. Inspection Summary (cont.) ;t-,; ,„ .,. ; �t•:} . .; yY; a . 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ` :+ ► t •, , , , ., _, f •'r tR�t.i . ;.i i r.l.•..3. S4• r G . :i: T h 11 FI r i .tj _ f 'r `l •'s${ '..i ..-sr` .... ,!'tf .. ,: y`. .J.':.,!'., .;; ,:#1.. •. ",�r:.. ., r- ❑ 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)? ' 'r tr.` ❑ broken pipe(s)'are'replaced �' r"" �.'❑ Y' ❑W"❑3tND (Explain below): f - - ❑ obstruction'is removed "� ra' ►,T� ` ❑'Y ❑N� ❑'ND (Explain below): ❑, 'distribution box i§leveled or replaced -" ❑Y - ❑'N. ❑"ND (Explain below): Y, • t'-1t' . -i,f.`,u . .,.(I -j ,., -t..., i t + nr. .,11 t, P ,i w J3'.:y +�t. .# ,. Pkti ^# ',iykr, t3 11 rr -PI(I(.1;' Y1 .v f'rC,n t ^ yY. 7 n'# :•'r f, -•.• It. F. •r �'�r't, M o-3 -ro-♦t'it, ( • r f:• S , j !•"� .`i.:. -.{li. .' ', Ik.� }•> ./ tl' tt. trN-Ki 1L.:t {� /'. . 1%t y�1''�.r •1 ,1'.it Hof«'.�:,r ❑ 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): 3) Further Evaluation is Required by the;Board;of,Health:;7.•.,;� ❑ 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 orthe environment.-µ a. 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, ' F safety and the environment:' c:it dr.''= _`. :!': •it i '11t•.. �r,t ft1 £ #3 Wit:'litlr Ct S' '.1'1�. ` r , ..•'3i-=k.+ ;4.1 M' IC+{'fr;�cc'7~t:i'+� t;.wu �`;si',t^,. • ' i, ,1 . r .�"..`+, t5insp.doc•rev.7/26/2018 • _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 16 - Commonwealth of Massachusetts Title 5 Official Inspection 1=orn p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -2` 34 Jason's Ln Property Address Bear Fisher Owner Owner's Name information is required for every Ostefyille MA 02655 5-6-21 ' page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cost.) ❑ 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 b. 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 u ❑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. c: Other: ! r 4 , 4) System Failure Criteria Applicable to`All Systems: ' You must indicate"Yes"or"Ni''.to each of the following for all inspections: Yes`; No Ate ❑ ® 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth,of Massachusetts Title 5 Official, Inspecti6m Forums, � { %M Subsurface Sewage Disposal System Form,-Not for Voluntary.Assessments,,1�•,-d, 34 Jason's Ln FA Wfl.,, Property Address Bear Fisher 4 Owner Owner's Name information is , + required for every OSterVllle; , . r'^^., . MA 02655 5-6-21�vai page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ,IFt 4) System Failure Criteria Applicable to All Systems;(cont.) • �. .r �.r' .e' r''i• " i� °;r. 't. .).}�°` rf f. r1 1`al .i Yes r NO �� ® Static liquid level in the distribution box above outlet`invert due to an overloaded or clogged SAS or cesspool `''`- J,4 ' ''' �P ` r ❑ r ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow' ,� ,7 .. , El ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ` ": ❑ -, 0 R . ,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 ' - "''1''tributary to*a surtace`water supply. Any portion of a cesspool or privy is within a Zone 1 of a public water supply ❑ " ' ®' t•t well.` ,ta, , �.: y,, , . . !', : � tn7. - ❑ ® ''Ariy'portidn'6f a cesspoolbr pnVy 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 w t and chaintof custody,must be attached to this form.], The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 god: - . •. e V h .� ., , •1 �. The system fails. I have determined that one or more of the above failure ❑ �® `� 'criteria exist as`described in'310 CMR15.303,therefore the system fails. The ;., . . system owner should.contact the Board of Health to determine what will be necessary to.correct the.failure:.. Iq 5), 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 CA.- 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 t5insp.doc-rev.7/26/2018 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System"Page 5 of 18 •. , Commonwealth of Massachusetts y Title 5 Official .Inspection Form i,01 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s_ 34 Jason's Ln Property Address Bear Fisher Owner Owner's Name information is required for every Osterville - u• ' MA 02655 5-6-21 page. City/Town _' State Zip Code Date of Inspection C. Inspection Summary (cont.) 1> " If you have answered "yes"to any question in Section Cis the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. - 6. You must indicate "yes" or"no"for each of the following for all inspections: t r 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? [Z ❑ 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), FF❑ 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? ❑ Wasthe 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)] t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 4,r Commonwealth of Massachusetts � r Title 5 Official. lnspec$ion,Fo'm- ,-}. r. ., ' a, ! r�I Subsurface Sewage Disposal,System Form -Not for Voluntary Assessments,'�=r 34 Jason's Ln Property Address Bear Fisher ^f=+ r Owner Owner's Name information is Osterville - t MA 02655 5-6-21.I;,, r_ _ required for every - page. City/Town State Zip Code Date of Inspection D. System Information L " 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of..bedrooms (actual): 2 DESIGN flowbased on 310 CMR 15.203 (forrexample, 110 gpd,-x#of bedrooms):, 330 Description: Number of current residents: "F. f< tt.1 ,;`nr t t,..:r;;rf, t� f: ,,,►:`r,, 2 Does residence have a garbage grinder?,. ,f,; , j1L.,,,,,.3,.,;_, �tR ,,; �sr.rr ram', ❑ Yes ® No Does residence have a water treatment unit? ,f• _�t�, t, ;- „^, ;ti,: �,, , ; ,�,� ;,:, ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ' '` ❑ Yes to No information in this report.) ' ' ' '� ' �`'`~[ Laundry system inspected? ❑ Yes ® No Seasonal use? - ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: AxA .r lit tL J: r %It j t , ;,y..T, _"t!ti_F ti'b c` 1).901n!Iq F �. ,�'ba J Sump pump? t, .,rr,,: ;.sr, rl�t• t.,r f1 ❑ Yes ® No a . Last date of occupancy: 2021 Date I rill 10 PC t5insp.doc•rev.7/26/2018•. • ,! t Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18,E• ;, ; Commonwealth of Massachusetts 4 Title 5 Official Inspection Form hl Subsurface Sewage:Disposal System Form -Not for Voluntary Assessments 34 Jason's Ln Property Address Bear Fisher Owner Owner's Name information is Ostervillis MA 02655 5-6-21 required for every page. City/Town ! State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: ' Design flow(based on 310 CMR 15.203): '' Gallons per day(gpd) �I Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No • Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date ' Other(describe below): 3. Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts ., 1 Title 5 Official, Inspection F-' orm . 01 Subsurface Sewage Disposal System Form -Not for,yoluntary Assessments s, `� :: ITc- `• 34 Jason's Ln Property Address Bear Fisher et ', Owner Owner's Name , information is " .e required for every Osterville-- E MA 02655 5-6-21 s ' page. City/Town _ State Zip Code Date of Inspection D. System Information (cont.) r � ,� 4. Type of System: 1.1-9 9-1,1 ® Septic tank, distribution box, soil absorption system- Single cesspool ;•, . f , ❑ , ,r; •, Overflow cesspool u f"rl ❑ 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 tr ❑ , {, , -Tight tank.-Attach a copy.of the.DEP.approval; , ❑ Other(describe): , ,., �n ►,� i 1,.• -. jw:1."f'- Approximate age of all components, date installed (if known) and,source of.information: 1991 Were sewage odors detected when•arriving;atthe site?, 1,,7,r- Ir, a1 w is+ ❑ Yes ® No 5. Building Sewer(locate on site plan): j -,-x�r t;�; ,. �,7,•t;,�;�rn,,;a 18 Depth below grade: feet '` , ,,f• •t l�ls},, f3. . .� n.G t) r`i,`!=i3':"� i,`{�'.ii,7tA�ft{j� � "''.`�,�`C Material of construction: s ;• -*`-°! f e.�:=t�, ., ,.r3`',r i �ISr t!r v.',e�"ai ,��'.. .l Fit',- 1 ❑'cast iron ``' ® 40PVC'" F r ' []'other(expla n): '" t' cry ni ` 'I Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. t5insp.doc•rev.+7/28/2018• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18••. c. Commonwealth of Massachusetts ,w, Title 5 Oif'�'icial• Inspection..Form C�'l Subsurface-Sewage Disposal System Form =Not for Voluntary Assessments 34 Jason's Ln Property Address Bear Fisher ,r Owner Owner's Name information is - MA 02655 Osterville 5-6-21 required for every page. Cityfrown ti State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 1211 Depth below grade:• I =' feet _t Material of construction: , metal f I other(explain)® concrete ❑ i r If tank is�metal, list age., years Is age confirmed by a Certificate of.Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 2 ,, t. ;• , . 1000 gal Sludge depth: 12" -Distance from top of sludge to bottom of outlet tee or baffle 20 Scum thickness _ Distance from top of scum'to top of outlet tee or baffle i }` L. Err Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? ., .Tape 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 is in good condition with baffles installed and,no,sign of leakage. Tree root intrusion. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 i Commonwealth of Massachusetts _•. ;- - c !: �;� , Title 5 Official i Inspection Form �I, Subsurface Sewage,Disposal.System Form Not for,Voluntary Assessments 34 Jason's Ln Property Address Bear Fisher Owner Owner's Name information is required for every Osterville a.' MA 02655 5-6-2.1_.r >; page. City/Town n-1 State Zip Code Date of Inspection f D. System Information (cont.) 7. Grease Trap (locate on site plan): _' ,-Jt t o! ; t' a •,. ;t' Depth below grade: feet • Material of construction: ❑ concrete ❑ metal ❑ fiberglass rEl polyethylene, ❑ other(explain): i-.d ', -] • '•4.:. ! -...i. .. ... ,. , „ r,. �jtlrar'.1_" rf'r•Y..r, r 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: _: ti �+ , ,•�7� •f-z Date- Comments (on pumping recommendations, inlet and outlet,tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage; etc.): ' ," ..rr3 .e. e';. ft�ti, .jt. .'e�Ic.•:!t 1:'.`t-K;;k" tI' ,•C i;: t':):,�"k ot:".e�,t �. _�. 8. Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: - Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 ; .,k a Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts ,'. Title 5 Official Inspection Form Fri Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Jason's Ln Property Address Bear Fisher Owner Owner's Name information is F required for every Ostervil►e *Y MA 02655 5-6-21 page. City/Town ` ': State Zip Code Date of Inspection D. System Information (cont.) j' a 8. Tight or Holding Tank (cont.) Alarm ❑ Yes resent: ❑ ` No P 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 9. Distriblution Box(if present must be opened)(locate on site"plan): . ` Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from field. p e 3 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts -. _ _ a-., �t'.">►;'ta^�:F a Title 5 Official- Inspection form"'.. Subsurface Sewage Disposal,System Form.-Not for Vol u nta ry,Assessments z,gun, .It .. 34 Jason's Ln Property Address `n , Bear Fisher Owner Owner's Name information is required for every Osterville MA 02655 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): ,aj('Ae, tsc,o r Pumps ifi working order: . r `a" • ,� +, t• t. : ;Jk Yes ❑ r r: ;_ IiPi, .. ,,i. . t • r, . No* •,,P }; ,Alarms in workingorder: :❑ Yes ❑ No* a?'irf1.: ..,. :* ,.y t� i... ' rrae a �fiS tfx`�'� •.it%�°t• Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass:.; ': •� 11. Soil Absorption System (SAS) (locate on site plan; excavation,not required): If SAS not located, explain why: •.�_i �r„ i, R n, ..fix _4.. ♦ . .r, -.,. Type: r • ;,; y .1��:•; Lr '� �r�.f;t. ,o :�1,r,- : ,o pit -�, ri—, F. 2-1000 gal ® leaching pits number:` ❑ leaching chambers - number: ❑ leaching galleries number: ❑ leaching trenches number, length: - ❑ leaching fields -number, dimensions: El overflow cesspool number: _ ❑ innovative/alternative system Type/name of technology: t5insp.doc,rev.7/26/2018• _ - w. ^n 4 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts r ; Title 5 O idial Inspection FOQ'Q1'1 N Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 34 Jason's Ln Property Address Bear Fisher r Owner Owner's Name information is required for every osterville -' t' MA 02655 5-6-211' •1- r page. City/Town State Zip Code Date of Inspection D. System Information (cost.) ' 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Pit marked "4" had water level and stain line at 12" below inlet.invert. Pit tmarked'5"was empty at inspection with stain line at 16" below inlet invert. 1 •� ! r ,, • .- . r �. '� P � art,. :f .': 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration= x + r Depth-top of liquid to inlet invert r' } Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): " n , t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18, Commonwealth of Massachusetts Title 5 official- Ihsipection Forte r i.A �.Ili Subsurface Sewage Disposal System Form•-Not,for,Voluntary Assessments- 34 Jason's Ln Property Address ;,,r.� Bear Fisher Owner Owner's Name t . information is required for every Cisterville. MA 02655 5-6-21 n. ` page. City/Town ,•,t State Zip Code Date of Inspection D. System Information (cont.) � 13. Privy (locate on site plan): +' '" t Materials of construction: �' '3 nt� i'r �' '� ..�' ' "-`r•r s<7. 1r : +ra 'itatsua:,'.7 Dimensions C*r3�";.,j,,;;,,�: •1 rFf rig".` -;3•')+iF,,• ''; Depth of solids Comments (note condition of soil,-signs of'hydraulid-failure;level of ponding, condition,of vegetation, etc.): �g 6 1 , r . i « .. r - � . - . - . ..w - rsr rr ti_fM�-r w--ti r • ..r r F { l t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 ., 1 ' Commonwealth of Massachusetts - -'y Title 5 Official- i nspectiom Form' i. 9 p Y Voluntary,I Subsurface Sewage Disposal System Form -Not for Volunta Assessments � r 34 Jason's Ln M Property Address Bear Fisher Owner Owner's Name information is required for every Osterville MA 02655 5-6-21 page. City/Town '' State Zip Code Date of Inspection D. System Information (cont.) 14. 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 5L.*.� 0 �. f _ Y � �- 4 Y4 6�3 31 rfd /✓ I1Y4-r A. 5 - 33 o. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 N. A � Commonwealth of Massachusetts Title 5 Official Inspection Fori* r �iNf Subsurface Sewage Disposal System.Form -Not for,.Voluntary,Assessments;,;-. ;_•_, 34 Jason's Ln k, r- Property Address Bear Fisher Owner Owner's Name information is Osterville - * MA 02655 5-6-21' - ` required for every = � page. City/Town + State Zip Code Date of Inspection D. System Information (cont:) , 15. Site Exam: i4. ❑ Check Slope fa-"t{, 73 .k, ;'.Ef,+. t`!{ 1C� s++elrifd "; rt •.',y ,,. .� ❑ Surface water t2, • 1 ," 7 . t .8 ❑ Check cellar ❑ Shallow wells K t .. t. ;'r�';•,� tt� , Estimated depth to high ground 12'+ water: �t t f+ .; ,c feet 01,t, Please indicate all methods used to determine the high ground water elevation: �+ ❑ Obtained from system design plans on.record,,, �,ins- .8 jr If checked, date of;design plan reviewed: •„•. , :r Date' ® . Observed site (abutting property/pbservation.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 and town maps show groundwater at greater than 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.=7/26/2018 y - y, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts + ' 2� Title 5 Official. Inspection for& Hi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �J 34 Jason's Ln Property Address Bear Fisher Owner Owner's Name information is required for every Osterville - - MA 02655 5-6-21 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ' Complete all applicable sections of this form inclusive of: �= ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked <; ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate p 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: =' For 8: Tight/Holding Tank-Pumping contract attached For 14: Sketch of.Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included p•. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 ""SENDER:'COMPLETE THIS SECTION • • ON DELIVERY ■ Complete iteris.l,2,dhd 3.Also complete A Sign re item 4 if Restricted Delivery is desired. ❑Agent ■ Print your na o'and 4451ress on the reverse X Addressee so that we Nt return the card to you. B. Rece ad by(Prin d C. D e of Delivery 9--Attach this'cafd to the.6ack of.the maiipiece, 1 ® I or on the front if space permits. L _. . ; D. I delivery address differs from item 1. ❑ es 1. Article Addre ed to: a' �,�} S If YES,enter delivery address below: 1No Lyn; offeY I 34�ason s Lane b 3. Service Type OsteNille,MA 02655 p Certified Mail ®Express Mail O'Registered ❑Return Receipt for Merchandise �( ❑Yes❑ Insured Mail El C.O.D. 4. Restricted Delivery? Extra Fee) 2. Article Number (Transfer from service iaben E i ! I; Z 3 .i ;7 0?0 6 30 810It 10 0 0 0 f3 5 2 4 5 461 PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1 40 ; 3: �: is s �i _ UNITED STATES POSTAL SERVICE "'" m� af3y as 'h9 eTgA--;A. . ;.�.'r*9 ( �'lilG Y,Sd�S�'?l��Y �X�\i M I.•�t•�,' � .�•..�� .�M,,�$ik� ...�,• Sender: Please print your name, address;and i� Ifni`b x� . I I I Town of Barnstable Public Health Division ; e 200 Main Street Hyannis, MA 02601 i `gk �i,;,r.,� '{:{if7tl111,l��1!lf7.!l1,If�111l11�1.lIDIIilllfi.l�11l11�11111I11l1 i F THE r Town; of Barnstable Barnstable Regulatory Services Department 1�"a�j �+ WBNSTABLE, • . MASS. 0 Public Health Division,039. Arf°µAS a 200 Main Street, Hyannis MA 02601 2e07 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL # 7006 0810 0000 M24 5461 November 8, 201.1 Lyn Coffey 34 Jason's Lane Osterville, MA 02655 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 • The septic stem located at 34 Jason's Lane, Osterville,MA was last inspected on . 10/18/2011,by Sean M. Jones, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed*that the system"Conditionally Fails"under the guidelines of the 1995 TITLE 5�(310 CMR 15.00) due to the following: • Outlet baffle was intact, but is rotting, needs to be replaced with sch 40 pvc tee. • D-box was inspected and found to have roots growing through the sides, box needs to be replaced. You are ordered to repair or replace the septic system within two (2) years from the date you receive this notification. Failure to repair/replace the septic system with the deadline period will.result in future ' enforcement action. PER ORDER OF TH BOARD OF HEALTH • Thomas McKean, R.S. CHO Agent of the Board of Health /!/�� /1/3/47, D Q:\SEPTIC\Letters Septic Inspection Failures\34 Jason's Ln.,Ost..doc rrt ru u7 frl : Postage 3 CCertified Fee l; M ReturnReceipt.Fee Postmark- (Endorsement Required) g Hire E3 Restricted Delivery Fee O/y rl (Endorsement Required) cc Total Postage&Fees S�Nty + .0 O" E3 Lyn Coffey1 34 Jason's Lane Osterville, MA 02655 Certified Mail Provides: J.', • A►nailing receipt .' %'Q (eerenet/)aooa eunr'oo9s uuoj sd • A unique identifier for your mailpiece • A record of delivery kept by the Postal Service for two years rm.dortant Reminders: a Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail& a Certified Mail is not available for any class of international mail. a NO INSURANCE,COVERAGE IS PROVIDED with Certified Mail. For valuables,'please consider Insured or Registered Mail. a For an additional fee, Re{urn Receipt ma be requested to provide proof of delivery.To obtain Retort Receipt seance,please complete and attach a Return Receipt(PS Form 3611)to the article and add applicable postage to cover the fee.Endorse mailolece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,'a LISPS®postmark on your Certified Mail receipt is required.''- jv/ *For an additional fee, delivery may be restricted to the addressee or addressee's authorized agqent.Advise the clerk or mark the mailpiece with the endorsement"RestricteNeliveryt a If a postmark on the Certified Mail receipt is desired,please present the arti- •1 cle at the post office for postmarking. if a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. r IMPORTANT:Save this receipt and present it when making an inquiry. Internet access to delivery information is not available on mail addressed to APOs and FPOs. } Town of.Barnstable Barnstable °p THE T°�y Regulatory Services Department + BARN.SCABLE, Q HASS m Public Health Division rF°N1°�b, 200 Main Street, Hyannis MA 02601 2007 Office: .508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL # 7006 0810 0000 3524 5461 November 8, 2011 Lyn Coffey 34 Jason's Lane Osterville, MA 02655 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 34 Jason's Lane, Osterville, MA was last inspected on 10/18/2011, by Sean M. Jones, a certified septic inspector for the State of Massachusetts. The inspection of the septic'system showed that the system"Conditionally Fails" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: .• Outlet baffle was intact, but is rotting, needs to be replaced with sch 40 pvc tee. • D-box was inspected and found to have roots growing through the sides, box needs to be:replaced. You are ordered to repair or replace the septic system within two (2) years from the date you receive this notification: Failure to repair/replace the septic system with the deadline period will result in future enforcement action. PER ORDER OF TH BOARD OF HEALTH Thomas McKean, R.S. CHO Agent of the Board of Health QASEPTIC\Letters Septic Inspection Failures\34 Jason's Ln.,Ost..doc r , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 34 Jason's Lane Property Address Lyn Coffey Owner Owner's Name information is Osterville Ma 02655 10/18/2011 required for every 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:When filling out forms A. General Information on the computer, � 0-5 I use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. C y e Enterprises � Company Name 153 Commercial St. Company Address l Mashpee Ma. 02649 Citylrown State Zip Code 508477-8877 SI 4522 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 10/18/2011 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 1.0,000 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 iuthority. ****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 of66E Ed �� iJU- i;"]v t5ins-11/10 Title 5 Official Inspection Form:Subs4Sew,� posal System-Page 1 of 17 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 34 Jason's Lane Property Address Lyn Coffey Owner Owner's Name information is required for every Osterville Ma 02655 10/18/2011 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 34 Jason's Lane Property Address Lyn.Coffey Owner Owner's Name information is required for every Osteryille Ma 02655 10/18/2011 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): 1) Distribution box was video inspected and found to have large amounts of roots penetrating through the sides. 2) Outlet baffle of septic tank was rotting, needs to be removed and replaced with a schedule 40 pvc tee. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Jason's Lane Property Address Lyn Coffey Owner Owner's Name information is required for every Osterville Ma 02655 10/18/2011 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 34 Jason's Lane Property Address Lyn Coffey Owner Owner's Name information is required for every Osterville Ma 02655 10/18/2011 page. Cityfrown 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. 1 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 16,000 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. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System,Page 5 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M r 34 Jason's Lane Property Address Lyn Coffey Owner Owner's Name information is required for every Osterville Ma 02655 10/18/2011 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): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 1 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �b 'Y 34 Jason's Lane Property Address Lyn Coffey Owner Owner's Name information is Osterville Ma 02655 10/18/2011 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: 2009= 38,000 total = 104 gpd 2010=62,000 total = 170 gpd Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Jason's Lane Property Address Lyn Coffey Owner Owner's Name information is required for every Osterville Ma 02655 10/18/2011 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °wM 34 Jason's Lane Property Address Lyn Coffey Owner Owner's Name information is required for every Osterville Ma 02655 10/18/2011 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: unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joints ok, no leakage, vented through roof Septic Tank(locate on site plan): Depth below grade: 1 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: 1000 gallons Sludge depth: 5" t5ins•11/10 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 34 Jason's Lane Property Address Lyn Coffey Owner Owner's Name information is required for every Osterville Ma 02655 10/18/2011 page. CityrFown 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 3.5' Scum thickness 2" 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 10" � How were dimensions determined? opened covers and took measurements 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 does not need to be cleaned now but should be done soon and again every 2 years as maintenance. Water level was ok, tank was not leaking and was structurally sound. Outlet baffle was intact but is rotting, needs to be replaced with sch 40 pvc tee. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Jason's Lane Property Address Lyn Coffey Owner Owner's Name information is Osterville Ma 02655 10/18/2011 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 34 Jason's Lane Property Address Lyn Coffey Owner Owner's Name information is Osterville Ma 02655 10/18/2011 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box was video inspected and found to have roots growing through the sides, needs to be replaced. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth &Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 34 Jason's Lane Property Address Lyn Coffey Owner Owner's Name information is required for every Osterville Ma 02655 10/18/2011 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ 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.): System consists of 2 leaching pits, one is original and one was added later. The newer pit was located and opened, this pit was found to have 1' of standing water with a stain line approx 1' higher. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 34 Jason's Lane Property Address Lyn Coffey Owner Owner's Name information is required for every Osterville Ma 02655 10/18/2011 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M l 34 Jason's Lane Property Address Lyn Coffey Owner Owner's Name information is Osterville Ma 02655 10/18/2011 required for every page. Cityfrown 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 �GP4 a no 2 A-1 L 13—t z3 > A-3 t o i3-3 34 ,q_y s� i�''1 Lll 13- 3s t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 e ' Comm'onwealth of Massachusetts u Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M a' 34 Jason's Lane Property Address Lyn Coffey Owner Owner's Name information is required for every Osterville Ma 02655 10/18/2011 page. City/Town 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: 20 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: 1)Groundwater elevation was established by accessing Town of Barnstable groundwater contour maps 2)Property is elevated compared to nearby pond across street. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins-11110 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System•Page 16 of 17 ' Commonwealth of Massachusetts - - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M a 34 Jason's Lane Property Address Lyn Coffey Owner Owner's Name information is required for every Osterville Ma 02655 10/18/2011 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage-Disposal System•Page 17 of 17 TOWN OF BARNSTABLE °L &TION � J CS 1�e1 [A.,�AJ SEWAGE # VILLAGE 42� [1 14. L E ASSESSOR'S MAP & LOT 7 I Z INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) /'�S,/� (size) ° NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: 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 L1 5 2 � b t TOWN OF BARNSTABLE 7LOCATION 3 L' S S b v`S Lm,,-� SEWAGE# o �� ' -3 VILLAGE ASSESSOR'S MAP&'P"ARCEL INSTALLER'S NAME&PHONE NO. L-�-C- c❑nrrn TA 11V r A tit.,—i� �'2�Qom\'(' '" �"OJ� 1�v�•��W.1 �+2� ���, LEACHING FACILITY:(type) (size) NO.OF BEDROOMS Z OWNER L� w t- �- PERMIT DATE: 0 - - l COMPLIANCE DATE: 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 E I0k, t�r�+aX_j rt 5-P-S P OA 05 AA �-S WP31 c- 3� No. / Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zipplitation for Misposal *pstem Construction permit Application for a Permit to Construct( ) Repair(k Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. S '�d�l Q G Owner's Name,Address,and Tel.No. Assessor's Map/Parcel i 0.1 -7 (X)! t Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. CA1PGwe D4r %J��1P0h<co J &'T SOM-4 Type of Building: Dwelling No.of Bedrooms . Lot Size sq.ft. Garbage Grinder( ) Other Type of Building I 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) 'Y'4 Ow ©QjLAj;� 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 Board of Healt Sig Date i i l Application Approved by Date Application Disapproved by Date for the following reasons Permit No. �� Date Issued j „• .'+ ........--a.+*+....✓-,w-..�,�.„y.-.^fit...--Fr+tirM. v^,::.. i t.. ...it,. ,r: 1•.. t - ..�.. _ _.,- ...... -..�..- .�.. No. /I 5 7`- Fee �Dv THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF. BARNSTABLE, MASSACHUSETTS Yes ftplication for Misposal *pstem Construction permit Application for a Permit to Construct( ) Repair(k Upgrade(.) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 3q I AS O N S (AN6 . Owner's Name,Address,and Tel.No. Assessor's Map/Parcel `7,1 i-.-L-7 3(4 T)ks C2v!C L.4&V G D V 1 LA Installer's Name,Address,and Tel No. '54 -4-n-gS 71 Designer's Name,Address,and Tel.No. CAINGW(Dli p 1sc=� t 15 3 cp roc _ rk S`t wf•4.SL{.ObZ- Type of Building: Dwelling No.of Bedrooms '11 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building la. 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) IV w SoW 'T4 dN OV-rLk-z: Pep LAPEF, 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 r - Compliance has been issued by this Board of Healt i Si 1:nZ Date f t Application Approved by Date 1 Application Disapproved by Date for the following reasons Permit No. 3� p Date Issued y I THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS f Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(y) Upgraded( ) Abandoned( )by 6/PSjL D9” EWMOA f.f k t-4.G at 3 4 Zk5aLk L o6u OVk //LLAE has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No! f 37 6 dated I 1 Installer C'*ayl LIB' / Designer #bedrooms '2-- Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system'will fu"nc_'tigned. Date Inspector No. y'1 _ - 7 Fee 100 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposai ,pstem Construction permit Permission is hereby granted to Construct( ) Repair(x) Upgrade( ) Abandon( ) System located at 3( -TM W iS (.r4 & OS 1/f_LAZg. J 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 us be completed within three years of the date of this permit. ~� Date �� Approved by, ��`�� Commonwealth of Massachusetts W " Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments / N 34 Jason Lane Property Address Wallace O,Hara Owner Owner's Name information is required for Osteryille Ma.' 02655 12/3/2007 every 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. Important: A. General Information When filling out forms on1he computer,use 1. Inspector: only the tab key to move your Robert Paolini Fri cursor-do not use the return Name of Inspector t ' key. Ca ewide Enter rises,LLC Company Name —q t� P.O.Box 763 t� Company Address N " c > Centerville Ma. 02632 _* City/Town State Zip Code ' (508)428-4028 S 14454 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 12/3/2007 Ins ctor'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. 34 jason lane•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 34 Jason Lane M Property Address Wallace O,Hara Owner Owner's Name information is Osteryille Ma. 02655 12/3/2007 required for every page. City/Town State Zip Code Date of Inspection B. Certification (Cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A). System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in porper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board"of Health, will pass. Answer yes, no or not determined (Y, N, ND)in the ❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are.replaced ❑ obstruction is removed 34 jason lane•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts w ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 34 Jason Lane M Property Address Wallace O,Hara Owner Owner's Name information Osterville Ma. 02655 12/3/2007 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: c ❑. 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: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS ismithin 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. 34 jason lane•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c,M 34 Jason Lane Property Address Wallace O,Hara Owner Owner's Name information is required for Osterville Ma. 026'55 12/3/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow El ® 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. R 34 jason lane•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 34 Jason Lane Property Address Wallace O,Hara Owner Owner's Name information is required for Osteryille Ma. 02655 12/3/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ®i Any portion of a cesspool or privy is within 50 feet of a private water.supply well. J ❑ ® 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 El El Area 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. 34 jason lane-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts W 'Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ,M 34 Jason Lane Property Address Wallace O,Hara Owner Owner's Name information is required for Osterville Ma. 02655 12/3/2007 every page. City/Town State Zip Code . Date of Inspection C. Checklist Check if the following.have been done. You must indicate "yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® 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? El ® 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)] 34 jason lane•06/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts N F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 34 Jason Lane Property Address Wallace O,Hara Owner Owner's Name information is Osterville Ma. 02655 12/3/2007 required for every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based-on 310 CMR 15.203 (for example: 110 g;pd x#of bedrooms): 330. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2005:98,000 g ( y g (gp ))' 2006:84,000 Sump pump? ❑ Yes ® No Last date of occupancy: 12/3/2007 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 34 jason lane•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts W Title ,5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 34 Jason Lane Property Address Wallace O,Hara Owner Owner's Name information is required for, Osterville Ma. 02655 12/3/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: J.P.Macomber Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Last service pump 11/15/05 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: New leaching pit installed 1991 Were sewage odors detected when arriving at the site? ❑ Yes ® No 34 jason lane-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts W ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 34 Jason Lane GSM Property Address Wallace O,Hara Owner Owner's Name information is required for Osterville Ma. 02655 12/3/2007 every page. City/Town State Zip.Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 1' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence.of Ieakage.System vented through the house vents. Septic Tank(locate on site plan): 1, Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass El polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 8'6"x4'10"x57' Sludge depth: 2., Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 8„ Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Measured 34 jason lane•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection, Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Jason Lane Property Address Wallace O,Hara Owner Owner's Name information is required for Osteryille Ma. 02655 12/3/2007 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.): Pump septic tank every 2-3 years.Precast inlet and outlet tees are in place.No evidence of Ieakage.Tank appears to be structurally sound. I Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: . Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural Integrity, Liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): 34 jason lane-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not.for Voluntary Assessments �M 34 Jason Lane Property Address Wallace O,Hara Owner Owner's Name information is required for Osterville Ma. 02655 12/3/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) 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 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No 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.): Box is Ievel.Box has two outlet laterals with equal distribution.No evidence of solids carryover.No evidence of leakage into or out of box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑. No Alarms in working order: ❑ Yes ❑ No 34 jason lane-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Jason Lane Property Address Wallace O,Hara Owner Owner's Name information is required for Osterville Ma. 02655 12/3/2007 every page. City/Town State Zip Code Date of Inspection .D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption.System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number:. 2-1000 gallon ❑ 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.):, Sandy soil.No signs of hydraulic failure.Leaching pits were dry at time of inspection.Old leaching pit has been full.New leach pit stain line was 28",to invert pipe. 34 jason lane•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts. W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 34 Jason Lane Property Address Wallace O,Hara Owner Owner's Name information is required for Osterville. Ma. 02655 12/3/2007 i every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation., etc.): Privy(locate on site plan): Materials of construction: Dimensions r Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 34 jason lane•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 l_ Map Page j of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size Zoom Out aar F In JI R. K v \ J RN s N s w r } } Ct;. o .:-;, •` f� UWeleYt�{° '•� r 5' '.y_ �`'z..3,.,✓,,.v7_ . ''art'` i �.- Set Scale 1" _'20 I Aerial Photos rnnvrinhf Inn S_9nn7 Tn,.,n of P—O. . KAA All 6 hfc roconn httn //www.town_barnstable.ma.us/arcims/annaeoann/man.asnx?nronertvID=121127&man... 12/3/2007 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' M 34 Jason Lane Property Address Wallace O,Hara Owner Owner's Name information is required for Osterville Ma. 02655 12/3/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to ground water: Bottom of LP 20' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As=Built Card ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: USED:Gaherty& Miller Model 12/16/94 ground water elevations.USED:USGS observation well data June 1992.USED:Technical Bulletin 92-000-01 Plate#2 annual ranges of ground water elevation. . 34 jason lane-08/,06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Town of Barnstable OF 1HE Tp� ti Regulatory Services BAR,STABLE ; Thomas F. Geiler,Director 9�A MASS. per Public Health .Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic stem inspection p y report was completed by a private inspector who is certified by the State of Massachusetts,Department of Environmental'Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic. System Inspector who conducted the inspection. TOWN OF BARNSTABLE LOC--ATION `/c)Gs op"a SEWAGE # �� y VIL;.AGE -�f 'hi l6'a'2 ASSESSOR'S MAP & LOT 4 l INSTALLER'S NAME & PHONE NO. 3 -il)/ acum L�er ySUlec%/Jc;, SEPTIC TANK CAPACITY LEACHING FACILITY:(type) / (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER . BUILDER OR OWNERP�- DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No t/ d. 10 �I r No....l.�:_. .. F�$.... ...30..0.. . THE COMMONWEALTH OF MASSACHUSETTS APPROVED BOARD OF HEALTH Barnstable Conservation TOWN OF BARNSTABLE ..Y- �- Appliration for %gpoiiFal Works Application is hereby made for a Permit to Construct ( ) or Repair �XX an Individual Sewage Disposal Syystem at: 34 Jasons Lane Osterville .....---•.......................................•--------....................-••--•-•---•--•------ --•-•-----•-..._......._...---•------------------..............-••---------•--............._----•- Hara Location-Address or Lot No. Wally 0' ..........................- - ............----•---------•-••---•-----.....--•-•------------ •-----••-••--------•-•---•-•-•-•-•-•-•-•----...-•-•-•--•----•---•......_................_....---•- W J.P.Macomber Jr. Owner Address Installer Address Type of Building Size Lot............................Sq. feet U Dwelling-2 No. of Bedrooms-------------- -Expansion Attic ( ) Garbage Grinder ( )a Other—T e of Building No. of persons............................ Showers — Cafeteria 04 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 ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ f14 Test Pit No. 2................minutes per inch Depth of.Test Pit...:................ Depth to ground water........................ ------------------------------------------------••-----.-.-------------- ------......------------------•-•-•--.---......................-------------•---- Description of Soil...Sand _& Grave 1 . x V :... W U Nature of Repairs or Alterations—Answer when applicable............................................................................................... __ 1-100 gallon leaching pit. -------------------------------------------------.................................................. 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 y p a Certificate of Compliance has been issued by th boar of health. system In operation until Signed ..... .- - 12/11/91 .. ....-. ...]-------.................... ...............'Date -----'------'--- Application Approved BY ..... ... . /..a. /..... Dale Application Disapproved for the following reasons- ------------------------------------------------------------------------------------------------------------ ----....- -............................................ ----------- -------- p r Date PermitNo. .........../-/--`----✓57-LI........................... Issued -- ----...............--------................................... Date l � No..7J.....a. . l THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Uiipnriial Workii Tomitrnrimi n amit Application is hereby made for a Permit to Construct ( ) or Repair �LX4 'an Individual Sewage Disposal System at: 34 Jasons Lane Osterville ................__.............................................................................. ........---------•-•..._....................•-----............--•------........---•--...........-- Wally O'Hara Location-Address or Lot No. ---•------•---•------• .... ................................................... ................................................................................................. J.P.Ma e omb e r Jr. owner Address Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling-y—No. of Bedrooms..............3_...........................Expansion Attic ( ) Garbage Grinder ( ) Other—ad Type of Building -------------------......... No. of persons............................ Showers Cafeteria 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 ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.........--............. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...._................... Descriptionof Soil.- ----&•----------------- -- --.--------------------••-------------••-•---------..-----------•------. -------------- ------------------------------------ ... .Sand Grave--1 x W ---------•-----•------------------•----------•-•-------------------•--------....-•-----•------ --•-----•--------------------------•---•-•------•-----•-----•-•--•------------•------•••••-------------- U Nature of Repairs or Alterations—Answer when applicable......-......................................................................................... L-01-1000 gallon leaching pit.•- ------------------•---._............---•--......... 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 jssued by the,boar of health. Signed . . . ----.. 12/11/91 � � ................ .....1............................. . -----.......Dace---------------- ApplicationApproved By --------------- ^^ ...-.... �. --.............-------- .......................................... -/ .-..1 a � Dace Application Disapproved for the following reafons: ........................ -------................................................. ---------------------- ------------------- --------------------- ------------------ -----CC..--........................... ---- --................... ----- -------- ------------.----.................... . ---------- ......................----------....... PermitNo. ...------? --55.Y.......................... Issued ............... ------------------------ .-.- Date .... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ter#ifirate of C�otttplittnce THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( X ) by J.P.Macomber Jr. - --------------------------------------------------------------- -- --- ------------------------------------------------------- ------------------........................ at ...34 Jasons Lane Osterville Installer - ----------- --------------------------------------------------------------------------------------------------------------------------------------- -- -------------------------------------------------- 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. ............ ..... dated -----------.---.-.---.---.-.-----------.....-... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................................................................................................ Inspector .................�j .......................................................... / j THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CCyy TOWN OF BARNSTABLE No..... FEE..�...30.00 Disposal Vork.5 (11111nntrudion rrndt Permission is hereby granted..LRIAacomb T Jx.........................................................-...................................... to Construct ( ) or Repair (�XX) an Individual Sewage Disposal System at No..F..•Jasons Lane Os.terville ------ .................... Street q �j as shown on the application for Disposal Works Construction Permit Dated.......................................... ....................••-•-•-••.�Y -------------------------------------------- --------------- DATE. j 1 ..................................... Board of Health FORM 36508 HOBBS Q WARREN.INC..PUBLISHERS LyO-C A T ION SEWAGE PERMIT NO. c LA iv VILLAGE / 111 17 I N S T A LLER'S NAME 8 ADDRESS D U I L D E R OR OWNER s DATE PERMIT ISSUED DATE C 0 M P L I A N C E ISSUED Lld I� d ti .. 1 THE COMMONWEALTH OF MASSACHUSETTS BOARD Off" HE L r4gr.C,4004.,10%�-....-....OF......... . ... .. . . ... ....--------..._-...--------- Appliration for Uiipoii al Works ustrurtiom ranfit Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal Syst..... ._..... - --- ----•_. ................. .. .:_ ...... :cam-�- . p do ddress d or Lot No. Own , Address a ----^....._.. ---•- _•__________ ..... .................^_____•________-_ ______•__ . :.?........ .... In er Address.. d Type of Buildin Size Lot----�.� �__._Sq. f t U Dwelling NO. of -2. Attic ( ) Garbage Grinder Other—Type T e of Building _______________ No. of ersons___-________________________ Showers — Cafeteria Pa YP g ------------- P ( ) ( ) Q' Other fixtures -------- �....................................................................................................................... W Design Flow............S_ .......................gallons per person per day. Total daily flow........ ®______._____________ Ions. WSeptic Tank—Liquid*capacity/&0-4'.allons Length___........ Width................ Diameter________________.Depth__ ----------- x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No----------_--- Diameter....... Depth below inlet....6._______.._. Total leaching area...�.v__�L.sq. ft. Z Other Distribution box ( ) Dosin t k ( Pq141 '-' Percolation Test Result Performed b -_ .. _________________ Date__7�` _�_ y- ------------•-_.. Test Pit No. I.... minutes per inch Depth of Test Pit____________________ Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit__.__._._____._.___. Depth to ground water........................ �^ - / t'--•-----------9------_/ --------•-j---.._.__.........-----....---- t f � aescrptono Soil---- - x `y ` / x ---------------------------------------------------------------------------- ------•---•-•--•-------------•--•---------------------•------•---•-----------------------•------•--------•-._...----------- 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 T MEj 5 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, Signe --..... -• -- .......:. .. ...... ----------------•--••-••--•---•-- ................................ Date Application Approved By........ r - - '-------- --- -- •- _.- ......... ---7----3....r_e.:.......... Date Application Disapproved for the following reasons:-----••---------------•--------------------------------•------------------------------------------•--....__-••-- ............................•-------------'-----...-----------------------•------•------•--•---------•---------'---------'-------••-------•-----••--•--------•-------•---------••-------•-•------------- Date Permit No. Issued........................ Date No....:`.��...... yF FE$... ©... THE COMMONWEALTH OF MASSACHUSETTS BOARD OFHEALTH App irFa#iun for BiipuuFal Works Tunitrurtiun ramit Application is hereby made for a Permit to Construct (' ) or Repair ( ) an Individual Sewage Disposal System att:1 .... - ..... - - . ........................................... o L. do ddress Ua or Lot No. .. ........ ......... -----•----.....................^_.......... ......... Ow Address a •-- -..... ... . `----..::... _ -----------------------•--•------ ---------- y: ....------........--------- I er Address QType of Build* Size Lot........ �_I...........Sq. f t Dwelling NO. of Bedrooms................ .......................Expansion Attic ( ) Garbage Grinder ( p)• .4 Other—Type T e of Building No. of persons............................ Showers A.I YP g ---------------•--...---.... P ( ) — Cafeteria ( ) Other fixtures .-•---_!x '-"`-`_---------•----•--•-•----------•-•-•-- W ._.: _ gallons r erson per day. Total daily flow.............. Des*gn Flow. = g P� P P Y 4 Y - ----�--- gallons. W Disposal Trench iqui 'capacity/'!::~ "°gallons Length------ Width... .......... Diameter................ Depth..?......... tic Tank—L* m o..................... Width.................... Total Length.................... Total.leaching area....................sq. ft. Seepage Pit No: ..:......._ .. Diameter * " ..... Depth below inlet... .._..... Total leaching area..:-•' G_5.sq. ft. Z Other Distribution box ( ) Dos'n t k Percolation Test Result r performed b :: t_ ...._ a Y M ... ... t�_. . Date .. ..................... ,-a Test'Pit No. 1.... '---minutes per inch Depth of Test Pit.................... Depth to ground water...................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ----•---•� f t I --•--•---------- O Description of Soil "' Q`-- �p x V W --------•--•-------------- ••-----•••--••-•----j--------------••••---•-----•-••--•----•------------- 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 TITIZ 5 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 ------ -•....... ..................................... D to Application Approved By..... ---- 7 " �'---....... Date Application Disapproved for the following reasons-------------------------•--•------------•---•------ •---------•-------------------------. ............... .....................................................-••----------------••--•••---•-•---•-••-----.....•--------------------•-•------•-----•--•-----------------••---••------------••--•-------...--•--- Date PermitNo......................................................... Issued---......------------------......••=••::------......-- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............oF.............. ' fitrr#ifirtt#r THIS I ZO CERTIFY, That the dividual Sewage Disposal System constructed ( _) or Repaired ( ) by ..............�� /............ at....... ��;Pd�'y-----�•;.rr�J9'�Y-t .t_.- -max• - -- - has been installed i*1'accordance with theNA�. of T )ofThe State Sanitary Code:as dr-scribed in the �applica for Disposal Works Constructi No. .__. ..._,�';._. Z.._..__..._. dated___7!? -vV#_........-•....... T UANCE OF THIS CERTIFLL.NOT BE CONSTR E A G ARANTEE THAT THE SYSTEM VIAL FUNCTION SATISFACTOR z,. �a. DATE............ �" .. Inspector ............................... THE COMMONWEALTH OF MASSACUSETTS BOARD ^F H LT OF A . T ...... •---.. ....... ....... r-t1 No.................. FEE........................ Mop Works Tuns n Vamit Permigsion is hereby ranted-°....... . ............................................................. to Cons t ct r Re it ( ) Indio' al Sewage '. s ystem 10 application for Disposal Works C Street as shown on the a PP Construction Wnstruction Pe No._:._ _:.--- :__ Dated.......................................... 4P, ... Boar of Health DATE..........,,� 1 � ................................... FORM 1255 HOB,BS & WARREN. INC., PU,B11SHERS ' 4'VVI�OF BAtEtN TAM sew vm it ISTAi# 1 PRONE AKA. 'TC'x'A1►�iC CA�+AC�'Y ldvo ldb,p�'H�RROOA�S tam Old O . caeca .�,arattto,n�tis�twa8atwae� �xs; � - Daximwnlj ity. .........wM Von k}��s,���letd �� tY� �vetls�nel�exist 3p�Esser o�ksaobisg „) r G fi�lshhod�� I Q © � m o a � � 5 e-3- 6-3- 3a6- -If_ ) q F" D-Y- Llwk -�- 33 ` 13-5- 35 4, too -cacti r ��� ��c:w 1;a 3 = 330 �•P.v. O-1 33G,e ISo % 4-95 ,CIS rr^C 1T - USE I OGC GA.l_. pea Zd �(ytrL:/1�1L AREA = t So S•F. f p SF 2.5 .9 :�;"7S G.P.D q$•o A r--A T Ex> Sr--. ToTAt. 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