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0022 LINDEN LANE - Health
22 Linden Lane Osterville P A = 1414 022 r. 1 vr d r,tAc /yS 0-" �NJ i I C TOWN OF BARNSTABLE LOCATION ,L n SEWAGE# �ZW(, —3yy ,VILLAGE e cw ASSESSOR'S MAP&PARCEI/ /q I yP_OAz INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY is sS8 t LEACHING FACILITY:(type) JK r1'Lc_���,(size) 12 y� NO. OF BEDROOMS OWNER PERMIT DATE: a-6 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility W Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY MI6 r' ' TOWN OF BARNSTABLE LOCATIONC;%� �/;gd&�j ,l o/?,p, SEWAGE # VILLAGEg %(>i���? ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. & FoR E01- V 14 99 SEPTIC TANK CAPACITY LEACHING FACILITY:(type)) (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER R OWNER ��ISC� DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ,�C K O [ s f B k 21472 Ps 2'92 0-67137 1��_-27--2006 01 a 07 'f NOTICE: The Town of Barnstable recommend is hat the-appUcad seek legal advice to prepare a property worded deed restrictibn document. E DEED RESTRICTION E WHEREAS, t'1 t1 �. � i ,.,,} j��-i �' ��l G�. i 1 of (owners name) -) R h't _F, f-ic MA (address) J / is the owner of (ot-" r� , 0Ej ( VJ 16cated (ad ss) at U-r�t--e&V 1 �1r1QXS6 , TT— MA (hereinafter referred to as and being shown,on a plan entitled "Subdivision of Land in . MA, Property of , Qj et at, duly recorded in Barnstable County Registry pa\ of LJrj Deeds in Plan Book Page ; Or on Land Court Plan Number WHEREAS, c b-f TC ttf C 1 as the owner of said lot has (owner's name) agreed with the Town of Barnstable Board of Health to a restriction as to the number.of bedrooms which can be included in any home built on said lot as a pre-condition to obtaining a disposal works construction permit in compliance with 310 CMR 15.000 State Environmental Code, Title V, Minimum ' Requirements for the Subsurface Disposal of Sanitary Sewage; WHEREAS, the Town of Barnstable Board of Health, as a pre-condition to granting a disposal works construction permit for a septic system in compliance with 310 CMR 15.200, State Environmental Code, Title V, Minimum -- Requirements,for the Subsurface Disposal of Sanitary Sewage, and authorizing the issuance of a building permit for the construction of a single,family home on this property, is requiring that the agreement for the restriction on the number of bedrooms in any house constructed on the lot be put on record witb the Barnstable County Registry of Deeds by recording this document, deedr f No.,. 0o 9 Fee o i / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplication for Bi!6poml �&yaem Cow5truction Permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) lxComplete System [:]Individual Components Location Address or Lot No. Owner's Name,Address,atio Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures L f/ Design Flow(min.61ZUji re ) gpd Design flow provided `7 - 7 gpd Plan Date Number of sheets ] Revision Date Title Size of Septic Tank 19 Q4 7 to Type of S.A.S. 92d, r1a Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 Y Compliance has been issued b this Board of Health. P Signed Date Application Approved,by Date Application Disapproved`by: Date for the following reasons Permit No. O C)G Date Issued d 6 ,4k TOWN OF.BARNSTAk LOCATION ,L SEWAGE# oZW(, -,3 I I VILLAGE ✓v ASSESSOR'S MAP&.PARCEL INSTALLERS NAME&PHONE NO. Ptak, I SEPTIC TANK CAPACITY l Sa D L•EACUING FACILITY: (type) j /� 1 r ��' v (size) >r2.K !ex r NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: .. Maximum Ad justed Groundwater Table to the Botto m of Leaching i n Fac ility ty Private Water Supply Well and Feet Pp y Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Feet FURNISHED BY l q r l �� ` .✓" �"?"r ,r#1` �",a•�` ...�:.:�n.�t i s !' .=x-... ...o.s='"..` ..:;;:f"'. -. ",`k k,. . R+� �. . �- 'No. a" ���F� -,..x'L.. Fee /(o ��.. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplication for Tig.po!gal *p.5tem Construction Permit rr Application for a Permit to Construct O Repair( Upgrade O Abandon O E Complete System F-1 Individual Components r �k Location Address or Lot No.�r Owner's Nam dr�S,o�Tel.No. � Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures L Design Flow(min.7rquired)/ /7 gpd Design flow provided ? gpd Plan Date 23/6 6 Number of sheets ( Revision Date t Title F I I // Size of Septic Tank � o (I C' d Type of S.A.S. /Ti' frti T ry /-f Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 Health. Signed a.J Date i! Application Approved by ✓/il Date i Application Disapproved by: Date for the following reasons rr r� p` // ,r ' Permit No. �n *O / Date Issued d/-7/0 4_ _. THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (' ) Upgraded Abandoned( )by 01c.n1 t, rr at Z'L Lx,6ft, � L%-.has•been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. :dQh - 3 q v I dated Installer �CtL M �aS Q" Designer ', P,%on #bedrooms Approved design flow u L 0 ! gpd The issuance of this perm•4 shall-not be construed as a guarantee that the system will unction ass designed' Date Cl lr/ ector '// 0 f � ,r Vi P' a/' Ins p No. 28o6 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS wi9poat *p! tem Con5truction Per it Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( Abandon ( ) System located at -L and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date/5oft is pernut. r r 'Date � �i - x Approved by L/0 Wed pl(Atl3 t✓I t-f one Ps' 5��� �Oct _27 06 11 : 13a Tadco Consultants 5083856003 p. l i . Town of Barnstable FED Regulatory Services �r DATE 4 � C� Thomas F.Getter Director i p Z't ,1 - M l Public Health Division (� ►Z% l o Thomas McKean;Director 200 Main Street,Hyannis,MA 02601 Office:.508-962-4644 Fax: 508-790-6304 Installer&Desiener Certification Form n Date: i��2��o Sewage Permit# al o6 - V 1 Assessor's MaplParcB— `�/ f Designer: Installer: Address: Address: f 8I 0(Z C lot -) On aA46 1�4.�kK, a„S was issued a permit to install a (installer) septic system at_ .Q?— Orr,--J asod on a design drawn by (address) �9tw S e^ dated. (V L)(4' c gact) .I certify that the septic system referenced above.was installed substantially according to . the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State &Local Regulations. Plan revision or certified as-built by designer to follow. Stripout(if required)was inspected and the soils were found satisfactory. �p1�1 A— (Instal er' ) .9 SignBtLt� ( x s ignature) (Affix Designer's Stamp ere) PLEASE RETURN TO BARNSTABIX PUBLIC HEALTH DIVISION CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE WEIVED BY THE BARNSTAIILE PUBLIC HEALTH DIVISION �NK YOU. — -- QAScpticV)csigntr rartiGcalion Form Rey 03-09-06.doe l _ oFIKE Regulator' Services P4 c ,f Thomas F. Geiler, Director BARNSCABM MASS. g Public Health Division i639' �0 'Oleo N►a+° Thomas McKean, Director 200 Main Street,Hyannis,,.NIA 02601 Fax: 508-790-63-04 Office: 508-862-4644 Installer& Designer Certification Form Date: OCJ,.d 5�,02__006 Installer: 3ruce l la�r~�l,sl o� Designer: Address: Address: t, 5Ar.4w,,it,t-t . MA, 0as3q G���ecu,l�e lYa- oa65S a aoab- y57 On c t �y OOE� ����G�- �S� _ was issued a permit to install a (da(e) (installer) septic system at 100 Se7 �copSD�� 4L&!�! -- C�;l- based on a design drawn by (address) .� t Meyer dated OCT ` . Q - - (designer) ' I certify that :the septic system referenced abase ��as installed substanttaily accordin�ac�' inor approved changes the design, which may include m such as lateral relocation of th`e` distribution box and%or septic tank. \N,71th major changes I certify that the septic system referenced above �t�a�rti calinstalrelocat on of any Plan revi'sfon or component _ greater-than l0' lateral relocation of the SAS or any of the septic system) but in accordance with State & Local;; , lations. certified as-built by designer to follow. tN of Mqs a o DA RE 0. 1140 (Installer' Signature) o �FarsTE��` SA N l TAR�t'� 2� 1 (Designer°s Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO B ARNSTABLE PUBLIC HEALTH DII TH-TRIOS FORfRT AND aAs- OF COMPLIANCE WILL NOT BE ISSUED L:�t'TIL BO BUILT CARD ARE RECEIVED BY THE BAR'VSTABLE PUBLIC HEALTH DIVISION. THA\K YOU. Q: Health.•'SepticlDesigner Certification Forth _........_ . __. '20 FT. MINIMUM FROM CELLAR 7..MINIMUM ,> 10. FT. MINIMUM FROM SLAB OR AWL`SP.CE a� 31� � erlAd CLEAN SANG ca l C fTE c>� ���5 or S I l� CO S 4' SCHEDULE 40 PVC PIPE �` ► LOAM AND SEED MIN. PITCH 1/8" PER FT. rJ (� 2' LAYER OF j 1/8" TO 1/2- ►S7 tRON.PIPE` "AV 11 WASHED STONE -QUAI M� NOTTREQUIRED r/4,PER FT. ? 1 CU. FT. OF CONCRETE F OW-Li o, ANCHOR ._.....� _ MIN. Y � �1 � 20� ° ° M ,� qi" LEVEL ,/j ° o O�V V. o/i :Y.t w � :• B&A ELEV. Rt. I 6 .SUMP ELEV. DISTRIBUTION Y � T BOX �fi0 BE PLACED ON FIRM,-BASE} �c1 � ������ NN S V' TO BE WATER TESTED ova l t'X 4 'g." IJ�1dw fg4s m wv 4 r IF MORE THAN ONE OUTLET 1= 00 GALLON � WELL '�t NCHE (TO BE PLACED ON FIRM BASE) J SOIL ABSORPTION ZONE ti SEPTI�C TANK � 3/4" TO 1 1/2" CLEAN INDEX . 3AIle_ 1<',,J" CAD DOUBLE WASHED STONE SYSTEM (SAS) ADJUST FREE OF FINES do SILT yAcnC.5 Iu l#eo PWS oe USGS PROBABLE WATER TA ELEV. SEWAGE DISPOSAL SYSTEM PROFILE OBSERVED WATER TABLE ( -- ELEV. NOT TO SCALE BOTTOM OF TEST HOLE ELEV. ?1.6s NOTES: 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. TITLE AND THE TOWN RULES AND REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE. 2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO WITHIN 6- C FINISHED GRADE. 3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF T. D. Consulting TADCO Consultants 26 COMPASS LANE DENNIS, MA 02638 508-385-2425 Fax: 508-385-6003 u Ted Dumas R.S. Tanya Johansen R.S. August 24, 2006 Mr. Donald R. Desmarais R.S. Town of Barnstable Public Health Division 200 Main Street Hyannis, MA 02601 RE: Septic system at 22 Linden Lane Osterville, MA Dear Don, On August 10, 2006 I made an on-site inspection of the installation of the septic system for the above referenced property and found the S.A.S. to be installed in substantial compliance with acceptable tolerances to the Massachusetts Sanitary . Code, Title 5, and the approved plan by TADCO Consultants dated 6/23/06. A concrete tank was used in lieu of a plastic tank that was proposed on the approved plan. Filter fabric was utilized in lieu of pea stone and thus the stone was not inspected. The"'as-built"card was supplied by the installer. If you have any questions, please call. Very Tr urs, Tanya J s S. 1 5 f Lt;Cb i Er D ru tr ED Postage $ J / Nn p p Certified Fee p Return p (Endorsement Required)ed)FeePo \ p Restricted Delivery Fee O Here, `. .A (Endorsement Required) r I Total Postage&Fees $ .G p Sent To p Street Ap:tyo.;__ _' "'-••• ____ or PO Box No. -------------- ---- City,State,Z/P+4 ..... ® Complete items 1,2 and 3.Also complete A: Signature item 4 if Restricted Delivery is desired.® Print your name and address on the reverse so that we can return the card to you. X 4/r kz;J'6bt r'n 0 Agent ® Attach this card to the back of the mailpiece, B. Received by(Printed N Addressee or on the front if space permits. • ame) C. at of D liv 1..Article Addressed to: D. Is delivery address different from item 1? ❑Y a If YES,enter delivery address below: ❑No Ms Edith Orbinson 22 Linden Lane Osterville, MA 02655 3. Service Type ❑Certified Mail ❑Express Mail ❑Registered ❑Return Receipt-for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) 2. Article Number � (Transfer from service/abelJ 7 0 0.5 116 0 6 o a a 0191 12 91 PS Form 3811,.February 2004 Domestic Return Receipt 102595-02-M-1540 Town of Barnstable FIHE tp� o Regulatory Services snxivsrAa �« Thomas F. Geiler, Director 9�A MAW. ••� Public Health Division lED MA'S� Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 June 22, 2006 Ms Edith Orbinson 22 Linden Lane Osterville, MA 02655 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5 The septic system owned by you located 22 Linden Lane, Osterville,MA,was last inspected on June 5tb,2006 by, Mark Polselli, certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that your system has "Failed"under the guidelines of 1995 TITLE-5 (310 CMR 15.00) due to the following: Cesspool has root and soil intrusion. Structuraly unsound You have 2 years from the date of the system failure to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. 4BARNSTAB HE TH DEPARTMENT Thomas A. McKean R.S. C.H.O. Agent of the Board of Health COMMONWEALTH OF MASSACHUSETTS W EXECUTIVE OFFICE OF ENVIRO_N, ,,v E-\ -A.L:=OFF:SIRS a DEPARTMENT OF ENVIRONMENTAL PROTECTION a TITLE 5 OFFICIAL INSPECTION FORIM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEtiI FOIL 1 PART A CERTIFICATION Property Address: 020�_ Z/h 01e., Owner's Name: Eal; !, pA6inSoh Owner's Address: _ l�S erv,% s7 6SS �� 1 Date of Inspection: Name of Inspector: (please print) Marhr Company Name: Mailing Address: — 0Y Ia ak a s*-7 Telephone Number:r,S�7f) [ CERTIFICATION STATEMENT _ that I have personally i I certify p y 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 mv_, training and experience in the proper function and maintenance of on site sewage disposal systems: I am a�DEP`�t approved system inspector pursuant to Section 15.340 of Title 5(310 ChiR 15.000). The sl istem: -I=- Tm— co ►Yt Passes Conditionally Passes _ �:�''ds Further Evaluation by the Local Approving Authority Fails Inspector's Signature: GVYt Dater G S L he system inspector shall submit a copy of this inspection report to the Approving Authority(Board of;Flealth 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 he DEP.The original should be sent to the system owner and copies sent to the buyer. if applic-ble; and the approvi o authority. Votes and Comments C e.ss/�OO rl Y/qS /c 007t- a0cj (eel��y sI o v7 / r-w G4C,✓a�h fir i�►SO u h d ****Thisd-- . ' report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 'Irspection Form 6/15/2000 page 1 Page 2ofil OFFICIAL INSPECTION FOR1M—NOT FOR VOLU1NT_ARY ASSESSIMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: ;-z L tom, Owner: Q/Z61n50-7 Date of Inspection: S 06 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 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. cnbed in 310 CldI2 Comments: B. System Conditionally Passes: . One or more system components as described in the"Conditional Pass"section repaired.The system, on need to be replaced or y m,upon completion of the replacement or repair,as approved by the Board of Health, will pass. Answer yes, no or not determined(Y,IV,TND)in the for the following statements.If"not determined"please explain. The septic tank is metal and,over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than.20 years old is available. \71)explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). ne sy szm:;ill pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: T;rlo 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLLTNT_4RY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ' CERTIFICATION(continued) Property Address: Owner: n 6r613'00 Date of Inspection: (v p C. Further Evaluation is Required by the Board of Health: /V 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 C_MR 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 r 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 I his system passes li the well water analysis,performed at a DEEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from poIIution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm provided that no other failure criteria are wagered.A copy of the analysis must be attacked to this fC;:^,t. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSNI TENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 0`z7 ✓ GYM' 141 Owner F, VIJ o Date of Inspection: ©�J D. Svstem Failure Criteria applicable to all systems: You must indicate "yes"or"no"to each of the following for all inspections: Yes No 4/` 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 logged 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%z day flow _./Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number _ �(times pumped y 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 tnlbutary to a surface �ater supply. �ny portion of a cesspool car privy is within a Zone i of a public well. y portion of a cesspool or privy is within 50 feet of a private water supply well. _ L/Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal 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.] 62 (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CVIIZ 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 20,000 gpd to 15.000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes n 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 _ e system is located in a nitrogen sensitive area(Interim Wellhead Protection Arca-rWPA)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 tlTeat, 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 accordant with 31��C v?R 15.304.The.system owner should contact the appropriate regional office of the Department. 4 page5ofil OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA PART B CHECKLIST Property Address: �/"t c v 0 O'e—, // C�JS ✓�r�e ^. /�/'{ Ode �SS Qwner: b1 n S0► Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the followjm_g: Yes �'o _ PPuu mg 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: Yes no _ Existing information.For example,a plan at the Board of Health. bete,=. iiried in the field(if any of the failure criteria related to Part C is at issue approxLmation of distance is unacceptable) [310 CMR 15.302(3)(b)] 'r;rio 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSVIE-N SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION Property Address: h / p5 e✓v�/ � /� D� bS5 Owner: v Q�JI wS0"1 O Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: o� Does residence have a garbage grinder(yes or no): y� Is laundry on a separate sewage system yes or no):� [if yes separate inspection required] Laundry system inspected(yes or no): _ Seasonal use: (yes or no):�ef Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no): A'O� Last date of occupancy: C O i0'MERCIALAND USTRIAL Type of establishment: Design flow(based on 310 C1VIR 15.203): gpd Basis of design flow(seas/persons/sgft,etc.): Grease trap present(yes or no):— Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records /n99 Source of information: Was system pumped as part of the inspection(yes or no):,LP If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _Septic t distributon.box, soil absorption system _S'i4e 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(te be obtained from system owner) —Tight tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Q�� S'h aL O(,vy�e✓ Were se:/age odors detected when arriving at the site(yes or no): 1610 6 Titlo S TnCn tin Perm 4:!1 Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORNI PART C SYSTEM INFORMATION(continued) Property Address: C4 z r CQCA Levi Py OS ✓v�' � � /�� O�.G S� Owner: -A Date of Inspection: i 0 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _4� 0 PVC_other(explain): Distance from private water supply well or suction liner Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TAINK: ��(locate on site plan) Depth below grade: Material of construction: concrete_metal_fiberglass_polyethylene —other(explain) Tf tank is metal list age: _ Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 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: How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels . as related to outlet invert, evidence of leakage,etc.): GREASE TRAP: (locate on site plan) Depth'below grade: _ 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: Dace of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, Liquid levels as related to outlet invert, evidence of leakage,etc.): _ Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNT_-A_RY ASSESSMENTS " SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR1/1 - P_-,kRT C 'SYSTEM INFORMATION(continued) Property Address: Z/h C rin Ge, Owner: I)ate of Inspection: 6 TIGHT or HOLDING TANK:4 (tank must be pumped at time 1of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass}_polyethylene$ other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: - Alarm in working.order(yes or no): Date of last pumping: u Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan);_ , Depth of liquid level above outlet"invert. , Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover; any evidence of leakage into or out of box,etc.):. PUMP CHAMBER: (locate on site planl Pumps in working order(yes or no): Alarms in working order(yes or no): Comments (note condition of pump chamber,condition of pumps and appurtenances, etc.).: TtYo � (r.cr.o�tinn Fnrin �. 1�/7(1M tg - page 9ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM NSPECTION FORM PART C SYSTEM INFORr1ATION(continued). property Address: v1 �, /l>� ©d—G S5 pwner o 6t 0 ti Date of Inspection: iO ✓� SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why:, Type leaching pits, number: leaching chambers, number: leaching galleries,number: leaching trenches,number,length: leaching fields,number, dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure,level ofponding,damp soil,condition of vegetation, etc.): CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)' dumber and configuration: Depth—top of liquid to inlet invert:o7 Depth of solids layer: . '/ O Depth of scum layer: Dimensions of cesspool: 6-X 6X Materials of construction... C-l" Indicarion of groundwater inflo (yes or no): _ // Co nts otef ondition o soil, signs ulic failure,level of p nding;.conaia n of vegetation,etcr� � �0075 GHd 5 0 i L �Ptf 00 _0 P- a►_7L t— '�/N f f 0�1 ✓ !rH G� i S fw 6,.f0b. Q /'/1 f 0'7 /11/7 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.): r page 10 of 11 OFFICIAL INSPECTION FORML -NOT FOR VOLU-�'tTARY ASSESSMENTS SUBSURFACE'�SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C , SYSTEM INFORMATION(continued) Property Address �� �l�/►CPS !�G�� Owner: f Date of Inspection: S 0:6 t. SKETCH OF SEWAGE DISPOSAL SYSTEM ` Provide a sketch of the.sewage disposal system including ties to at least two permanent reference landr-narks or benchm rks. Locate all wells within 100 feet.Locate where public water supply enters the building. C� .. 4 '00� .. t x i ,)nnn 10 Page l l of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSNIE`TS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INiFORMATION(continued) Property Address: pri ps {boa .6s:' Owner: D✓.0�r h./or Li Date of Inspection: SITE EXAM Slope f /� Surface water Check cellar o 14 r Shallow wells Estimated depth to ground water, feet Please indicate(check)alI methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: d site(abutting property/observation hole 1�feet of SAS) with local Board of Health Z � S Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe ow you established the high'ground water elevation: s, Gr'o H.� w�-/�ri A 4- f t f t COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS A r DEPARTMENT OF ENVIRONMENTAL PROTECTION F d {' F If V r TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFALE'SEWAGE DISPOSAL SYSTEM FORM PART A t CERTIFICATION Property Address: 22 LINDEN LANE OSTERVILLE, MA 02655 Nk 022, not d Owner's Name: ORBISON t't. Owner's Address: 22 LINDEN LANE OSTERVILLE,MA 02655 RECEIVED Date of Inspection: 6/5/02 { w JUL 0 8 2002 Name of Inspector: (please print)1t1 ;� JOdhN CRACI Company Name: �SERTIC' INSPECTIONS TOWN OF BARNSTABLE Mailing Address: Pb.'FOX 2119 TEATICKET, MA. 02536 HEALTH DEPT. q� Telephone Number: 508-564-6813-FAX 508-564-7270 V CERTIFICATION STATEMENT 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 maint6nanee 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: t.. %i X Passes. P' _ Conditionally ses _ Needs Furth aluation by the Local Approving Authority Fails y Inspector's Signature: !' Date: 6/5/02 The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspec on. 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- mit 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. Notes and Comments t SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. y.+st*\ ****This report only describes cQnglitions at the time of inspection and under the conditions of use at that tiwc.'Phis inspection does not address how the.systera.will perform in the future under the same or different conditions of use. � I Title 5 lncnartinn Fnrm oli Onnno ' Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM x• PART A "t`..CERTIFICATION (continued) y Property Address: 22 LINDE`_N LANE OSTERVILLE, MA 02655 Owner: ORBISON Date of Inspection: 6/5/02 Inspection Summary: Check A,B,C,D,br E/ALWAYS complete all of Section D A. System Passes: X 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.' 1 Comments: SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVEi,:Y TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: `. _ One or more system components as described in the"Conditional Pass"section rietJ to be replaced or repaired.The system, upon completion of the replacement or..,repair as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in'the for the following statements. If"not determined"please explain. t > i n/a The septic tank is metal aril"over k 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;s structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old`is'lavailable. ND explain: n/a •;Rey, a n/a Observation of sewage back'6p'or'lire'ak nut 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): f' _ broken pipe(s)are replaced obstruction is'removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more thGn`4 times a year due to broken or obst,•,cad pipe(s). The system will pass inspection if(with approval of the Board o.(Health): ,t _broken pip (s)are replaced Obstruction is removed ND explain: n/a z , Page 3 of 1 I OFFICIAL INSPECTIONFORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 22 LINDEN.LANE,OST'ERVILLE, MA 02655 Owner: ORBISON Date of Inspection: 6/5/02 C. Further Evaluation is Required 6y 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 iof 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: { F _ Cesspool or privy iswithin 50 feet of,a surface water _ Cesspool or privy is within 50`feet of a bordering vegetated wetland or a salt marsh .t 2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the system is functions ng in a manner that protects the public health,safety and environment: .a _ The system has a septic tahkk aril 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. tl' _ 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 n/a "This system passes if theIt well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicases that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal io or less than 5 ppm,provided that no other failure criteria are triggered. A copy fir1 . of the analysis must be attache, d,to this form. 1 " N 3. .Other: n/a • u: .;Ili. +e . • 'al ._fit Page 4 of 11 1 1 OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ti ', CERTIFICATION(continued) Property Address: 22 LINDEN LANE OSTERVILLE, MA 02655 Owner: ORBISON '} Date of Inspection: 6/5/02 11::: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"°to each of the following for alLinspections: Yes No X Backup of sewage i,ko`facility`or system component due to overloaded or clogged SAS or cesspool X Discharge or pond ing=of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6" below invert or available volume is less than ''/day flow X Required pumping more than`4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Wa. q'a4" X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or::privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is'within a Zone 1 of a public well. X Any portion of a cesspool or privy'is within 50 feet of a private water supply well. X Any portion of a cesspool or privy,is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality:analysis. (This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that faality 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.l (Yes/No)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 faik"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 now of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) +. , yes no , _ X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of aFtributary to a surface drinking water supply X 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 Scctiun D above the largc sysleni lies failed. The owner or operator of any large sySlcm 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. Page 5 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM `- PART B CHECKLIST Property Address: 22 LINDEN LANE OSTERVILLE,MA 02655 Owner: ORBISON L Date of Inspection: 6/5/02 Check if the following have been don&You must indicate"yes"or"no" as to each of the following: ; :` Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health s , _ X Were any of the system components pumped out in the previous two weeks r X _ Has the system received normal flows in the previous two week period? X Have large volumes of water bee'n`•introduced to the system recently or as part of this inspection ? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) :1 X _ Was the facility or dwelling,in'spected for signs of sewage back up V Q tI X _ Was the site inspected for signs of break out') V, X _ Were all system components,excluding the SAS, located on site 9 X _ Were the septic tank manlhd' eVuncovered,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? X _ Was the facility owner(and occupants if different from owner)provided with inforation on the proper maintenance of subsurface sewage disposal systems") m ;r The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information. FO'r example;a plan at the Board of Health. X _ Determined in the field(if any ofthe failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] ' `; 3 ' Page 6 of 11 t s •. c qy- .# "Yt 1 t OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C t` SYSTEM INFORMATION Property Address: 22 LINDEN LANE OSTERVILLE,MA 02655 Owner: ORBISON Date of Inspection: 6/5/02 FLOW CONDITIONS RESIDENTIAL {' Number of bedrooms(design): 4; Number of bedrooms(actual): 4 DESIGN flow based on 310 CMk 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 2 { Does residence have a garbage grinder(yes or no): NO Is laundry on.a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)):d1/a o 0 a 35 7C)Z)(D Sump pump(yes or no): NO Last date of occupancy: 6/27/02 , COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15:201)'. n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no):NO - Industrial waste holding tank present(yes'or no): NO Non-sanitary waste discharged to the Title-5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a . OTHER(describe): n/a . r' GENERAL INFORMATION Pumping Records 't Source of information: n/a ?t Was system pumped as part of the inspection(yes or no):NO If yes,volume pumped: n/agall`o,.,How wasFquantity pumped determined? n/a. Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box;soil aFi§orption system _Single cesspool s _Overflow cesspool _Privy Shared system(yes or no)(if yes,attachYprevious inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a :1 Approximate age of all components,date installed(if known)and source of information: 1962 BY OWNER Were sewage odors detected when arriving'at the site(yes or no): NO r Page 7 of I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM ISPECTION FORM s PART C SYSTEM INFORMATION(continued) Property Address: 22 LINDEN:LANE!OSTERVILLE,MA 02655 Owner: ORBISON Date of Inspection: 6/5/02 BUILDING SEWER(locate on site plan) Depth below grade: 7" , Materials of construction:_cast iron:_40 PVC Xother(explain): ORANGEBURG Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage, etc.): r TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 1" a k Material of construction: Xconcrete_metal fiberglass_polyethylene other(expla:n).i/a , If tank is metal list age: n/a Is,'age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 6' X 6' BLOCK CESSPOOL Sludge depth: 0" : Distance from top of sludge to bottom of outlet tee or baffle: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum"to bottom of outlet tee or baffle: n/a 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): CESSPOOL AND ALL COMPONENT'S ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY',•TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. CESSPOOL WAS EMPTY AT TIME OF INSPEC s.1,9N. GREASE TRAP:_(locate on site plan) " a Depth below grade: n/a Material of construction:_concrete_metal fiberglass'_polyethylene_other(explain): n/a _ Dimensions: n/a , Scum thickness: n/a d , Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a.. Comments(on pumping recommendation s, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a b - j t! r Page 8 of I I t_ OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 22 LINDEN LANE OSTERVILLE,MA 02655 Owner: ORBISON Date of Inspection: 6/5/02 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day `t Alarm present(yes or no): N/A "a Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and fldat,switzhes,etc.): n/a DISTRIBUTION BOX: _(if presenryom t be opened)(locate on site plan) Depth of liquid level above outlet invert: n/a o 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.): n/a a; PUMP CHAMBER:_(locate on site plan) ; Pumps in working order(yes or no): NO "} Alarms in working order(yestor no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): n/a f t , I F - R Page 9 of I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 22 LINDEN LANE OSTERVILLE,MA 02655 Owner: ORBISON Date of Inspection: 6/5/02 SOIL ABSORPTION SYSTEM.(SAS):. X (locate on site plan,excavation not required) If SAS not located explain why: s n/a Type n/a leaching pits, number: n/a n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a 6' X 6 BLOCK CESSPOOL ,, overflow cesspool, number: n/a s::innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): OVERFLOW IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.OVERFLOW WAS EMPTY AT TIME OF INSPECTION.STAIN LINES INDICATE OVERFLOW HAS NEVER BEEN MORE THAN 3/4 FULL. BOTTOM IS AT 8'. CESSPOOLS: (cesspool must be`puanped as,part of inspection)(locate on site plan) Number and configuration: n/a I '' Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a i Depth of scum layer: n/a Dimensions of cesspool: n/a r. Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil',signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs;of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a ,s i a ' Page 10 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ,,. SYSTEM INFORMATION(continued) Property Address: 22 LINDEN LANE OSTERVILLE,MA 02655 Owner: ORBISON Date of Inspection: 6/5/02 .z ti SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. pd o PA n; i n ` Page I I of I 1 -y OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 22 LINDEN LANE OSTERVILLE, MA 02655 Owner: ORBISON Date of Inspection: 6/5/02 ' SITE EXAM a :6{.t 1 4• Slope �p _Surface water _Check cellar + I Shallow wells .f, t Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation:., NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators,,installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the"lligh ground water elevation: HAND AUGER- 12+FT. 7 ' t r1 j L i i e t' * �6 5.4 a Tw BENCHMARK SOIL TEST °,: TOP OF FOUNDATION 20 FT. MINIMUM FROM CELLAR "r ELEV. )I�� 10 FT. MINIMUM 10 FT. MINIMUM FROM SLAB OR CRAWL SPACE I CLEAN SAND DATE OF SOIL TEST (ASSUMED) -*— CONCRETE SOIL TEST DONE BY _ Apt - _ A COVERS LOAM AND SEED _` __F =,� ': �rrt` �� 4" SCHEDULE 40 PVC PIPE WITNESSED BY w. ,. , MIN, PITCH 1/8" PER FT. OF _` 7' ''� -a \ z" LAYER 1/8" TO 1/22 " OBSERVATION HOLE 1 ELEV.= ` t� \ V� ? ' PERCOLATION RATE _ <_ __ MIN./INCH AT __ _ INCHES ` WASHED STONE — 4• CAST IRON PIPE NOTTREQUIRED DEPTH HORIZ TEXTURE COLOR MOTT. OTHER " ..- 'M `'°}�, 'O"� ` (OR EQUAL) MINIMUM I rr PITCH 1/4' PER FT. 1 CU. FT. OF ry n CONCRETE - - s-�� ; -- ! �. -- - 1 l.�t ? '�r .' . L�� ANCHOR g _.,r FLOW LINE j' r ° IjC _� �j*� L.✓� > �..,.i+r'`F" t'( s P. •� 10" y?.. ELEV. i MIN. /{ o j ...I t �r: � >« •• _ s r' µ- \' _ ~( .• 0., IN-! _ J Y FC b- LEVEL o G �o o� - EL V. ,je �a�o`Sa�4 0 00 o,Y.. GAS 5 6" SUMP ELEV. :~ 4t1- w 'x, i �Dfc rir; .v4x+ ELEV. ELEV. _ �. - _ �»� 1 r A, BAFFLE NO WATER ENCOUNTERED AT _�` ` ELEV. - _ r +� tr r r DISTRIBUTION tw- JL tf 1.. 1�I�t ;LJOUID OUTLET DEPTH TEE (TO BE PLACED ON FIRM BASE) B CAPALr1Y NZ 1RAJA4S M/1H S 4 FEET 14 INCHES TO BE WATER TESTED wy AN *X, ,11 novoy ftmmmv 5 FEET 19 INCHES 1500 GALLON IF MORE THAN ONE OUTLET TO h WELLf� NOT FOR ZONING I PLANNING USE 6 FEET 24 INCHES PLACED ON FIRM BASE) SOIL ABSORPTION 7 FEET 29 INCHES ( BELA ZONE _ 8 FEET 34 INCHES SEPTIC TANK 3/4" TO 1 1/2" CLEAN SYSTEM (SAS) INDEX DOUBLE WASHED STONE ADJUST FREE OF FINES do SILT / / _ 0 �� 1 USGS PROBABLE WATER TA LE ELEV. _ j ,, /"'\/ � _ _ - - _ _ SEWAGE DISPOSAL SYSTEM PROFILE OBSERVED WATER TABLE ( _f ' ) ELEV. _ _ /`�` NOT TO SCALE BOTTOM OF TEST HOLE ELEV. _ _ 101.55� 1 99.39 `ksq NOTES: 1. ALL\ / WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. TITLE S `� T.Q.F.=100.C 93.68 �Q�Y G� Z. �� AND THE TOWN RULES AND REGULATIONS FOR THE SUBSURFACE DISPOS Gl " 98 98 �' OF SEWAGE. 2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT T'_� WITHIN 6" OF I \ r/'" FINISHED GRADE. 3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL 8E CAPABLE. OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS. 4. ANY MASONRY UNITS USED TO BRING COVERS TO GRADE SHALL BE DESIGN CALCULATIONS ,r MORTARED IN PLACE. 8.34 .5 �� $ O . f 5. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED I NUMBER OF BEDROOMS OR ZONING REGULATIONS. OWNER / APPLICANT IS TO OBTAIN SUCH . r — r r — r r r — r —► �8 �,t„ r ;5�+ GARBAGE DISPOSAL UNIT DETERMINATION FROM APPROPRIATE AUTHORITY. 46 r xr{ TOTAL ESTIMATED FLOW a ►P A _� �i e{ 6. UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCAVATION CONTRACTOR > « ( 110 GAL /bR./DAY X at) a GAL./DAY IS TO CALL "DIG-SAFE" AT 1-888-344-7233 AT LEAST 72 HOURS 8.89 II ' REQUIRED SEPTIC TANK CAPACITY I GAL. PRIOR TO COMMENCING WORK ON SITE. �t I ACTUAL SIZE OF SEPTIC TANK 'I GAL. 7. CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL AS 501E CLASSIFICATION SITE CONDITIONS PRIOR TO COMMENCING WORK ON SITE. ANY DESIGN PERCOLATION RATE < 5 MIN./IN.EFFLUENT LOADING RATE VARIATION IS TO BE BROUGHT TO THE ATTENTION OF THE DESIGN I - p.74 ENGINEER IMMEDIATELY. LEACHING AREA 30. FT. g PARCEL IS IN FLOOD ZONE - C � 9. LOT IS SHOWN ON ASSESSORS MAP _1�t__ AS PARCEL LEACHING CAPACITY (AREA X RATE) GAL./DAY \ ? 7' I 9350 GAL. DAY RESERVE LEACHING CAPACITY / .57 o .-* - t,�' TAN'rA e , . ►, ` �^ , DAIGNEAULT 1'� JAIS'SMUO-Z) -Z� C6 jCYu � J Vo. 1095 o , r; ,; S�,rSTE APPROVED: BOARD OF HEALTH 8j 1 \ a C ,i�.r`I"• gNITA N 99 SS W { I_ �{r1Vx" („ >4 t Q'. ' DATE AGENT TEE � �.,� .�,� f��..-.�' � B�NST��, Ass PROPOSED SEPTIC DESIGN _ ! (OS TER VILLE) FOR / \D f - ORSINSON I s' / 30 71 - o PROj: 22 LINDEN LN, LOT 2 n 93,98BARNS TA"B.L,.E, MASS. \Z I O S TE FR V,'L E�) �;• -�;�0000 / 9386 �F� ! o� OAK ! T NTAL CONSULTANT gloss _ TADCO EN 'IR01vME 26 OMPA,S SANE, DENNIS, MA �J263 96.75 ��1/ - �� _ I oy I i (508) 385-2425 LEGEND: EXISTING SPOT ELEvATION %0.0 I r--_- 8 EX:STING CONTOUR - --00---- DATE ' SCALE 1 (� � l j Co 9k� }/ _�� i FINAL SPOT ELEVATION 0( ��0 o I ---1 FINAL CONTOUR —�QG ___— ---, SO±L TEST LOCATION 'I'W SA97 REv'SF✓ JOB N0. } - UTILITY POLE �� � I � 4t�f� --� Q3a TOWN WATER W W I - / t CATCH BASIN 95 REVISED 9, C LOCATIC MAP I SHEET 1 OF 1 lg \ 10.j.11" �ESSPOU� P CLEANOUT --e C C. C: I S9 I PROJ 12909-OC 1 dwg 12909-SAS.PhiS 0 2C06- TAIDCG