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HomeMy WebLinkAbout0086 LEONARD DRIVE - Health 86 Leonard Road A 114-030 Osterville TOWN OF BARNSTABLE r LbCATION sod SEWAGE # VILLAGE 610 /' ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO.X/z c-ll Ci,S7" SEPTIC TANK CAPACITYl� LEACHING FACILITY•(typeq_,�1) Alf,1,45— (size) NO. OF BEDROOMS 7 PRIVATE WELL OR PUBLIC WATER /t,� i WJtUDERvOR OWNER DATE PERMIT ISSUED: //�? _,2 Aw f DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No 01 r L ?/o o TOWN OF BARNSTABLE L tC:ATION P=d SEWAGE # VILLAGE S �' I`l C-C� ASSESSOR'S MAP 6: LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY ovu G, i LEACHING FACILITY:(type) �Y y L,/Q,� (size) ` . NO. OF BEDROOMS PRIVATE WELL OR PUBLIC z TE BUILDER OR OWNER j'' �/ pewe a DATE PERMIT ISSUED: �/�z` DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No t , a CT1 w C), O REGISTERED CTF. 109696 L.C. PLAN 2664-18 26A rn -0 Z'll+s orn I K:D - 71's N,Do (5� �6.3 ll � � A cF� N Asti 3. 1,, F•UJ.A. �O�p FO 335± qp UNREGISTERED PL�pA�N V- ..�5B4OOOK � - 26/2E:H/9K1'C T 6/41 Oo�syF� „ �u - - - - o I PARKER ROAD . AD RES. ZONE,•RF-/ FL OOD ZONE.' C THIS MORTGA G'E 2NSF-ECT10N PLAN IS FOR I TOWN:. BAN ...5 ONLY . OSTFRV/ F REGISTRY OWNER: O.B.dP.A,MADDOX DEED REF: CTF-/09696 BUYER: PAMELA K.HARRIS DATE.:• 7/k. PLAN REF: F.C.-2664-18 SCALE: I 40'" ere y cerU y that the building 1 shown on this plan is located on �LHo� VANKEE SURVEY the ground es shown and It posl conror tlon does p e i CONSULTANTS n a .zoning law setb eck re qulrea ento the t of A. 70 RASPBERRY LANE R NEW MARSTONS MILLS A S No.J2oBa MASS 02648 and does not 11e within the sp00l.l prsr Fto flood hazard area as shown on 'eoy4 WO dated i s p an not aede }roo an .Ins— ent Paul A. Merltheu, RPLS survey, not to be used:for fences et 52741 14 �' 3o d 1 Kc- a Commonwealth of Massachusetts0z, �� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 6 y G a 86 Leonard rd Property Address Nancy & Steven Panagiotes Owner Owner's Name information is Osterville Ma 02655 4/12/16 required for 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. Please see completeness checklist at the end of the form. - Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: , key to move your cursor-do not Michael DiBuono . use the return Name of Inspector key. . DiBuono Sewer and Drain r� Company Name 8 Johns path _ Company Address S Yarmouth Ma 02664 City/Town State Zip Code 508-364-9587 S103522 Telephone Number License Number B. Certification 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 0 4/12/16 nspector'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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 86 Leonard rd Property Address Nancy& Steven Panagiotes _ Owner Owner's Name information is required for every Osterville Ma 02655 4/12/16 i 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: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GSM 86 Leonard rd - • - - _ Property Address Nancy & Steven Panagiotes Owner Owner's Name information is required for every Osterville Ma 02655 4/12/16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage.backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):' ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y .❑ N ❑ ND (Explain below): H2O 2,000 Gallon septic tank is leaking at middle seam. System is in great shape other wise. ❑ 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•3/13 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 86 Leonard rd Property Address Nancy& Steven Panagiotes Owner Owner's Name information is required for every Osterville Ma 02655 4/12/16 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 %day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .'' 86 Leonard rd Property Address Nancy & Steven Panagiotes Owner Owner's Name information is required for every Osterville Ma 02655 4/12/16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be ' necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El 0 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 86 Leonard rd Property Address Nancy& Steven Panagiotes Owner Owner's Name information is required for every Osterville Ma 02655 4/12/16 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): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts 4 W Title 5 Official Ihspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 86 Leonard rd Property Address Nancy & Steven Panagiotes Owner Owner's Name information is Osterville Ma 02655 4/12/16 . required for every - page. Cityfrown State Zip Code Date of Inspection D. System Information Description: System contains a 2,000 Gallon H2O septic tank as well as a Distribution box and two 1,000 gallon leach pits. Both pits were dry at time of inspection. Septic tank needs to be sealed at seam. Staining in pits shows levels no higher than 18" up from the bottom. Number of current residents: Vacant Does residence have a garbage grinder? ' ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection, ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No 4 Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 210 Gpd 9 ( y 9 (gp ))� Detail: • Sump pump? ❑ Yes ❑ No Last date of occupancy: 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? No Yes ❑ Industrial waste holding tank present?' ❑ Yes ❑ No R. Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 i Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Leonard rd Property Address Nancy& Steven Panagiotes Owner Owner's Name information is required for every Osterville Ma 02655 4/12/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Seasonal/Weekends Date Other(describe below): General Information Pumping Records: Source of information: None provided Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 86 Leonard rd Property Address Nancy& Steven Panagiotes Owner Owner's Name information is Osterville Ma 02655 4/12/16 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: System install date is 11/22/1991 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): ; Depth below grade: 2.5feet 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.): System is vented through the roof Septic Tank(locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) H2O 2,000 Gallon If tank is metal,list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins-3/13 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 86 Leonard rd Property Address Nancy& Steven Panagiotes Owner Owner's Name information is required for every Osterville Ma 02655 4/12/16 page. Cityrrown 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 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees and or baffles in place at time of inspection. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 i Commonwealth of Massachusetts' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Leonard rd Property Address Nancy& Steven Panagiotes Owner Owner's Name information is required for every Osterville Ma 02655 4/12/16 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.): Tees are in place and levels are normal. 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•3/13 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 86 Leonard rd Property Address . Nancy & Steven Panagiotes Owner Owner's Name information is required for every Osterville Ma 02655 4/12/16 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 Level and at normal level 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.): No signs of carry over 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.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments: pN 86 Leonard rd Property Address Nancy & Steven Panagiotes Owner Owner's Name information is Osterville Ma -02655 4/12/16 required for every , page. City/Town 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.): 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,. 86 Leonard rd Property Address Nancy & Steven Panagiotes Owner Owner's Name information is required for every Osterville Ma 02655 4/12/16 page. Cityrrown 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.): No ponding no break out 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 TOWN OF BARNSTABLE L_JCATION SEWAGE # VILLAGE DS T Z� r✓//�P ASSESSOR'S MAP & LOT ' INSTALLER'S NAME & PHONE NO.X-e-/4J 13 Q, SEPTIC TANK CAPACITY LEACHING PACILITY:(typef�2) (size) /oo� F NO. OF BEDROOMS 7 PRIVATE WELL OR PUBLIC WATER f,,z B':.4UPER-OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No (� + t: '4 C, 5 % , Cw Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 86 Leonard rd Property Address Nancy &Steven Panagiotes Owner Owner's Name information is Osterville Ma 02655 4/12/16 required for every page. CitylTown 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 a a _ a t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 86 Leonard rd Property Address Nancy & Steven Panagiotes Owner Owner's Name information is required for every Osterville Ma 02655 4/12/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10+ ft 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: 11/22h991 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: Test hole data on plan dated 11/22/1991. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 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 86 Leonard rd Property Address Nancy & Steven Panagiotes Owner Owner's Name information is Osterville Ma 02655 4/12/16 required for every page. Cityrrown 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 t t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 f i Health Master Detail Page 1 of 1 Logged In As:�TOWN\flynnj Health-M caster Detail Wednesday,April 27 2016 ' Aol)lication Center Parcel Lookup Selection Items Reports - - Parcel —1 Septic f Perc ( Well ( Fuel Tank ` Parcel:114-030 Location:,86 LEONARD DRIVE,µOSTERVILLE Owner:PARISI,ALFRED TR - Septic 2,4/20/2016 Septic 1,4/15/2014 New Septic... Permit number: 2016130 Permit type: Repair Complete system: ❑ Issue date: 4120/2016 Complete date: 4/21/2016 Septic tank size: 2000 Type/Size of SAS: NA Installer:I DiBuono,Michael A. Card on file: ❑ I/A service type:ISelect Service Y1 Innovative/Alternative Technology type: Select IA type Variance date: Abandon complete date: Abandon permit number: Repair deadline date: Repair notification date: ^^•sa Keyword: tic Comments: seal septic tank [. D eleteSe p Inspection 4/12/2016 New Inspection... I Number Inspection Date Inspector Result 11536 4/12/2016 DiBuono,Michael,DiBuono Sewer and Drain v CP(Conditional pass) v Received Date Comments 4/20/2016 (=� Delete Inspection ,,� Save SepticChanges 71 r,7Retum to Lookup , I ° http://issgl2/intranet/healthMaster/H6a.1thMasterDetail.aspx?ID=l14030 4/27/2016 Y Commonwealth of Massachusetts 1/,11- O30 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 86 Leonard rd Property Address Nancy & Steven Panagiotes r-a Owner Owner's Name information is required for every Osterville ✓ Ma 02655 4/12/16 page. City/Town State Zip Code Date of Inspectied V1 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 A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain reb Company Name 8 Johns path Company Address S Yarmouth Ma 02664 City/Town State Zip Code 508-364-9587 S103522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by.the Local Approving Authority 4/12/16 I 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. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts ` W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51F ;-86 Leonard rd P•;roperty Address fancy& Steven Panagiotes OwnerOwner s Name information is ;psterville Ma 02655 4/12/16 required for every page. g pityrrown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 86 Leonard rd Property Address Nancy& Steven Panagiotes Owner Owner's Name information is required for every Osterville Ma 02655 4/12/16 , ;page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): j ❑ 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): H2O 2,000 Gallon septic tank is leaking at middle seam. System is in great shape other wise. _ ❑ 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•3/13 Title 5 Official Inspection Forth: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 86 Leonard rd Property Address Nancy& Steven Panagiotes Owner Owner's Name information is required for every Osterville Ma 02655 4/12/16 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 forma 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 El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. M !'' 86 Leonard rd Property Address Nancy & Steven Panagiotes Owner. Owner's Name information is Osterville Ma 02655 4/12/16 required for every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or'privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of"a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. 'I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large'Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. . i 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 El ❑ 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. l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •�'' 86 Leonard rd Property Address Nancy &Steven Panagiotes Owner Owner's Name information is required for every Cisterville Ma 02655 4/12/16 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): 4 Number of bedrooms actual 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 n Commonwealth of Massachusetts } 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 86 Leonard rd Property Address Nancy & Steven Panagiotes Owner Owner's Name information is Osterville Ma 02655 4/12/16 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: System contains a 2,000 Gallon H2O septic tank as well as a Distribution box and two 1,000 gallon leach pits. Both pits were dry at time of inspection. Septic tank needs to be sealed at seam. Staining in pits shows levels no higher than 18" up from the bottom. Number of current residents: Vacant Does residence have a garbage grinder? C u r ., �® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system'inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ ; No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 210 Gpd 9 ( Y 9 (9P ))� , Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Leonard rd Property Address Nancy& Steven Panagiotes Owner Owner's Name information is required for every Osterville Ma 02655 4/12/16 page" City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Seasonal/Weekends Date Other(describe below): General Information Pumping Records: Source of information: _None provided Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection ion Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ��M ,•'' 86 Leonard rd Property Address Nancy& Steven Panagiotes Owner Owner's Name information is required for every Osterville Ma 02655 4/12/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) + Approximate age of all components, date installed (if known) and source of information: System install date is 11/22/1991 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.5 p g 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.): System is vented through the roof Septic Tank(locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) H2O 2,000 Gallon If tank is metal, list age: yearn Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes '❑ No Dimensions: Sludge depth: t5ins•3/13 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 �. 86 Leonard rd Property Address Nancy& Steven Panagiotes Owner Owner's Name information is Osterville Ma 02655 4/12/16 required for every — page. Cityrrown 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 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No evidence of Ieaking,Tees and or baffles in place at time of inspection. 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 86 Leonard rd Property Address Nancy & Steven Panagiotes Owner Owner's Name information is Osterville Ma 02655 4/12/16 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.): . Tees are in place and levels are normal. 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-3/13 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 86 Leonard rd Property Address Nancy &Steven Panagiotes Owner Owner's Name information is required for every Osterville Ma 02655 4/12/16 ` 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 Level and at normal level 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.): No signs of carry over 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.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 .: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 86 Leonard rd Property Address Nancy &Steven Panagiotes Owner Owner's Name information is Osterville Ma 02655 4/12/16 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 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.): 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M yey < 86 Leonard rd Property Address Nancy& Steven Pana iotes Owner Owner's Name information is required for every Osterville Ma 02655 4/12/16 page. Cityrrown 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.): No ponding no break out 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.): 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 4/19/2016 Assessing As-Built Cards i TOWN OF BARNSTABLE LOCATION�6 Le���a��G;" �;-fir SEWAGE #�3� VILLAGE O j T 14 ✓l/'�f ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NOXo r./-' �,'��� %7s�13 b/ I i SEPTIC TANK CAPACITY r , I LEACHING FACII.ITY:(rype)�J `��'= r'Sr _ (size) C' NO.OF BEDROOMS PRIVATE WELL OR PUBLIC WATER,,� B'51EKROOR OWNER ;'/a�< /'S i Il^ t DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED, j VARIANCE GRANTED; Yes No (j, i v+ s ` A I • �y ox http://www.town.barnstable.ma.us/assessing/HMdisplay.asp?mappar=114030&seq=2 1/2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 86 Leonard rd Property Address Nancy& Steven Panagiotes Owner Owner's Name information is Osterville Ma 02655 4/12/16 required for every page. CitylTown 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 , Commonwealth of Massachusetts - Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Leonard rd Property Address Nancy & Steven Panagiotes Owner Owner's Name information is required for every Osterville Ma 02655 4/12/16 page. Cityfrown 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: 10+ ft 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: 11/22/1991 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: Test hole data on plan dated 11/22/1991. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 86 Leonard rd Property Address Nancy & Steven Panagiotes Owner Owner's Name information is required for every Osteryllle Ma 02655 4/12/16 page. Cityrrown 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 f t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 No. "� V Fee !/ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftpliLation for jBispo8al bpstpm Construction permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 6 eo-a�' Owner's Name,Address,and Tel.No.4 Assessor'sMap/Parcel Jv 0 gb L o`" De- D,5t-vP//e Installer's Name,Address,and Tel.No. n n (� Designer's Name,Address,and Tel.No. W a gc> -0- /' �� L D lee, Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) /y gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Z Oo Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) _<,ls 04 lkH k c. 'f 5-e o v41 e-y (icJe CY10, 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 He Signe Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. _ I a Date Issued Lf 't c 5 ' No. t Fee - -, THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftplitation for Disposal *pstew Cons trUttion VPrmit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. A-/ Owner's Name,Address,and Tel.No. Z J�a /16 9 Assessor's Map/Parcel l l U d 6 ��` G`r� D ie o,3 t-v✓`i le 11f 14 Instaplller's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. ��tStsaKJ SLo�a t r �n soh �-1- Type of Building: Dwelling No.of Bedrooms �' / Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures ^ / Design Flow(min.required) ;/y gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank 2J 0::)o Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) / /k H C. f s�6 rti a tOl &'Je c� A-o C hx r I • / I 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 He t � Signe Date c( Ao - 1 6 Application Approved by Date 1 Application Disapproved by Date i for the following reasons Permit No. ;0' — e) Date Issued �! --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (tertifitate of Compfiante THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( n) Repaired( ) Upgraded( ) Abandoned( )by 17 i�j w6 rr�+ v 4 J -cl o� L)fG „` at L Pa h k/r,4 �./�- has been constructed in accordance - f with the provisions of Title 5 and the for Disposal'System Construction Permit No.OWG- /�0 dated LI/-Ao-'G Installer Designer #bedrooms Approved design flow /v gpd The issuance of this permiyshall not a construed as a guarantee that the system wilhf ncfio as geed. j Date Inspector --------------- �v ---- -------------------- Fee aaJ6 - THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction I)Prmit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) System located at l-e O k, D X i 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. i I Provided:Construction must be completed within three years of the date of this permit Date Approved by �� i r , P r n � i t f Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments PARISI ALFRED TRUST Property Address 86 LEONARD DIRVE Owner Owner's Name information is required for every OSTERVILLE MA 02655 07/30/2014 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 A. General Information filling out forms on the computer, n I4 use only the tab 1. Inspector. v\' key to move your VVV V cursor-do not JOHNGRACI use the return Name of Inspector key. GRACI SEPTIC INSPECTIONS, LLC r� Company Name PO BOX 2119 Company Address TEATICKET MA 02536 CityFrown State Zip Code 508-641-6694 S 1468 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 1her Evaluation by the Local Approving Authority, _ 07/30/2014 Inspector's ture Date The syste inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health o 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. t t5ins•3/13 Title 5 Official Inspection Form:Subs rface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c�M PARISI ALFRED TRUST Property Address 86 LEONARD DIRVE Owner Owner's Name information is required for every OSTERVILLE MA 02655 07/30/2014 page. City/Town State Zip Code Date of Inspection B. Certification Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSES TITLE V INSPECTION. SYSTEM APPEARS TO BE STRUCTUARLLY SOUND AND FUCTIONING PROPERLY AT TIME OF INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS. RECOMMEND RAISING ALL COVERS. 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): NA t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts ` W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments cM PARISI ALFRED TRUST Property Address 86 LEONARD DIRVE Owner Owner's Name information is OSTERVILLE MA 02655 07/30/2014 required for every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): NA ❑ 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): NA 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-3113 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 �M PARISI ALFRED TRUST Property Address 86 LEONARD DIRVE Owner Owner's Name information is required for every OSTERVILLE MA 02655 07/30/2014 page. City/Town 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: NA 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M PARISI ALFRED TRUST Property Address 86 LEONARD DIRVE Owner Owner's Name information is required for every OSTERVILLE MA 02655 07/30/2014 page. City/Town State Zip Code Date of Inspection B. Certification (cost.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteriia 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts _ Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments PARISI ALFRED TRUST Property Address 86 LEONARD DIRVE Owner Owner's Name information is required for every OSTERVILLE MA 02655 07/30/2014 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? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® El available 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? Y p 9 ® ❑ 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): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° M PARISI ALFRED TRUST Property Address 86 LEONARD DIRVE Owner Owner's Name information is required for every OSTERVILLE MA 02655 07/30/2014 page. City/Town State Zip Code Date of Inspection D. System Information Description: 2000 GALLON SEPTIC TANK DISTRIBUTION BOX AND 2-1000 GALLON PRECAST LEACH PITS Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d TOWN 9 ( Y 9 (gp ))� Detail: - 2012 - 173,000 2013 - 193,000 Sump pump? ❑ Yes ® No Last date of occupancy: OCCUPIED Date Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): NAGallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): NA 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: NA t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M PARISI ALFRED TRUST Property Address 86 LEONARD DIRVE Owner Owner's Name information is required for every OSTERVILLE MA 02655 07/30/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): NA General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: NA gallons ' How was quantity pumped determined? NA Reason for pumping: NA Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach'previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments PARISI ALFRED TRUST Property Address 86 LEONARD DIRVE Owner Owner's Name information is required for every OSTERVILLE MA 02655 07/30/2014 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: NOVEMBER 1991 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 20feet Material of construction: ❑ cast iron ❑ 40 PVC 40 PVC • ® other(I explain): Distance from private water supply well or suction line GREATER THAN 10+ FEET feet Comments (on condition of joints, venting, evidence of leakage, etc.): NO COMMENT Septic Tank (locate on site plan): 1.4" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: NA years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑. No Dimensions: 2000 GALLON Sludge depth: (5) FIVE INCHES t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments PARISI ALFRED TRUST /'JAM Property Address 86 LEONARD DIRVE Owner Owner's Name information is required for every OSTERVILLE MA 02655 07/30/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle (29)TWENTY NINE INCHES Scum thickness (3)THREE INCHES Distance from top of scum to top of outlet tee or baffle (6) SIX INCHES i Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? MEASURED Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): SEPTIC TANK APPEARS TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY RECOMMED PUMPING AND EVERY TWO YEARS. RECOMMEND RAISING COVERS. Grease Trap (locate on site plan): Depth below grade: NAfeet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: NA Scum thickness NA Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA Date of last pumping: NA Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 iL Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M PARISI ALFRED TRUST Property Address 86 LEONARD DIRVE Owner Owner's Name information is required for every OSTERVILLE MA 02655 07/30/2014 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.): NA Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): NA Dimensions: NA Capacity: NA gallons NA Design Flow: gallons per day Alarm present: ❑ Yes ' ❑ No Alarm level: NA Alarm in working order: ❑ Yes ❑ No Date of last pumping: NA Date Comments (condition of alarm and float switches, etc.): NA *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 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 PARISI ALFRED TRUST Property Address 86 LEONARD DIRVE Owner Owner's Name information is required for every OSTERVILLE MA 02655 07/30/2014 i page. City/Town State Zip Code Date of Inspection D. System Information (cont.) I Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert BOTTOM OF PIPE 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.): APPEARS TO BE STRUCTUARLLY SOUND AND FUNCTIONING PROPERLY AT TIME OF INSEPCTION Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System SAS locate on site plan, excavation not required): If SAS not located, explain why: NA t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 l Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M PARISI ALFRED TRUST Property Address 86 LEONARD DIRVE Owner Owner's Name information is required for every OSTERVILLE MA 02655 07/30/2014 page. City/Town State Zip Code Date of Inspection- D. System Information (cont.) 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.): LEACH PIT 1 APPEARS TO BE FUNCT4ONING PROPERLY AND STRUCTURALLY SOUND LEACH PIT 1 HAS (1) ONE FOOT OF LIQUIDS LEACH PIT 2 WAS VIDEO INSPECTED DUE TO SPRINKLER LINE OVER COVER. RECOMMEND REMOVING SPRINKLER LINE OFF LEACH PIT COVER#2. _ Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth—top of liquid to inlet invert NA Depth of solids layer NA Depth of scum layer NA Dimensions of cesspool NA Materials of construction NA Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .w PARISI ALFRED TRUST Property Address 86 LEONARD DIRVE Owner Owner's Name information is required for every OSTERVILLE MA 02655 07/30/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.).- NA Privy (locate on site plan): Materials of construction: NA Dimensions NA Depth of solids NA Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 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 PARISI ALFRED TRUST Property Address 86 LEONARD DIRVE Owner Owner's Name information is OSTERVILLE MA 02655 07/30/2014 required for every page. CitylTown 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 A u G PIT* AA-25 2CO (-Au.pN 1 A 0-34 SETMc- Ti4t-X - 1000 a,0Nor1 A0- 45® 9 E_�s BR-27 6Pr 33 a D-5(o,& ° Q2w gE-72 .1 Ia0o e,a_ y-79 C.0, � c c_ L42 y �E_gij t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° .N PARISI ALFRED TRUST Property Address 86 LEONARD DIRVE Owner Owner's Name information is required for every OSTERVILLE MA 02655 07/30/2014 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: GREATER THE 10+ FEET 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: HAND AUGER Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 f Commonwealth of Massachusetts 92 W Title 5 official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M PARISI ALFRED TRUST Property Address 86 LEONARD DIRVE Owner Owner's Name information is required for every OSTERVILLE MA 02655 07/30/2014 page. CityrTown 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 - r f APPROVED No................ ....... Fes$............. .. Cot�rvation Department THE COMMONWEALTH OF MASSACHUSETTS �rnsgtebW, � aa,IJ `BOARD OF HEALTH Signcd Date TOWN OF BARNSTABLE elg9isuiee NOWiration for Dispnsa1 Works Tomitrurtua rruttt Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal Syst at. 2e� LocaVon-Address or Lot No. ........................ A......f.� ...••---•........--•--•------•--......•...... i9 ..................... ............................................... a '09� , so J S ner S / Address ----....'••--•-•----...-----• ............................................. ..^--.......... ._____...._'_.___________.______.__............______....________..............-------••---...... Installer Address q. feet I Type of Building Size Lot___________________________S� U Dwelling—No. of Bedrooms-_...................................Expansion Attic ( ) Garbage Grinder '4 Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ------------------------------ . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacityZaNgallons Length................ Width................ Diameter---------------- Depth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. . Seepage Pit No......o?............ Diameter.................... Depth below inlet..................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date..........----------------------------- aTest 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---_--_____--__.--.__-_- a •-•--•-•--••-----•-•••-•-•-•-------•-----•-•••--•••----•---•---•-•---•......................•-•--........................................................... 0 Description of Soil........................................................................................................................................................................ W ------------------------------------------------------------------------------------------------------------- .f- . ----•-•-- U Nature o -R pairs or Alterations—Answer when applicable v-O---_� �_-_-/_1.T�e ¢CEO f -----------•-•-- -------------- ............._..----- 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 Complian has been iss ed by kfe boar of e Ith. Sign - C� ------------ ------ / /..... Date Application Approved B -==-_-------- --- l ------- Application ' PP PP Y --------------------------------- ate...... Disapproved for the following reasons- -------------------------------------------------------------------------------------------------------- - ------- ----------- ---- - -- -------- ------ --------------------------------------------------------------------- ----- -- -- ------..........................................................-------- ------------------ ------------- ate Permit No. -- .��..��---------------------------------------------- Issued ....----.....f.-.'.�i���e.�....--`�...-�------- /---- No........................ THE COMMONWEALTH OF MASSACHUSETTS of HEALTH -r TOWN OF BARNSTABLE �! A plira#ion for Bivpniia1 Works Tonfourtinn Vamit AppliLtij n is hereby made for a Permit to Construct ( ) or Repair (/�anndividual Sewage Disposal System at:� Location-Address or Lot No. ...................... .._ .J ------ ••--•-•--•--------------------•..... ...................j-y--C--••--•--•-••-• -••--------••-•--•••--•-••••---.......____...-- owner Address ----�-!.�2-� /�!_._.c o-�.S':7=---------------•------•-----�---�5....f .............'.. Installer Address Type of Building t Size Lot............................Sq. feet l--1 Dwelling—No. of Bedrooms._' __________________________________Expansion Attic ( ) Garbage Grinder ( � aa Other—T e of Building No. of ersons____________________________ Showers YP g ---------------------------- P (---->..— Cafeteria ( ) Otherfixtures ..............................................-•--•---•---•----------••-•-------•--•---• _-••---•----------•-- ---••----- W Design Flow............................................gallons per person per day. Total daily flow.............................................gallons. WSeptic Tank—Liquid'capacity ca Caallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leeching area....................sq. ft. Seepage Pit No______ __________ Diameter._______.___.____.__ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (L Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -•-••-----••-----------------••-••---•-•--•--••••....-•----••-------.._...----------.............--•......................................................... ODescription of Soil........................................................................................................................................................................ x U -•-----•••••...............••••------••------•--•--.._..--••••-•-•••••-•--•••------•-•--••--•-•-•••--••-•-•-•--------•------•---•-•-•----•----•----•---•---•------•----------------•...•-------------•- �Wy ______________________________—___.....__._._...___._._____......._.._.__._.._________..______._.._________-_____-_-__.____..._ ------- GUo_ ._f A _ .. 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 issued by .41e board of -ealth. ............................... f' 7 i Date Application Approved By ........ ------------ ---------------- .. - .-- ........................................... Dare Application Disapproved for the following reasons- --------------- ------ ---------------------------- - - ----------------------------------------------------------------- ------------------------ ----------------------- --- -- -------------------------------------------------- - ----------------------------------------------------------------------------------- ---- ------------------- ------- Date Permit No. ....-, `... Issued 1 � ` Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Tertiftrate of Torapti an.ee THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by 1-1) G< < /� .......... .. .. -- -------- -- -------- ..........................------...............--------------............------....---------------- --- . ...............----------------------- Installer:. ~" - ------------------------------------------------------------------- ------- - ------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Enviro.-imental Code as described in the application for Disposal Works Construction Permit No. ..,.. +.... ..�'�-....... 1 dated ...- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED'AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE -- .! '' '"... --------------------------------------------- Inspector .............................................. .`.�' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �t-3 TOWN OF BARNSTABLE No._........-- FEE.....a�-•- Disposal n k.5 Tomitr inn ataft �C G' Permission is hereby granted ••--- --•----•- -- ----- ----------- to Construct ( )or Re air (� Individual Sevttage Disposal System atNo.. ---�•-•��c/.9aE�-•J���'�-•----.... --------=-------------•--•--------------------•---•"----------------------......_..-•---•- Street �^- as shown.on the application for Disposal Works Construction Permit No- __��n at d ____ ____ _ f DATE_ / �� -� Board of Health / FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS f f k, TOWN OF BARNSTABLE `" LOCATION �6 �e�j/�i c����. i'ti.�� SEWAGE # VILLAGE ASSESSORS MAP S: LOT /`%l -D3l� INSTALLER'S NAME 6z PHONE N0. 2 /- !-ai,5-7 SEPTIC TANK CAPACITY �� LEACHING FACILITY:(typei-Z " ' (size) NO..OF BEDROOMS. PRIVATE WELL.OR PUBLIC WATER i v. BlUIEV00OR OWNER /JA?c . DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ( � ni {/ 1 s ,