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HomeMy WebLinkAbout0064 JASON'S LANE - Health �r 64 Jason's Lane }` ' r, Osterville ;.. 21 - 115 1 - A= >, i. , , 4 , w � 1 e 3 v F � e F a f • V 4 y " n u u a � 4 i u . . a „ e ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ..'' `64 Jason's Lane Property Address Geary Owner's Name Osterville MA 02655 1/31/14 Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Inspector: Frank Nunes III Name of Inspector sea Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 Telephone Number f 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 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority3. 1/31/14 Inspector's Signet 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. 64 Jasons Lane-03f08 Title 5 Mal Ins pection F bsurface Sewage Disposal Syster 1 of 15 e �. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y< 64 Jason's Lane w Property Address Geary Owner's Name Osterville MA 02655 1/31/14 Cityfrown 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: ® 1 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: Pumping suggested every 3 yrs to prolong the life of the system 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: n/a ❑ 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 64 Jasons lane•03/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 64 Jason's Lane Property Address Geary Owner's Name Osterville MA 02655 1/31/14 City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cunt.): ❑ distribution box is leveled or replaced ND Explain: n/a k ❑ 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: F , n/a C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: - ❑ Cesspool or privy is within 50 feet of a surface water- ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health,, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is.within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 64 Jasons Lane-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 64 Jason's Lane Property Address Geary Owner's Name Osterville MA 02655 1/31/14 C4rrown 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 afDEP 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: n/a 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 ❑ ® 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. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 64 Jasons Lane•03/08 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts a v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . < 64 Jason's Lane Property Address Geary Owner's Name Osterville MA 02655 1/31/14 Citylrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cunt:): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to`a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 64 Jasons Lane•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 't 64 Jason's Lane Property Address Geary Owner's Name Osterville MA 02655 1/31/14 City/rown 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)] 64 Jasons Lane•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 64 Jason's Lane Property Address " Geary Owner's Name Osterville MA 02655 1/31/14 Cityrrown State Zip Code. Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): n/a Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220 _ Number of current residents: 0 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)): Sump pump? ❑ Yes ® No Last date of occupancy: unk Date Commercial/Industrial Flow Conditions: Type of Establishment: n/a 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): n/a 64 Jasons Lane-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 64 Jason's Lane Property Address Geary Owner's Name Osterville MA 02655 1/31/14 City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: No history given Was system pumped as part of the inspection? T❑ 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): Approximate age of all components, date installed (if known)and source of information: 1983 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ® No 64 Jasons Lane-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 64 Jason's Lane Property Address Geary Owner's Name Osterville MA 02655 1/31/14 City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 4 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.): Septic Tank(locate on site plan): Depth below grade: 316"feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) Inlet cover raised If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No ----------------------------------------------------=--------------------------------------------------------------------- Dimensions: . 1000g Sludge depth: 1 Distance from top of sludge to bottom of outlet tee or baffle >12" Scum thickness trace >211 Distance from top of scum to top of outlet tee or baffle „ Distance from bottom of scum to bottom of outlet tee or baffle >2 How were dimensions determined? measured 64 Jasons Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 64 Jason's Lane Property Address Geary Owner's Name Osterville MA 02655 1/31/14 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.): Pumping suggested every 3 yrs to prolong the life of the system Grease Trap(locate on site plan): Depth below grade: feet Material of construction: s: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): n/a 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.): n/a 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): n/a 64 Jasons Lane•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts lugTitle 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 64 Jason's Lane Property Address Geary Owner's Name Osterville MA 02655 1/31/14 Cityrrown 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.): n/a y *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 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-Box in average condition for its age Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑•Yes ❑ 'No 64 Jasons Lane!03/08 Title.5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Jason's Lane Property Address Geary Owner's Name Osterville MA 02655 1/31/14 City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): n/a Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: . 1 ® leaching pits number: ❑ 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.): Leach pit is 4'below grade, cover raised to 18"of grade, it is dry at this time, stain line 3' below invert, no indication of past backup 64 Jasons Lane-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts : W Title 5 Official Inspection Formj Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' 64 Jason's Lane Property Address Geary Owner's Name „ Osterville MA 02655 1/31/14 CitylTown State Zip Code Date of Inspection D. System Information (cont.) v 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 , Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): n/a y 64 Jasons Lane•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 64 Jason's Lane Property Address Geary - Owner's Name Osterville MA 02655 1/31/14 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. t L---► as G • 64 Jasons lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "t 64 Jason's Lane Property Address Geary Owner's Name Osterville MA 02655 1/31/14 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: >15' 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: per elevation of home 64 Jasons Lane-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 • SECTION ® Complete items 1,2,and 3.Also complete A. Signature Item 4 if Restricted Delivery is desired. V, ❑Agent ■ Print your name and address on the reverse t Addressee so that we can return the card to you. B. Received by(Printed Name) of Delivery ® Attach this card to the back of the mailpiece, or on the front If space permits. ' �'9 D. Is delivery address different item 1? t. Article Addressed to: If YES,enter delivery ad e0:0 T j� �t,.j NooC"� two Nfl . ;G; -� l� 8b0I1d a n�-�fin` 1 �- 3 1 3. Service Type 00 12 Certified Mail ❑Express Mail ❑Registered Q Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. I } i 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number c 0 0 5 116 0 0 0 0 0�'0191 0 5- (rransfer from service label i 1 7. PS Form 3811,February 2004 Domestic Return Receipt 702595 o2-M-1540 UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid USPS Permit No.G-10 • Sender: Please print your name, address, and ZIP+4 in this box • I I I Town of Barnstable a 4 Health Division 1 g 200 Main Street Hyannis,MA 02601 . —'THE Tp Town of Barnstable Barnstable ty I,HAP, �yT J Regulatory Services. Department I nAFz E �'ca� MASS. �0, \1639• I� Public Health Division �PrFD MA�A' 200 Main Street, y Hyannis MA 02601 2007- Office: 508-862-4644 Thomas F.Geiler;Director FAX: 508-790-6304 Thomas A.McKean,CHO January 3, 2008 Ray Vaillancourt 240 North Fig Tree Lane Plantation, FL 33317 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 64 Jason's Lane Osterville, MA was inspected on November 6, 2007 by James Sears, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system CONDITIONALLY PASSES under the guidelines of 1995'TITLE V (310 CMR 15.00) due to the following: System is not designed for a garbage disposal. You are ordered to repair or replace the septic system within Two (2) years from the date of this notification by removing garbage disposal. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH ::a c e r.S.,CHO Agent of the Board of Health ,. Q:\SEPTIC\Letters Septic Inspection Failures\64 Jason's Lane.doc �nnr. i.i.hn nnnn ni.gi. nigi. Commonwealth of Massachusetts W Title 5 Official Inspection dorm Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M Inspection results must be submitted on this form.Inspection forms may not be altered in any way. A. General Information Important: When filling out 1. Property Information: forms on the �— computer, use 64 JASON'S LANE-OSTERVILLE, MA 02655 only the tab key Property Address to move your RAY VAILLANCOURT. cursor-do not Owner's Name use the return key. 5490 30T"AVENUE SOUTH® /V of Xl. Owner's Address1a��11o1 GULFPORT FL`, 33707 City/Town State Zip Code Date of Inspection: 11/06/07 -� 2. Inspector: �= i.j. JAMES D. SEARS r c- M^ 3 Name of Inspector bluewater-CANCOzK .. Company Name 350 MAIN STREET v� Company Address op IR WEST YARMOUTH MA " U02673 CitylTown State Zip Code 508-775-2800 Telephone 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 16.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails Needs,Further Evaluation by the Local Approving Authority 19 spector'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. t5insp.doc.doc-03/2006 Title 5 Official I ection Form:Subsurface Sewage Disposal System. Page 1 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form a Not for Voluntary Assessments: Subsurface Sewage Disposal System form B. Certification (cont.) 64 JASON'S LANE Property Address O.STERVILLE MA 02655 City/Town State Zip Code RAY VAILLANCOURT 11/06/07 Owner's Name Date of Inspection Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: 0 I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass: Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*.or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: --- GARBAGE DISPOSAL MUST BE REMOVED t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System • � Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M B. Certification (coot.) 64 JASON'S LANE Property Address OSTERVILLE MA 02655 Cityrrown State Zip Code RAY VAILLANCOURT 11/06/07 Owner's Name Date of inspection 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 ❑ obstruction is removed, ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: 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 t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 64 JASON'S LANE Property Address OSTERVILLE MA 02655 City/Town State Zip Code RAY VAILLANCOURT 11/06/07 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (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 tributaryto a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine'distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria 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: t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System. Page 4 of 16 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form a p Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M 5•y, Bo Certification (cont.) 64 JASON'S LANE Property Address OSTERVILLE MA 02655 _ City/Town State ZipCode RAY VAILLANCOURT 11/06/07 Owner's Name Date.of Inspection 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 eesepeel-is less than 6" below invert or available volume is less than %day flow Required pumping more than 4 times in the last year NOT due to clogged or El ® 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. Yes No ❑ ® The system fails. l 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. t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form. w Be Certification (cont.) 64 JASON'S LANE Property Address OSTERVILLE MA 02655 City/Town State Zip Code RAY VAILLANCOURT 11/06/07 Owner's Name Date of Inspection E) Large Systems: To be considered a large system the system must serve.a facility with a design flow of 10,000,gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. YES NO ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any questioh 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. t5insp.doc.doc a 03/2006 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts Title 5 .Official Inspection Form p , Not for Voluntary Assessments - ,M Subsurface Sewage Disposal System Form C. Checklist 64 JASON'S LANE Property Address OSTERVILLE MA 02655 Cityrrown State Zip Code RAY VAILLANCOURT 11/06/07 Owner's Name Date of Inspection 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? A ® ❑ Was the site inspected for signs of break out? 'tvFe�vcla�q ® ❑ Were all system components,e*G6diog 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)] t5insp.doc.doc•03/2006. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form G'M D. System Information 64 JASON'S LANE Property Address OSTERVILLE MA 02655 City/Town State Zip Code RAY VAILLANCOURT 11/6/07 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 1.10 gpd 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 0 No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 05-208.2 GPD g ( Y 9 (gP )) 06-79.4 GPD Sump pump? ❑ Yes N No Last date-of occupancy: SEASONALY 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): titles 2006_blank.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form ° Not for Voluntary Assessments q,M Subsurface Sewage Disposal System Form D. System Information (cont.) 64 JASON'S LANE Property Address OSTERVILLE MA 02655 Cityrrown State Zip Code RAY VAILLANCOURT 11/06/07 Owner's Name Date of Inspection General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? Yes N p o 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) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1982 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp.doc.doc•03/2006 ,Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 I f Commonwealth of Massachusetts m Title 5 Official Inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M D. System Information (cont.) 64 JASON'S LANE Property Address OSTERVILLE MA 02655 City/Town State Zip Code RAY VAILLANCOURT 11/06/07 Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 4 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line- feet Comments (on condition of joints, venting, evidence-of leakage, etc.): SCHEDULE#40 PVC GOOD Septic Tank(locate on site plan): _ Depth below grade: 4311 feet Material of construction: ® concrete ❑1metal * ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of ❑ Yes ❑ No certificate) -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1,000 GALLON PRE CAST Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 2611 Scum thickness 311 811 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 1511 How were dimensions determined? PLAN, TAPE AND SLUDGE JUDGE . t5insp.doc.doc.03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System �� Page 10 of 16 r Commonwealth of Massachusetts F Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System,Form D. System Information (cont.) 64 JASON'S LANE Property Address OSTERVILLE MA 02655 City/Town State Zip Code RAY VAILLANCOURT 11/06/07 Owner's Name Date of Inspection 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 AT WORKING LEVEL. TANK AT 43" BELOW GRADE WITH IN COVER 16". OUTLET AT 2'. INLET AND OUTLET TEES. NO SIGN OF LEAKAGE OR.OVERLOADING. MAINTENANCE PUMPING SCHEDULED AFTER INSPECTION.' Grease Trap (locate on site plan): Depth below grade: feet - t . Material of construction: El-concrete El 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(ta*must be pumped at time of inspection)-(locate on site plan): Depth below grader Material of construction: , ❑ concrete ❑ metal ❑ fiberglass ❑, of eth lene ❑ other(ex lain ) t5insp.doc.doc^03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 I Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ^N Subsurface Sewage Disposal System Form 5•y`• D. System Information (cone.) 64 JASON'S LANE Property Address. OSTERVILLE MA 02655 City/Town State Zip Code RAY VAILLANCOURT 11/06/07 Owner's Name Date of Inspection 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 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:): DISTRIBUTION BOX LOCATED AND INSPECTED WITH CAMERA. BOX IS CLEAN AND SOLID. 4' BELOW GRADE. Pump Chamber(locate on site plan): Pumps in working order: ❑. Yes ❑ No Alarms in working order: ❑ Yes ❑ No, t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System 00- Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 64 JASON'S LANE Property Address OSTERVILLE MA 02655 City,/Town State Zip Code RAY VAILLANCOURT 11/06/07 Owner's Name Date of Inspection 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: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): LEACHING IS ONE 1,000 GALLON PRE CAST PIT WITH COVER AT 2' BELOW GARDE. 20" IN PIT. NO HIGH STAIN LINE. NO SIGN OF OVERLOADING OR SOLID CARRYOVER. t5insp.doc.doc 03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 I Commonwealth of Massachusetts Title 5 Official Inspection- Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form M D. System Information (cont.) 64 JASON'S LANE Property Address OSTERVILLE MA 02655 City/Town State Zip Code RAY VAILLANCOURT 11/06/07 Owner's Name Date of Inspection 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 ❑ SNo 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.): t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System �� Page 14 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 64 JASON'S LANE Property Address OSTERVILLE MA 02655 City/Town State Zip Code RAY VAILLANCOURT 1.1/06/07 Owner's Name Date of Inspection Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or.benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. o G i330`� t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.• Page 15 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments . 41M Subsurface Sewage Disposal System Form D. System Information (cont.) 64 JASON'S LANE Property Address OSTERVILLE MA 02655 Cityrrown State Zip Code RAY VAILLANCOURT 11/06/07 Owner's Name Date of Inspection Site Exam: SlopeL "� Surface water Al Check cellar /t/E 5 - Da Shallow wells Estimated depth to groundwater: 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: USGS WELL DATA: USGS WELL SDW 252 ZONE C. LEVEL 48.8.ADJUSTED 6'. t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System �� Page 16 of 16 A,, �'A lDP � r , . s8 �3 Town of Barnstable OF THE A yP� o� Regulatory Services M B, ST" Thomas F. Geiler, Director. 9$ ' ,0� Public Health .Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic p system inspection 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. t I :St►.JGLL- FAMt�`! - � B��RQoM � � 11C� �� ' V uo G�AtZBAGC- Gtzlt.la��2 15,00o S. �r. DA.%Ly FLOW z 110 A 3 3 0G Pa 5EPT1G TAQK Z30x15c>% =A95G.P. 0 ILG. ► 12y . I � USE- 100o GAL. o15Po5At_ PiT y�E 1yo0 6AL. Izi. 7 S%r)SWALL A2L-A = 1 jo S.� 111 t 5O 5.t X 2.5 t 37 5 G.I'� i BOTTOM. AQEA F._ Q 0 5� S.F X 1• D � 7O G.Po� t2 Q 4 123 I ; IL4.9 • -raTA rF.SIGN 4 {¢25 6•Pv. z9�t PAov�oseo i 'Z'oT At.. T'pA 1 LY F L.ot�.( .- ��O G,PO, ,. rovn►D�\T to zx'3 PEIZCOLATtO?4 RATG r 1''tN 2MIN or-.Lr=55, ILL 1 Izt tk-k 5 to0000AL MM At, •,���,t.., , �r`-��a'4 ti (�f � 1t t00%i�s�P. 11�.0 �•� iIAX1 Ln .t�T' F, r�c,'�t 4y �'.7 •.� JnrlrS 1J . .� ,,. . 11.5 o N l��L�� Atp-CJ3q TOP F W D s 1'L.d--r w , W o LC- �J p���i'JF• �Y INV. lid LOAM INY. Su?a DtST. 1)4v, (000 56vTtG 1J1•L !��( TANK _ to.3 LPIT� INV. 'INV. _ Yopp Mt✓p�ur1 utI7W I'/3/9..1 t�a. StoPE � j I�so = 3C. • 0l1.. t �i SA1.OtJ WASUGD 6T0►.d t:s IC*3 Ct;RTIFIG0 PLOT PLA►J l.oC4'c 1oN OS'T ►04. 3 FlO� SG�.L.E. ra o w f\-r�R mac.=I oa•,o Po►�o I�l Zg/er p1-A►.a6V-SW c GaPAT 1=K WHAT THrc�'RpF+osC.p FaQ.gl•104YN i ►. r,.P-F=01.t LOMPI.`(5 YdtTF•t ZNE �,1��L1I�1 t- L o T \\ O A o.t D S>i=T�.GK 6�.6.Q v 1 IZ�M 1✓.t�!'t'> o F -t�� It>WtS OF �AeNSTh�LEAtJ'D IS N aT f� OSTEQV t�'`.0 �,�( OODSp LOCN-TED 'WIT1111`l'TNt F1.0o PLA1fJ pATe IZ-2-�YL BA, Tszt- NYc INc. IITw:1 PL&tJ 115 NOT 5A5Gt> p►d AN . C�STEtZVILL& 40 I�5-rR.�M6NT SV'2vG--Y 'THE ot=t=5ET5asuoul,� ., n-riti... r-ir ^r:r V_AAJ.AIG -! n1 .t:_ t►Jt".�, A.P..PL.LI.AN'>• Tntit TI),F�.,.� f, . � r J w LOCATION SEWAGE . PERMIT NO. VILLAGE t ` x 1NSTA LLER'S NA^ E i ADD.R.ESS cpfii H ao ffi B U I L D E R OR OWNER DATE PERMIT ISSUED r.� f t' DATE COMP- LISANCE ISSUED F 1 F 4 t- w F �t t ..3e� _. x` a I • l � s` �� —.44 oa Ficia THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1 9 1 _down............:..".....of................ arnst.4.ble--- ................................ Appliratiou l r i 1 � 1 rk Cola r r i�t� p i Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: U4•••_Jason-!-s• Lane Lot 110 Location.Address or Lot No. Tad__Dewire--Landscaping_.___Design--&••Const._-_Co,._,_,:_329,--W Main--St.-._-:Hyannis_ Owner Address a Carl_-_Lampi____________________________________________________________________ _Cedar...Street.I...W.__ Barnstable, Installer Address QType of Building Size Lot15 , 0 0 0...........Sq. feet Dwelling—No. of Bedrooms.......2..................................Expansion Attic ( ) Garbage Grinder ( ) p`4 Other—Type of BuildingWood frame- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a Other fixtures . ..-lays_,___2 toilets r-- 2 tubs-,-__kitchen sink ----.-._... W Design Flow............................................gallons per person per day. Total daily flow........_-__3 3 0 gallons. WSeptic Tank—Liquid*capacity.l.r•9 illons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.1,-0-0-0---gS)laaneter-------6 f t. Depth below inlet.................... Total leaching area........... .__...sq. ft. Z Other Distribution box ( X) Dosing tank ( ) Percolation Test Results Performed by......................................................................... Date.----------............................ Test Pit No. 1...... .......minutes per inch Depth of Test Pit.................... Depth to ground water........................ fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...-_-.-._-----.-_.._... a •-•------•-•---•------------------•---•---••----------------------------•-•-----------------•------------------ •--•-----------------..._--•------------------ di0 Description of Soil.....Meum....sand...............................--------------...---------------------------------------------------------------........--------... W --------------- --------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------ U Nature of Repairs or Alterations—Answer when applicable..............................................•._-__---.._.-.-...---_-..._..-._._-.-.._._.----- ..-----•--------------------------------•-----•-...-•-........._.............._..----•-----------------------------•------------------------------------•---•----...............-------------•...---_.. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITL L 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:'=.� .................... ... 11 Date Application Approved By-----2 - A -----------•--•-•-----•-------------------------------•-------•--•---•-•---•--•---•---- ---------------------------------------- Date Application Disapproved for the following reasons:................................................................................................................ -------------------------------••-----•-•-------------••------•------------------•---......._..---------------------•------------------------•-----...........----•-----------------_._......----------- Date PermitNo........ .......................•----- _ Issued -dzi ---- No..,... 7.- FEB '� f THE COMMONWEALTH OF MASSACHUSETTS BOAR`® OF HEALTH TOWn......................O F................Barnstabie--------------•--------•----•----------- Y Applira#ion for Uiipoii al Vorkg Tontrnrtion rruq; t,;z )kppl>catioA' is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage,-Disposal System at .Iasan-'s-•Lane. .. -- Imo... 314------------ ....---•--. .. -----•-- Location-Address ::'#; or Lot o. Tad..Dewize•••Landsc plug-,--•Dear•'&---Coast..•--C©.-,---3,2�•W,.-•-Na1A 9% r-• Kyai nnia- Owner Address a Carl__S�Smpi...........................-......-----.............--____............. -Cedar---Streetv...W.-.-SarnStablevi.-Ma....... Installer Pq Address UType of Building Size LotlS,,.0.OA........}___Sq. feet Dwelling—No. of Bedrooms......2...................................Expansion Attic ( ) Garbage Grinder ( ) ALI Other:=.Type of BuildingU`taOxl___frme. No. of persons____________________________ Showers ( ) — Cafeteria ( . ) a Other fixtures _2__.lauS,----2-.toilets.#__2...tubs_#___.k3_t.Chen...sink------------- W Design Flow..._........................................gallons per person per day. Total daily flow...........334----•__---- #___gallons. WSeptic Tank—Liquid capacity_1 f-O00allons Length................ Width................ Diameter_............. Depth................ x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area............._...__sq. ft.- Seepage Pit No.l_#_4ao-_.g a1j ameter._.__.5__.f t_.... Depth below inlet____________________ Total leaching area._2.0.07,_.___sq. ft. Z Other Distribution box (X ) Dosing tank ( ) `-' Percolation Test Results Performed b Date_________________________________ _ . a y-------------------------------------••---•---•-•••---------- Test%"Pit No. 1.....2........minutes per inch Depth of Test Pit____________________ Depth to ground water........................ fT, Test Pit No. 2................minutes per inch Depth of Test Pit------_............. Depth to ground water...___:................ a Description of.Soil- I�eE� �liti 8a .....-9 ►E= ' ................................................................................ a V -----•--------------------------------------•--....---•--•--•-••-----------------•-------•------------...-•-•••----------•------•-••••-------••-------•--•------••-------------•-•---•----• ----------------- -------------------•------------------------------------------------------------•-------•--•--------------•---...-----•-----•-----------•-------•---•------••-•-•......-----•......•--` U Nature of Repairs or Alterations—Answer When appliicable.................................................................. ___.______._...:_:_. t -•------------•----•------•---...---•-----------•-•-----•--•------------------------••--•-••-------•----...-•-------------------------------•-•---------------------•-------------------...•..•------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal S.;,stem in ccg an itli the rovisions of iITLL 5 of the State Samtar �drs p he ' p rtei tl t to la t s m operation until a Certificate of C inpllanee'lias lie issued by the boar Vf health. ASigned. -------------•--•-•----••-------..............----- Date ApplicationApproved By.................................................................................................. Date Application Disapproved for the following reasons----------------------------•-----------------------------------------------------------------•-•--------•••--- ................... s Date Permit No............3 y '2.......................... Issued ................ ----------------------•-------• 'Date THE COMMONWEALTH OF MASSACHUSETTS 1�sv� B0ARC$,PZ;, ALTH ....O F.............................................. {; :.. .z (9rdif iratr of Toutplianrr THI��,S TO CEIg4IF , That the Individual Sewage Disposal System constructed (A or Repaired ( , ) - '7% by............................................................................................. ---------------------------•-------------...._......._..-•-------•-•-----------•---------•-------••••. {D /Ctyles�fNGE�staller G tT+�'�!/i�6 r►^. at ... •--•• •---- • ••-• -------------- ...----- has been installed in accordance with the-.provisions of ;I,�, TThe State Sanitary Code as described in the application for Disposal Works'Construction Permit No_ ................................. THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUEDAV A GUARANTEE THAT THE oe SYSTEM WIJA. F I&TION SATISFACTORY. `. DATE... . .................................. Inspector-- ...... .....................-•------------------._.........__-___-- THE COMMONWEALTH OF MASSACHUSETTS y' BOARD 6#.` ktALTH .... J�'•�'�F7�,lTT�i�t.-cr g ..OF.. ... .......................:•..._.._....__._.._......-. ........ No..... P.2* FEE........................ io�roo 1 orkii Q'Ion#r ion irmi# . Permission is hereby granted.......... "-----�A� __--..______ ------ to Construct ( or Repair ( an Individual S wage Dispo al System at No.........L,a1_.. ,.. _.Z/ ..-- h�so =•` ta/cc J . ------- ................. as shown on the application for" Disposal Works Construction' Permit No. __ ,Dated.........`...... '� -- w "�s'a�. •,i ' Board of Health DATE_'L'..'........... .............: ...... • .) FORM 1255 HOBBS & WARREN, INC., PU SHr&R ry f A ,:wn{:♦ _....vn:..' �sc,d#�....v`�.c:�•; ""1..:'.�3.w:t„ -r....m. :..e:e';i,r�" .. ...-.,. ..... THE FOLLOWING , IS/ARE THE BEST-. IMAGES FROM, POOR QUALITY ORIGINALS) Im DATA f✓ Se.�"Cq��FA►��,�� -_ � BEORooM � - ...-..... II C) �\ �' Wo GARBAGE 000 S. F*- vA,L.�( Flow ,Z 110 A 3 3306.po jib Iz9 : I SEPTtG 330x15c ®% 6RO L15E Iooc> GAL. c�15Po5�L PI-T" v5E Ivoo 6a�. 5 t DSWALL AR-r-A 150 5A 111 - � 1 oq 15 o 5.1~. X a•5 a 3? BOTTOM, 0 Iesec� S0 S.F X I, o ® G.Po_ tzs •4 Iza wl ►L4.4 0 -taTAL- �ESIC.N * .4-25 GP. D. . Q -T&TA%_ 'PA IL`( FL.DW = 330G,PO, room D�Ttp z2' PE lZCoL.ATjaq RATE t I'1IN 2MIN oV_Lr=55. Its •I ICI � L 13lZoa� ptT a n T.f{, I • �o' � (J�1aiO4At Ap i PIKE A CAP. �r • d3j�,t ����.N I�Ct.f'1'A.�1�114�1lnAV;t JtA.0 NSI �ORA (AXIE O�. r te �Q _ F� O 6A >�\k a1STE %emJ Su I � py43q T65T �l. .l �Z TOP FNDsaZ1L- . . Inc w lie, VvAM t .1000 INV. SO ebMST. INY 11'1•!3 ' I so°°- BoyC If"I•L SCDT°G I� I IZo 3 I ooa r_­ 1 Pop b •.EAGtI INV. INV. .. PIT IIS-o Mt.o°vM 4/1Tu ICio Q 3C. SP�t� WA Sut:D 1( STaN& Cawrtr-iso PLOT PLAN •� PROFILE I. 109. 3 W0 5GAL EE. 5CALE 64:`SOFT. T)ATE Z I *a0 wA-Test �.-loo•o �Po�� ____.____ e/e 6Q61� GE . 1 C E�f 1 t=Y THAT T N�'Q Rflpos�'p F N to 5>•10 µlN - ( .. N6.R6oN GOMPU. !S WIMP-CMS S 1 DEL%W r_— A u D -tx-s eaGK V_rm0 V 19.eMeGWrt5, o P -t µ E- ToWt.I OF '�,A�NSTAgLc„r�►►sav IS N ':TrOODSp t_OGp.TE� •W ITF111J TNEz !~Loo PLA.t h1 12-Z-8r1. G � DATE- Cl B AxT6 IJI yE INC. II7u15 Pl-b,KI 115 RIOT $A`jC3P Gkd AN • 4;13TG9-VILLrr . Mp►6 INST�-uMt�t.IT Sv2vcY "TNE or-r5E-76 Suou1,D . , . _. ., ,_ .r r�-r.n..._C�r�t.t' v...M,l..bit'_.._!._.nC..�._ 1►1�'_�. A.P_P.�, I.�.A�T'. TnKA T)t��,.� LOCATION SEWAGE PERMIT NO. PILLAGE / 1 /7 k INSTALLER'S N AAdE i ADDRESS 11UILDER OR OWNER DATE PERMIT ISSUED 0 ' DATE COMPLIANCE ISSUED M /T