Loading...
HomeMy WebLinkAbout0338 MAIN STREET (OST.) - Health 3381_ "Ma'in Street It Osterville P ` l ,r,L_ `1'65 '0300 r I a o o i M ISM A,1- v�.s fi��'^ TOWN C AR2�iSTABL. y. /'v►;f S 3 �" W. Y1LIAGF� S �'�U l� ASSESSOR'S A►iAP�b.QT 7AFSTAi.LER'� tAl�tE&PRONE N SBPT'IG TA iK CAFAdtl {507� LEACfIING EACH ' t ) �Ld✓ri Lj�rj (sszel .SDI NO OFBF.I3taONiS EVILQF, t OR OWi�tER IRATDATE C{31��TANCE°BATE: Separation Distaz►cc Between Ebe MaxtnaumAdjusteclGroundwat�xTableto theBoCtom ofLeacfiengFaM,Ity Feee' ti MCI Wall�uid).eac2ung Pasil�ty tf aayre1ls ex�xt on�s�te ar.v�nttun?A�feet of leaching far.�icy) Test: Edgeof Wetland and I.eachrngacty(If aiy wetlands exist vnttua�3tl(1 feet o teaehm fa«lrty} Fw7us4ed.by` P Eil® , -I- 04 , 6 ,i- /36 TOWN 4 �JAYtT�ISTABI/.E U 17 ;:,� LO�A'f'LON 33 Yit.IAGF �°!' ��II e� �A.SSESSOR�`NiAP�bOT INSTALLER`g IAA L�PHONE Yv4 S61yIZC TA'�IK CAFAOITY �._�.. �0 'I �Ae�r�Nc�Acl •t � �� �- cs��i l D v y� � :: NO OFBEDROOPJIS TO.�`� BUIIDISR,OR OWT*tER PERI�TDATE • C{)1V�i'LIAAlCE DATE: Sepazanon Distance Betw.,cn Ebe MaxunumAdjnsted GroandwaterTabletothe Bottom of I.eanhtngFaGility Fee€ Pnvate�4tatar Supply Well andLeachmg Baetlity (f auy wift exss€ at seta of. at�un?Atf feet of leacw fat ty) Feet': Edge:of V►lettand and�Leadung 1"�a�ty(if any wetlands exist vnttun 3U0 feet €�Ieaaluns facnlitj►) J � ' Feet I p3 y (� /� 3- J,3` To 0 030 Commonwealth of Massachusetts + �,_► ' '°' a= Title 5 Official Inspection .Forte EF ,., il-I Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments -Tv 811 338 Main St (System 1 of 2 Front System)er + i . ; {'_ + J Property Address 1.9 Fred Ryan + Owner Owner's Name m_;i ,. information is u required for every Osterville ;,_A .i MA 02655 10-28-17: page. City/Town State Zip Code Date of Inspection j* ` _ . . . a .R Inspection results must be submitted on this form. Inspection formsf may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information "/.200 ' t ... 1: Inspector: ° r r*, t <6, t + ,. "Shawn Mcelroy Name of Inspector Upper Cape Septic Service Company Name P.O, Box 73 Ali, + _ A� �� :�.s. :�- k.-... 4 irr+:'a-' .+:, Company Address E. Falmouth MA 02536` ' City/Town State Zip Code a 1.508-495-0905 S13971 Telephone Number License Number B. Certification �,� ; certify that l have personally inspected the-sewage disposal system at this°address'and that the ° +c 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 15.006).The system: "``��"" ► ` ,' r ' `} �` ``� "`� `- . ®, Passes;3 ❑ Conditionally Passes;: ; �,❑. Failst , ( At �q, �' �!' Y.;'r en -r ^'.i, �.t�^� � �»%'.ate : t• .i .< .� ,� •• ❑ ;Needs°Fu E I n by°the1ocal Approving Authority, '..•P 3yt. t `r t4#' t `"t r 4 i r ' �� w''f c d;pF' !>f `` a t 10-28-17,, Inspector's Signature° '° + LL' ` ' '"' bate' The system inspector shall submit alcopy of thls inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd'or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 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.doa•rev.6/16 �' i Title 5 Official Ins ection Form:Subsurface Sewage Disposal System• 1 7 ,� Page of 1 P 9 P Y 9 Commonwealth of Massachusetts '- � Title 5 Official Inspection Form 1a=1 f� " , �� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 338'Main St (System 1 of 2 Front System) Property Address Fred Ryan Owner Owner's Name information is required for every Ostefville ' MA 02655 10-28-17 " 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:. '1" ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 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): rt t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts - :a=1 Title 5 Official Inspection Form W Subsurface Sewage Disposal.System Form,-Not.for Voluntary Assessments 338 Main St (System 1 of 2 Front System) Property Address [ ' Fred Ryan ' 1 Owner Owner's Name information is r required for every Osterville MA 02655 10-28-17 page. City/Town • e State Zip Code Date of Inspection B. Certification (cont.) f•r_ , El 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 inthe 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): . ,�. .. .� • i,. r.-!. .. A :. K.� ••'tea �''. _..."., , ❑ broken pipes) are replaced ❑ Y' CQ 'N ❑ ,ND (Explain below): El obstruction is removed _ ❑hY `❑ W -❑ *ND (Explain below): .- ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): r .,:r , e;a :fa""� -. y q .�:, Y r k+;• ° ' t .i - +u, �,§ r •, .i ( 7 !> ., f,'i :-e ...l:i i - .f•xt'., {a' ,, 'r:,a.: ' ."!' �li 4'!f.�. .=#"v.a-, _ ,. ! •' C, # 9 ❑ 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:4t, rr'. ,• _n ,�„'. ❑ 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. System will"pass-unless Board ofHealth determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a mannerwhich will protect public health, `§afety 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17' Commonwealth of Massachusetts la} Title 5 Official Inspection Form ' 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 338 Main St (System 1 of 2 Front System), Property Address Fred Ryan Owner Owner's Name information is required for every Osterville MA 02655 10-28-17 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: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 I Commonwealth of Massachusetts. a,I f Title 5 Official Inspection Foem' 13 Subsurface Sewage Disposal System Form:_z Not for Voluntary,Assessments 338 Main St (System 1 of 2 Front System) r . Property Address Fred Ryan tri; Owner Owner's Name ; information is required for every Ostefville a; tir «,: MA 02655 10-28-17-5i a" page. City/Town I State Zip Code Date of Inspection .. B. Certification (cont.) 'Yes:-t No - •;� .,..+. i+ ►5.,.�e ;r ' :3. >r r:c'L C. :, ..fie, .yJt. �::,�.'�t f . ' f ., «a•:.t:, El ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s), Number of times pumped: r0 jq® r )IAny,portion of,the SAS, cesspool or privy is below high'dround 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 prnv'y is within 50 feet of a private water supply well. .r,..:. r❑ ., • An!,t,y portion of 6 ,s7 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 i +nf%, system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence r-��• 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.] ❑ T ® The system is{a cesspool serving Fa facility with a design flow of 2000gpd- " 10,000gpd. The system fails.') have determiried that one or more of the above failure "❑'" ® rf criterid exist as described•in 316 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., ; ' '. . t�*.' .1 Sa '�'. ii.3�� .�f .m �.1 •5'a• ,. �.: ;,r,��",r�rF�rY f' ., ,- .rf,. " 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• _ ri ..f• ..� r• .. rl ttE'r •� - .. . ^. . .. � .. t^` t.� J ,r :For large systems, you must indicate,either"yes",or,"no"to each of the following, in addition to the f •questions in Section D:, ,,. Yes No 1❑ 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.doc-rev.6/16 ,, _- + Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form =Not for Voluntary Assessments 338 Main St (System 1 of 2 Front System) i Property Address Fred Ryan Owner Owner's Name information is Osterville MA 02655 10-28-17 required for every _ page. City/Town 1 State Zip Code Date of Inspection C. Checklist e Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No - i ® Pumping information was provided b the owner, occupant, or Board of Health p 9 P Y P , ❑ ® 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 f ❑ ® this inspection? ® Were as built plans of,the system obtained and examined? (If they were not of ' available note as,N/A) " ® ❑ t Was the facility or dwelling inspected for signs of sewage back up? '® ❑ ' Was the site inspected for signs of break out? ., • 4 ' f .� t 1 t ® ❑ 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, k dimensions, depth of liquid, depth of sludge and depth of scum? ® ' El 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: , t 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 II . t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts r -a. Title 5 Official I nspection•• o-rm' n ,-II Subsurface Sewage Disposal System Form Not for Voluntary Assessments,.._ a. ..'t.r' a� ;�_;;!✓ 338 Main St (System 1 of 2 Front System) Property Address Fred Ryan Owner Owner's Name information is OSteNllle +; , r ` required for every MA 02655 10-28=17 page. City/Town State Zip Code Date of Inspection D. System Information Description: , Number of current residents: - 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection, r, El Yes No information in this report.) Laundry system inspected? ' t. ,;t,, ; ❑ Yes ® No ` Seasonal use? ,, , ,_ �, « �. -,,_ ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): :; crf •,; •' .P, f Detail: • ,� tr1: T� is (' ., r.f- , 'a". .. r e.•=w: — •. Sump pump?,;=,.} El Yes ® No Last date of occupancy: {, , ., ,,., Unknown Date Commercial/industrial Flow Conditions: 11 Type of Establishment: .Design.flow(based on:310 CMR,,15.203): .,� �M Gallons per day(gpd) - Basis.of.design flow(seats/persons/sgft:,•etc.):, - 1� Grease trap present?. },o n ;; ,. -J • ❑ Yes ❑ No Industrial waste holding tank present?- i ' ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev..6/16, . Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ia=1 j�s �+ -1l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ��.p.�,.:✓ 338 Main St (System 1 of 2 Front System) Property Address Fred Ryan Owner Owner's Name information is Osterville MA 02655 10-28-17 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: r Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection form �11�1 Subsurface Sewage Disposal System Form--Not for Voluntary Assessments 338 Main St (System 1 of 2 Front System) '0 { ,.t: -' r� r .j ° *� Property Address 1 Fred Ryan Owner Owner's Name information is ;;; • *,. required for every Ostenrille ':.; MA 02655 10-28-17t 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: 2002 Were sewage odors detected when arriving at the site? . .A,=,�• , ,,;❑ Yes ® No Building Sewer(locate on site plan):-;f 24" Depth below grade: it, : �, '.. :� . r '�" , _ 'feet Material of Construction: ® cast iron `{ 40 ' ' '' ottier;(explain):' ® PVC ❑ Distance from private'wafer supply well or suction line: feet Comments (on condition of joints,-venting, evidence of leakage, etc.): Good cond tion. Septic Tank(locate on site plan): 18" Depth below grade: feet' '" Material of construction: i •,,. ,:., 440 ® concrete ❑ metal ❑ fiberglass ❑.polyethylene.:,'rw« ❑ other(explain) [!,�'. -,� �f '! t'"' ): { ,{ �h:r• _, ,c.t _.. _a �� any • If tank is metal, list age: years' Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) r:a!❑ Yes ❑ No r Dimensions: 1500 gal Sludge depth: 12" t5ins.doc.rev.5116 »_+. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts f Title 5 Official . Inspection -Foem ��I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 338 Main St (System 1 of 2 Front System) Property Address Fred Ryan Owner Owner's Name information is OSteNllle required for every MA 02655 10-28-17 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 20" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle ° 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet•invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts r .1 .a=1 Title 5 Official Inspectiori - Form - I Subsurface Sewage Disposal System Form,.-Not.for Vol u ntary,Assessments 338 Main St (System 1 of 2 Front System)!:, Property Address r - Fred Ryan ° Owner Owner's Name information is required for every Ostefville MA 02655 10-28-17,:a„f 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:):"', ' r � 6.. 4�..'7, I• IZ 'a#.r. T..r.' r,�, l r _ 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 t Design Flow:, s. ; f. I f 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.doc•rev.6/16' Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form hI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `.f+ 338 Main St (System 1 of 2 Front System) + Property Address Fred Ryan Owner Owner's Name information is required for every Osterville MA 02655 10-28-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) - • �£ Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from field. 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.doc-rev,6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts -,r, , 1. : =1 l� Title 5 Official Inspection Form -,1 Subsurface Sewage Disposal System Form='Not for Voluntary Assessments 338 Main St (System 1 of 2 Front System) Property Address r Fred Ryan %r Owner Owner's Name - ter• information is required for every Osterville { MA 02655 10-28-17 . page. City/Town State Zip Code Date of Inspection D. System Information (cost.) .t ;•� rr t ,. fi4 i1,.. .t4 x' `r',tf rfa':,r.,7 e. J : i ,� `'7 it,u Type: leaching pits number: ® leaching chambers number: 3-500's ❑ leaching galleries number: ❑ leaching trenches - number, length: ❑ leaching fields number; dimensions:t% ❑ overflow cesspool ',.number:. 5 .. ❑ 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 chambers in good condition and empty at inspection with no visible stain lines. 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.doc-rev.6116 < Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 338 Main St (System 1 of 2 Front System) Property Address Fred Ryan Owner .Owner's Name information is required for every Osterville MA 02655 10-28-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) , Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 :& Commonwealth of Massachusetts :+ f� Title 5 Official Inspection Form ' . I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a r 338 Main St (System 1 of 2 Front System) Property Address Fred Ryan " Owner Owner's Name ' information is ill tOserve 4 r ' required for every MA 02655 10-28-17 , page. City/Town ;. State Zip Code Date of Inspection D. System Information (cont.) a i. , �•. 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 separatelyTj 1's ' '',r"`• -� - •�i1::; 1 !. e:+". '!; .•.7r t� ,r.. •r_r a� t_ a+ - t+'r . - "' _w i r - �(w ".Ji� s � /� _.�'�,:n'. i i _�'f .�:^Y. r�1�' •,1r. I fa r 1 - 19 y ,,,+ 1 ter■ 'i�' .r.a•Y •'.1 i fib x, sgi,) ia....fir} re'+7 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts 1a=1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 338 Main St (System 1 of 2 Front System), Property Address Fred Ryan Owner Owner's Name information is Osterville MA 02655 10-28-17 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ` ❑ Surface water r ❑ Check cellar ❑ Shallow wells ' Estimated depth to high ground water: 12' feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record . If checked, date of design plan reviewed:, Date ® Observed site (abutting property/observation hole within 150 feet of SAS) 112 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: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form N Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 338 Main St (System 1 of 2 Front System) Property Address Fred Ryan Owner Owner's Name information is OSterville MA 02655 10-28-17 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspect;on 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts �l,I&S 63 Title 5 Official, Inspection Form. ' ,.lI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments;:� :�>>• ' ;�• CID I 338 Main St (System 2 of 2 Back System) L J' Property Address Fred Ryan r Owner Owner's Name information is Osterville '✓ t "-.. MA 02655 10-28-17•- "`' required for every State ZipCode Date of Inspection page, City/Town . . , - p iv Inspection results must be submitted on this form. Inspection for•m`sxmay not be altered in Ay way. Please see completeness checklist.at the end of the form. A. General Information �. ,r."j.t Inspector:..e. !., , M . i,z, ,.t:,I' .."s'`j't'.P ..s rF;�, o S� 't),+ :.r.i .. 4`n� •tx+r('' ; c •:s, Shawn Mcelroy ,{. 1 r� t Name of Inspector Upper Cape Septic Service Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected.the-sewage disposal system at this address and that the t 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 16.340 of ' Title,5 (310 CMR 16.000).The system: ®. Passes t ;• � , a� ,,, Conditionally Passes,. • .� El, Fails _ r.. i • . •-j• - L, , r! , ' r*y 0:;W ,by thelLocal Approving Authority. - rfj tt a +a-' •,t N ' ;- i�, ). r 't.,, '�f !3 _:. t ' ' , 10-28-17.. Inspector's Signature` " Date The system inspector shall submit alcopy'ofthis-inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of.the DEP. The original 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.doc•rev.6116 - , Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 • Commonwealth of Massachusetts ' Title 5 Official Inspection Fora + lf;�I Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments 338 Main St (System 2 of 2 Back System) Property Address Fred Ryan R Owner Owner's Name information is required for every Osterville - MA 02655 10-28-17 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: System is in good working order with no sign of failure. i B) System Conditionally Passes: F ❑ 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 • Commonwealth of Massachusetts ;, � .p Title 5 Official Inspection' Ford. �I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments,r,,t+�e+j .6 338 Main St (System 2 of 2 Back System) Property Address Fred Ryan , Owner Owner's Name information is , required for every Osterville, r MA 02655 10-28-17.-t- ' 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: "# �. 1. ; 21,0 ;.t� f f�: ° ' . B) System Conditionally Passes (cont.): ;, : ,Y;,. t, t• ;,. , ❑� 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 "f' ' . - • pass inspection if(with approval of Board of Health): ' El broken,p$e(s) are're'placed'-`= Y f'❑ N''�❑i ND (Explain below): ❑` obstruction is removed 't° �;1• t , El-,Y »❑f N.,-❑-NDT(Explain below): ❑ distribution box is leveled or replaced- ❑rY� t❑ N' "E]`ND"(Explain below): r + 1 ' 1 � s. f•` - 4` • ;.:'•� i•y;F. r,rr air :i�: ,: 9.1, ,. r,...a. r :. 5. ,•. .tr T ❑ 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 0 N ❑ ND (Explain below): ❑ obstruction,is removed ❑ Y ❑ N ❑ ND (Explain below): .7 is �G ' • -r; �- ;c.. t" i,.. I- ... ,.. ,i.r 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:Sysstem 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, A ' ;i`' '`'safety andthe environment: ;t r a, ❑ - Cesspool or privy is within150 feet of a surface water f f' - _ ❑'A Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16, _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 t Commonwealth of Massachusetts a=1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments o% 338 Main St (System 2 of 2 Back System) Property Address Fred Ryan Owner Owner's Name information is required for every Osterville _ MA 02655 10-28-17 f 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 an_d 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 El ® 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.doc rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts - :a=i Title 5 Official Inspection .Form . 1 I, Subsurface Sewage Disposal System Form -Not for Voluntary,Assessmentst 4�. ! 338 Main St (System 2 of 2 Back System) r. - ;� �.� - r s Property Address 4 , Fred Ryan Owner Owner's Name ,r information is Osterville r' MA 02655 10-28-17 required for every - page. City/Town A State Zip Code Date of Inspection B. Certification (cont.) jry r: Yes?: .No . ' .... E] ® Required pumping more than 4 times in the lass 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. 0 ' " ® `"_ Any portion'of'a cesspool or privy is within 50 feet of a private water supply well. y ❑ ® - t 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 t .v 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 r and chain of custody,must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000gpd- ❑ ®, 10,000jpd. ` Ttie system fails.I have determined'th_at one or more of the above failure ' E] f® '`criteria exist as'described in 316 CMR 15.303,therefore the system fails. The $1,4, system owner should contact the Board of Health to determine what will be necessary to correct the failure:. , ,, V t r ' • 1 _ i , i S �'a r'e_ L ' �= i '�. . •a i-.II: _•A� 'l�,. E) Large Systems: To be considered a large system4he system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. .f. .. r^.. SA.I..F .x 4 .sett L� , • . . • • / .♦ , tyli. _ r i For large.systems, you must indicate either `yes",or"no"to each of the following, in addition to the questions!in Section D. ty Yes No b ❑ v ❑ the system is within 400 feet of a surface"dunking 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 El ' ' 0= 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts �a} Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,!a 338 Main St (System 2 of 2 Back System) Property Address Fred Ryan Owner Owner's Name information is required for every Ostefville MA 02655 10-28-17 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? ® ❑ 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? a ® ❑ 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts r • Y Title 5 OfficialIrispection Form ' Subsurface Sewage Disposal System Form Not for Voluntary,Assessments �.s,��• `� 338 Main St (System 2 of 2 Back System) Property Address Fred Ryan Owner Owner's Name information is Ostefville ;t required for every MA . 02655 10-28-17,. page. City/Town t. State Zip Code Date of Inspection y D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ,1.,, El Yes ® No information in this report.) `.. . ''`'- Laundry system inspected? 7, ,. ; Err. ❑ Yes 0 No Seasonal use? + , y• r, t + f . ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail Sump pump?,j� ,c1; .. , (� 011Ff r ,{; El Yes ® No Last date of occupancy: Unknown Date Commercial/Industrial Flow Conditions: R,< ,+ ,• ) " Type of Establishment: 9 t_, Design flow (based on,310 CMR+15:203): f +"M Gallons per day(gpd)` Basis of design flow_ (seats/persons/sq.ft.;:,etc.): -_,,• -: Grease trap present?.! 0:,) °'� i= , , , ❑ Yes ❑ No Industrial waste holding tank present?, " e," ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6/16 T Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Ian Title 5 Official Inspection Form ' 'f.;I Subsurface Sewage Disposal System Form Not for Voluntary Assessments � 338 Main St (System 2 of 2 Back System) Property Address Fred Ryan Owner Owner's Name information is Osterville MA 02655 10-28-17 required for every ' page. City/Town , State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information } Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts I-7, f Title 5 Official Inspection- Form` , ' 'RI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t°-.;*h F)_ ;_�:J,!✓ 338 Main St (System 2 of 2 Back System) Property Address ± - Fred Ryan Owner Owner's Name information is required for every Ostefville _ ,,J MA 02655 10-28-17.:. 1 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source.ofl information: 1980's • Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site,plan): ; + k• ; : : Depth bellow'grade: P . c, . . tE. ..� ., ,. 3011 feet' Material of construction: ® cast iron ® 40 PVC" 'f'"❑'other(explain)FR Distance from private water supply well or suction liner feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: ' s 18"feet'' Material of construction: , c4 ® concrete ❑ metal ❑ fiberglass ,,,❑f polyethylene• ❑ other(explain) If tank is metal, list age: yearn' Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal-H-20 12" Sludge depth: t5ins.doc•rev.6/16 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 338 Main St (System 2 of 2 Back System) Property Address Fred Ryan + Owner Owner's Name information is required for every Osterville MA 02655 10-28-17 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 20" Scum thickness 0 - Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? r Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 f Commonwealth of Massachusetts :+ f Title 5 Official Irispection Foem Subsurface Sewage Disposal System Form,-Not for Voluntary Assessments q PIt frt4 7 338 Main St (System 2 of 2 Back System) Property Address , Fred Ryan ,.ram; Owner Owner's Name „r information is required for every Osterville : = MA 02655 10-28-17,,Y�, : page. City/Town - State Zip Code Date of Inspection , D. System Information (cont.) .y• ,, w Y a `_ *� Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert;'evidence of leakage, etc.) - _ ♦` r sr ' Yr. .^4.` .fir t• a.1 ,.•k ' k.. &�.. .� Y , .,` 1 L- .,. T '... ...♦ ,_.. i {' .. . _5 a f�,. •>. I Y.f-1: Y,1. I "'.YYLY� IR • :h, .f ai.+ 'w Yt. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth be'ow grade: Material of construction: - - ❑ concrete ❑ metal ❑ fiberglass M ❑ polyethylene ❑ other(explain): Dimensions: ,•, <.:.:. , , , Capacity • gallons Design Flow. `Y r f; - .r ; 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.): `C ',...-)s fi• .. IY; .' 41.I J :.•,, .t .it.` .' .V i..i.. r .r , - • . ;' .� u. .... . asp . ..a. *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins.doc-rev.6116. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17- Commonwealth of Massachusetts rr Title 5 Official- Inspection-- Form �5I Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments U f}!a 338 Main St (System 2 of 2 Back System) ? - Property Address Fred Ryan Owner Owner's Name information is required for every Osterville MA 02655 10-28-17 page. City/Town - State Zip Code Date of Inspection D. System Information (cost.) Distribution Box (if present must be opened)F(locate on site plan): ,. . Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from pit. 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: rr t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 f • Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form ' ,.W-1 Subsurface Sewage Disposal System Form Not for Voluntary Assessments r4 't`v,.1� 338 Main St (System 2 of 2 Back System) Property Address y , Fred Ryan Owner Owner's Name ; information is required for every Osteryille ,f "" t : MA 02655 10-28 17 page. City/Town - 1; State Zip Code Date of Inspection D. System Information (cont.) 'Type. ® leaching pits number: 1-600 gal ❑ leaching chambers number: ❑• leaching galleries number: r ❑ leaching trenches number, length: ❑ leaching fields .number,dimensions:,. , ❑ overflow cesspool number:,,- 1, t 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 in good condition and empty at inspection with stain line at 18" off bottom of pit. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): j 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.doc•rev.6/16. - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts ' .a=1 Title 5 Official Inspection Form ' ' ��w� Subsurface Sewage Disposal System Form Not for Voluntary Assessments � 338 Main St (System 2 of 2 Back System) Property Address Fred Ryan Owner Owner's Name information is required for every Osterville MA 02655 10-28-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate'on site plan): P Materials of construction: Dimensions Depth of solids Comments.(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts . - 1++ f Title 5 Official Inspection.T drm Subsurface Sewage Disposal System Form -Not for,Voluntary,Assessments.#, W. �!a 338 Main St (System 2 of 2 Back System) Property Address Fred Ryan r#,r r �;:�'I Owner Owner's Namec information is OSterville �. ':a`.w` F required for every MA 02655 10-28-17 � page. City/Town .' ,¢ State Zip Code Date of Inspection D. System Information (cont.) Sketch Of,Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells'witfiin 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 Y" 4jl' "- 'ij lt4 j �.. z E Aft �� .r"e*'s+.i�"�L ��.x1 f, d�..�,fi»+}���`s +S •nu 4 F s°*Gfd��+�„��fSt¢ ��s •''�'„�:`.LAi�;r«'s45�`.k����s. - - ' i 4 ` EE. `.�` ;+� d t.,fit`' , •(' � .�1u,r. ..ta.}. '3 `s{6,�' ."#t+�rt'�rl�"�F,r�1k`a• :'�y�#`.� , ..ls'°°#s�'�,,.,g� 'r,i�''�*'..���+°� � elf ) t ^.f ➢.r .k� y!� e°`.s p t# S f �' #3 4.- i &±. ... a - �•1 & {' #�f:ciL 1�+r t �{'�a•94�tie 1 f� 4,a 7. 1: e-..?,°t .�1y+'l�/}f- E" t't'�k'": ,i,�"is1,`-..0 :e.i/ ".• �:.ab/ - - � ��►► • I j - ! rwrrr�s �sr�• s � sr— '���l�;t 6 k'�..:" ., ��l ��j'� { d"='1.�.� I6�E :ip Ft f�• n r � 1 F , 3 V a' t5ins.doc•rev.6/1.6 r " a Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 } r Commonwealth of Massachusetts a=� Title 5 Official Inspection, Fora T a' 0-1 Subsurface Sewage Disposal System Form-Not for,Voluntary Assessments ' 338 Main St (System 2 of 2 Back System) r Property Address Fred Ryan Owner Owner's Name information is required for every Osterville` MA 02655 10-28=17 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: 12' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on'record If checked, date of design plan reviewed: 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: Design plans for front system show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 f Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form W.", Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 338 Main St (System 2 of 2 Back System) Property Address Fred Ryan Owner Owner's Name information is required for every Osterville MA 02655 10-28-17 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page'15 or attached in separate file J t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 t1 `T a. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ,i DEPARTMENT OF ENVIRONMENTAL PROTECTION co , _.. i TITLE 5 = OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASS SSMF7NTW SUBSURFACE SEWAGE DISPOSAL SYSTEM FO10, C' M PART A CERTIFICATION P Property Address: 338 Main Street(Front S sty ens) RCCL G Osterville,MA 02655 T " Owner's Name: John Fallon Owner's Address: Date of Inspection: February 17, 2005 Name of Inspector: (Please Print) James M. Ford Company Name:' James M.Ford Mailing.Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT 1 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 Needs Further Evaluation by the Local Approving Authority Fails Inspector's .Signature: Date: February 21, 2005 The system inspector sha\suba 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. Notes and Comments ""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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 338 Main Street(Front System) Osterville, MA Owner: John Fallon Date of Inspection: February 17, 2005 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup.or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 338 Main Street(Front System) Osterville, MA Owner: John Fallon Date of Inspectioa: February 17, 2005 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. T-ie system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. Tae system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. T-ie system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private wafer supply well". Method used to determine distance "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. 3. Other: 3 r Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 338 Main Street(Front System) Osterville: MA Owner: John Fallon Date of Inspection: February 17, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"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 ✓ 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 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.] No (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 fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow 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 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 338 Main Street(Front System) Osterville. MA Owner: John Fallon Date of Inspections February 17, 2005 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: Yes No 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(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 338 Main Street(Front System) Osterville, MA Owner: John Fallon Date of Inspection: February 17 2005 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 4 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n/a [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)): 2003-460 000 gals.•2004-no reading Qals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,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 Source of information. Never umped-per owner Was system pumped as part of the inspection(yes or no): 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed on 4111102=per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 338 Main Street(Front System) Osterville, MA Owner: John Fallon Date of Inspection: February 17, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: P' (locate on site plan) Depth below grade: 15" Material of construction: ✓ concrete _metal _fiberglass _polyethylene other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1500 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: Measuring stick 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 were present The liquid level was even with the outlet invert. There did not appear to be any signs of leakage. GREASE TRAP: None (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: Date of last pumping: Continents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 338 Main Street(Front System) Osterville, MA Owner: John Fallon Date of Inspection:: February 17, 2005 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): . I Alarm level: Alarm in working order(yes or no): : Date of last pumpin;: 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: Even 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.): The D-box was level and clean No solids were present PUMP CHAMBER: None (locate on site plan) 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.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 338 Main Street(Front System) Osterville. MA Owner: John Fallon Date of Inspection: February 17, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 3 dryvells(12'10"x 33'6')-per as built card 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.): The leach field was dry and clean There did not appear to be any signs of failure. CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 338 Main Street(Front System) Osterville, MA Owner: John Fallon Date of Inspection: February 17, 2005 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. P+ 15 3 O A� 13c- 3 o 3 O Y 3Y a� 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 338 Main Street(Front System) Osterville, MA Owner: John Fallon Date of Inspection: February 17, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 45 +/- feet Please indicate(chick)all methods used to determine the high ground water elevation: Obtained From system design plans on record-If checked,date of design plan reviewed: Observed:site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable `opographic and water contours maps the maps were showing approximately 45'+1-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarante=s, either expressed, written or implied,relating to the system, the inspection and/or this report. 11 l COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS f DEPARTMENT OF ENVIRONMENTAL PROTECTION ^; C ir> co r C) r TITLE 5 ; OFFICIAL-INSPECTION FORM-NOT FOR VOLUNTARY ASS SSMENTSPE SUBSURFACE SEWAGE DISPOSAL SYSTEM FO C M PART A CERTIFICATION Property Address: 338 Main Street(Back Svstem) Osterville, MA 02655 Owner's Name: John Fallon -ARCEl. �0 _ Owner's Address: Date of Inspection: February 17, 2005 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 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 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 Needs rther Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: February 21, 2005 The system inspector shall sub ' 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. Notes and Comments ****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. Title 5 Inspection Form 6/15i2000 page 1 Page 2 of 11 ;. OFFICIAL INSPECTION FORMi-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 338 Main Street(Back Swim) tem) Osterville. MA Owner: John Fallon Date of Inspection: February 17. 2005 i Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: i. ✓ 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. t Comments: I B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the i for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed r distribution box is leveled or replaced ND explain: The system required,pumping more than 4 times{a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: t I 2 i Page 3 of 11 OFFICIAL INSPECTION FORM!-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A. CERTIFICATION (continued) Property Address: 338 Main Street(Back Svstern) Osterville, MA Owner: John Fallon 1 Date of Inspection: February 17, 2005 I 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 i i 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: i The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface wat.-r 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. I The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,!performed at a DEP certified laboratory, for coliform bacteria 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. i i 3. Other: i i i i 3 i i Page 4 of 11 OFFICIAL INSPECTION FORM!-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 338 Main Street(Back System) Osterville, MA Owner: John Fallon Date of Inspection: February 17, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: i Yes No ✓ Backup of sewage into facility-or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to thei surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped— G ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. " ✓ Ai y 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 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.] i No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as de.3cribed 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 System: To be considered a large system the system must serve a facility with a design flow 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 additionto the criteria above) 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 j 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 and--r 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. i i 4 I Page 5 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 338 Main Street(Back System) . Osterville.MA Owner: John Fallon Date of Inspection: February 17, 2005 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: Yes No ✓ _ 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(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 338 Main Street(Back System) Osterville, MA Owner: John Fallon Date of Inspection: February 17, 2005 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 4 ' Does residence have a garbage grinder(yes or no): I Yes Is laundry on a separate sewage system(yes or no)::, n/a [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)): 2003 460,000 gals.:2004-no reading gals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 systeni.(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping.Records Source of information: Pumped in 2001 -per owner Was system pumped as part of the inspection(yes or no): 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Date of installation unknown Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C }SYSTEM INFORMATION(continued) Property Address: 338 Main Street(Back Svstem) Osterville, MA Owner: John Fallon Date of Inspection: February 17, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 21" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain), If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 100.0 Qal. (H-20) Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 5" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10 How were dimensions determined: Measuring stick 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 were present. The liquid level was even with the outlet invert There did not appear to be any signs of leakage GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of iscum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date 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.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 338 Main Street(Back System) Osterville, MA Owner: John Fallon Date of Inspection: February 17, 2005 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: J (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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.): The D-box was level. No solids were present. PUMP CHAMBER: None (locate on site plan) 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.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 338 Main Street(Back System) Osterville. MA Owner: John Fallon Date of Inspection: February 17, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: _I-4'x 6'(600 gal)with 3'stone leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching f_elds,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.): The leach nit had T'ofliauid on the bottom. The scum line was at the same level There did not appear to be any igns offailure CESSPOOLS: None (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 grounewater inflow(yes or no): Comments (note.condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 r - LL Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: _ 338 Main Street(Back System) Osterville, MA Owner: John Fallon Date of Inspection: February 17, 2005 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. A (3A2� ®� O O A3 3 ao O 3 314 yo 10 c. Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 338 Main Street(Back System) Osterville. MA Owner: John Fallon Date of Inspection: February 17, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 45+/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observes site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: UsingBarnstable to o ra hic and water contours ma s the ma s were showing a roximatel 45'+/-to round water at this — pg B p p Spp v g site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied,relating to the system, the inspection and/or this report. 11 -� TOWN OF BARNSTABLE 6C V A P-.oN 3 39- IM)4 S �" SEWAGE # 4 LAGE �Sf P•k'lls�i� ASSESSOR'S / MAP & LOT -O3 INSTALLER'S NAME&PHONE NO. iCdlS� i' SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ��/ �/r2o� S (size) /07I4 NO. OF BEDROOMS BUILDER OR OWNER ©� PERMIT DATE: / _COMPLIANCE DATE: II U Separation Distance Between Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i Frmi 00 J Esc 33' ,P p(f Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: r Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYicatton for loizpaal 6p.5tem Conztruction Permit Application fora Permit to Ccnstruct( )Repair j(Qb-�-Upgrade(V)"Abandon( ) ❑Complete System O Individual Components Location Address or Lot No.338 MAIN 5T. Owner's Name,Address and Tel.No. 0STERV1LLF., Allk 3011N TALON Assessor's Map/Parcel ►Te5 03U 338 MAIN SIT. OSTEKV1ll.E, Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. SVct_tUAN EN6liqu miff � P.O.13px to59, 9 Y =G'KVILLG,MA 50%-'Q -334y Type of Building: Dwelling No.of Bedrooms y Lot Size 1.4(n AC, sq.ft. Garbage Grinder WU Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow yS5 gallons per day. Calculated daily flow 1440 gallons. Plan Date IYW IR. ZOo 1 Number of sheets 1 Revision Date — Title SITE RL04 1QOPOSETA �,�TI C�RRDt Size of Septic Tank ISCO 64& Type of S.A.S.3-5oD 6A- LEAthW6 C. MKaR.S W A 12'-io'3L39'-V AEA Description of Soil: 0-te A j)b&X Rkow)J- SAMbj Laky'-N tb R DA k yEuowtStl BRow�J r-rik SE swb , sta-�b C1. myeT YEt1 CoA Q SAND 10-RO' C2 OWE 4EQ00 RME 5WS_-> Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees o 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 Certifi- cate of Compliance has been issued by Board of Health Signed Y-�4v-, Date Z I O-L Application Approved by Date 10 2� Application Disapproved for the following reasons Permit No. 1 H Date Issued GG k I ' No. 6p A Fee { _ -Entered computer:d i THE COMMONWEALTH OF MA SACHUSETTS — Yes _, PUBLIC HEALTH DIVISION -TOWN OF"BARNSTABLE, MASSACHUSETTS 0(ppYication for Migpogal *pztem-�lCon�truction errntt- Application for a Permit to Construct( . )Repair(-Upgrade(V)Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.3 316 M A,N S 1. Owner's Name,Address and Tel.No. OSTERVIL.LF. slit\ 30NN FALLON o Ts$ 1"1AY N 51. Assessor's Map/Parcel (-,5 0 3D OSZ E RV I LLC� ,Y 1+l Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ttLetL-y (Ao,sv �U<.L1t\/AN E/V0NCEPIN& �J10 Ste. P.0. t3ox tv 5'1, 3 y 0516RVIt,I.E.01A ro`d Ll-e 44 l �,.. e. ^16 4 Type of Building: Dwelling No.of Bedrooms y Lot Size I.4(a A(.. sq.ft. Garbage Grinder WC)) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow H 5 S gallons per day. Calculated daily flow q4 b gallons. .Plan Date N0 18, Zoo 1 Number of sheets i Revision Date -- Title SITE ?(.AiJ _ (j`0 k,6 `E:. T Q�6RkbE Size of Septic Tank ISb) C,A%,, + Type of S.A.S. 3-5013 toAL. CrAWktJ6 0*111;LKS W _ A iZ'-to" Description of Soil 0-16' A DANK RROwu SIWI&/ l 4iy ilk-EC ►2, DNRK kIElL0Wk�1:A1 GROWo COR1SE swt) %-16' C 1 bu e YEuoL.). COA(LSE 'sWb .10-RU" CZ OWE `IEk-WO EkME 1 AW7 �. 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 Certifi- cate of Compliance has been issued by!nard of ealth Signed ,. �-�^ l'�.,,�.] Date Application Approved by. 0 ' �1• Date QU'l Application Disapproved for the following reasons Permit No. QC)b 1- D�( � Date Issued c)1 THE COMMONWEALTH OF MASSACHUSETTS _ BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERT that the On-sit a Sewage Disposal System Constructed( )Repaired( )Upgraded Abandoned( )by %-\k e-`C~` Gw IV at 3 3 2) MN\) ) <\. O!S'K W►l l.,L has been constructe4 in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.1Q0/_(off dated " 5 C) Installer Designer The issuance of this permit shall not be construed as a guarantee that the sys willtfunction as d signed. Date �• Inspectors 4,J v A ^� No. UU�' V�gy Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS lwi5poal *p!5tem Construction Permit Permission is hereby granted to Construct( )Repair( )Upgrade( V )Abandon( ) System located at 33 23 N N\.N SL Q�STE.SW tLl-G and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this t. Date: t�U 'U-2 Ya f`4 f Approved by TOWN OF BARNSTABLE 6C LOCATION 33,� SEWAGE # VILLAGE dI4f — 'Vl I ASSESSOR'S MAP & LOT "0 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /sue LEACHING FACILITY: (type) ' r / (size) Z �� X NO. OF BEDROOMS BUILDER OR OWNER PERMIT DATE:_ COMPLIANCE DATE: /�� a S 0 Separation Distance Between th Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility,(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by , i F-0 A 00 c6 ` plop COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS j DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 338 Main Street Osterville, MA 02655 SYSTEM#1-FRONT YARD Owner's Name: John Fallon Owner's Address: Same RECEIVED Date of Inspection: April 14, 2001 MAY ® 8 2001 Name of Inspector: (Please Print) James M. Ford ABLE Company Name: James M. Ford TOWN OF BARNST HEALTH DEPT.. Mailing Address: P.O. Box 49 Osterville,MA 02655-0049 Map: 165 Telephone Number: (508) 862-9400 Parcel: 030 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 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 N her Evaluation by the Local Approving Authority Fa is Inspector's Signature: Date: April 17, 2001 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 Y P g P . the inspector and the stem owner shall submit the report to the appropriate regional office of the d orgreater, sy gP P 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 ****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. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 338 Main Street Osterville, MA Owner: John Fallon Date of Inspection: April 14 2001 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined";please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): _ broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 338 Main Street 4 Osterville, AM Owner: John Fallon Date of Inspection: April 14, 2001 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh „ 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria 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. 3. Other: i 4` 3 . Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 338 Main Street Osterville, MA Owner: John Fallon Date of Inspection: April 14 2001 D. System Failure Criteria applicable to all systems: You must indicate either`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 '/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ 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 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.] No (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 fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: 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 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 338 Main Street Osterville, AM Owner: John Fallon Date of Inspection: April 14, 2001 a 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? M ✓ 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 ofthe 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. ✓ 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(3)(b)]. 5 . r Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 338 Main Street Osterville, MA Owner: John Fallon Date of Inspection: April 14, 2001 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 3 Does residence have a garbage grinder(yes or no): Yes 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)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/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 Source of information: Pumped two years a-go-per owner Was system pumped as part of the inspection(yes or no): 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Unknown Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 338 Main Street Osterville. AM , Owner: John Fallon Date of Inspection: April 14, 2001 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line:. 3 Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 22" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: !" Distance from top of sludge to bottom of outlet tee or baffle: 31" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet Levert,evidence of leakage,etc.): The tees were present The liquid level was even with the outlet invert. There were no signs of leakage. Recommend instal'ing risers to bring covers within 6"ofgraik GREASE TRAP: None (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: Date 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.): 7 ' P Page 8 of l 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 338 Main Street Osterville, MA Owner: John Fallon Date of Inspection: April 14 2001 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None (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: None (locate on site plan) 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.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 338 Main Street Osterville, MA Owner: John Fallon Date of Inspection: April 14, 2001 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: 1 Type ✓ leaching pits,number: 4'x 6'w/3'stone(hand probed) leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: - Innovative/alternative system Typetname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The leach pit had 6"of water on the bottom The scum line was 1'up from the bottom. There were no signs offailure. The bottom to grade was approximately 7' The cover was 20"below frade ' CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 4 9 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 338 Main Street Osterville, MA Owner: John Fallon Date of Inspection: April 14, 2001 Map: 165 Parcel. 030 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. SYSTEM#1-FRONT YARD A A g► - a3 Aa- O A3 - Sy e g3- 3a 3 O 10 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 338 Main Street Osterville, AM Owner: John Fallon Date of Inspection: April 14, 2001 SITE EXAM Slope Surface water v Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: The bottom ofthe leach pit to grade was approximately 7' Using the Barnstable topographic map and the Cape Cod Commission water contours map the maps were showing approximately 45'+/-to groundwater at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied, relating to the system, the inspection andlor this report. 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 338 Main Street Osterville, MA 02655 SYSTEM#2-BACK YARD Owner's Name: John Fallon Owner's Address: Same Date of Inspection: April 14, 2001 F Name of Inspector:(Please Print) James M. Ford Company Name: James M.'Ford �® Mailing Address: P.O. Box 49 qY Osterville.MA 02655-0049 aPT � 8?�0 Telephone Number: (508)862-9400 Par 6q Ty FATrga�F CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information rep 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 Needs Further Evaluation by the Local Approving Authority Fa' Inspector's Signature: Date: April 17, 2001 The system inspector shall subTZpy co 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. Notes and Comments ****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. Title 5 Inspection Fotm 6/15/2000 page i Page 2 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 338 Main Street Osterville, AM Owner: John Fallon Date of Inspection: April 14 2001 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 338 Main Street ; Osterville, AM Owner: John Fallon Date of Inspection: April 14, 2001 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. ` f 1. System will pass unless Board of Health determines in accordance with 310 CAM 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: d. . Cesspool or privy is within 50 feet of a surface water _I Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines-that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria 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. 3. Other: r 3 1 Page 4 of l l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 338 Main Street Osterville, MA Owner: John Fallon Date of Inspection: April 14 2001 ' D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No _ ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow ✓ 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 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.] No (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 fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow 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 _ 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 338 Main Street Osterville, AM Owner: John Fallon Date of Inspection: April 14, 2001 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: Yes No ✓ _ 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(3)(b)]. a r { 1 Page 6 of i l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 338 Main Street Osterville, MA Owner: John Fallon Date of Inspection: April 14, 2001 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 3 Does residence have a garbage grinder(yes or no): Yes 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)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COIVIA'IERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/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 Source of information: Pumped two years ago-per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: Qallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box, soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Unknown Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 338 Main Street Osterville, AM Owner: John Fallon Date of Inspection: April 14, 2001 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 21" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. (H20) Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 31" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): The tees were present The liquid level was even with the outlet invert There were no signs of leakage. Recommend installing risers to bring covers up to grade in the driveway, GREASE TRAP: None (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: Date 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.): 7 r �1 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 338 Main Street Osterville, AM Owner: John Fallon Date of Inspection: April 14 2001 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: Not Found (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: None (locate on site plan) 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.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 338 Main Street Osterville, AM ' Owner: John Fallon Date of Inspection: April 14, 2001 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 4'x 6'w/3'stone(hand probed) 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.): The leach pit had 6"of water on the bottom. The scum line was ]'up from the bottom. There were no signs offailure. The bottom to grade was approximately 8'. Recommend installing risers to bring cover up to grade in the driveway. CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 338 Main Street Osterville, AM Owner: John Fallon. Date of Inspection: April 14 2001 Map: 165 Parcel. 030 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. SYSTEM#2-BACK YARD �AL 0 O 3 y Aa — 1 c,' Ba- 'PO A3- 3y (o 63- y0� O 3 br W WAS 10 r Page 11 of i l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 338 Main Street Osterville, AM Owner: John Fallon Date of Inspection: April 14, 2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: The bottom ofthe leach pit to grade was approximately 8'. Using the Barnstable topographic map and the Cape Cod Commission water contours map the maps were showing approximately 45'+/-to groundwater at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed written or implied, relating to the system, the inspection andlor this report. 11 PROPERTY ADDRESS:_-33-8_LILin_S.i`r-€e-t-_______ Osterville,Mass . 02655 ------------------------ On the above date, I Inspected the septic system at the above address. This system consists of the following: i A. 1 -H2O 1500 gallon septic tank. B. 1 -109-0-_:gallon septic tank. I C. 2-distribution boxes. D. 2-4 ' leaching pits. Based on my inspection, I certify the following conditions: A.,-This is a title five septic system ( 78 Code ) B. The septic system is in proper working order .at the present time. I I SIGNATURE• Name:_1 p Mar omhp-L jr ------ i Company: J.P_Macomber & Son Inc. Address:_Rox_66__ Centerville,Mass__02632 Phone: 508-775_3338-___--___ THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY o J CP OSEPH P. MACOMBER & SON, INC. Tanks-Cesspools-Leachfields ? Pumped & Installed oD � •'"' • Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775.3338 775-6412 S c cs 6 r RONALD J. CADILLAC, PLSI RS Land Surveyor & Sanitarian page 1 Box 258, W. Yarmouth, MA 02673 (508) 775-9700 SUBSURFACE SENVAGE DISPOSAL SYSTEM INSPECTIOIi FORM Address of property 339 e2 J/. , Owner's name (and/or resident) /Zc6,5W Date of Inspection S PART A CHECKLIST Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Healt /Il�Ul e h o� None of the system components have been pumped for at least 30 days and the system has been receiving normal flow rates during that period. Large volumes ON Iurne weds of'water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained. s v The facility or dwelling was inspected for signs of sewage back-up. P The site was inspected for signs of breakout. 1� All system components, excluding the SAS, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the sep tic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the SAS on the site has been determined ba sed on existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. page 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential number of bedrooms Z. number of current residents ��5 garbage grinder, yes or no y1b laundry connected to system, yes or no F seasonal use, yes or no If nonresidential, calculated floe: Water meter readings, if available: See #A G eG0 l Last date of occupancy GENERAL INFORMATION `A -Inping records and source of information: n S'e a c tied �o �O V0 System pumped as part of inspection, yes or no if yes, volume pumped 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) Other (explain) Approximate age of all components. Date installed, if known. Source of information: ? SAIJ Aa dLLIL7- — 0 8 6, %c/a �b Sewage'odors detected when arriving at the site, yes or no F page 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORAIATION continued SEPTIC TANK: (locate on site plan) /�depth below grade: material of construction: v_concrete metal _FRP _other(explatn) dimensions: �U /�D J N L sludge depth distance from top, of sludge to bottom of outlet tee or baffle scum thickness r distance from top of scum to top of outlet tee or baffle /JoVe �� -� CD ze�i�c�?� 70�' ZZ `� distance from bottom of scum to bottom of outlet tee or baffle ,i y Comments: (recommendation for pumping, condition of inlet and outlet.tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence m of leakage, recomendations for repairs, etc.)/ / T LA Ile, DISTRIBUTION BOX:�5 ------- (locate on site plan) depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc,) page 3 B SUBSURFACE SENVAGE DISPOSAL SYSTEM INSPECTION FOR-1%I PART B -_ SYSTEM INFORMATION continued SEPTIC TANK: Y15-S (locate on site plan) depth below grade: material of construction: /concrete metal FRP other(explain) dimensions: � �- 3'' sludge depth �ZN 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 Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to, outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc.) e2� — /20 9a)1,7 42 DISTRIBUTION BOX,:�FS (locate on site plan) Ny depth of liquid level above cutlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc.) D/G page 4 A PUMP CHAMBER: h0 f S ate on site plan) pumps in worki g order, yes or no Comments: (note condition of purr chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc.) SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type leaching pits and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc.) a I-1A zj ee SG/J7 n . page 4 B PUMP CHAMBER: ate on site plan) _S Szr'7�1 pumps in working, order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc.) SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type leaching pits and number ��:,�� T leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc.) e �1 L(� GC�lJ PY [�� 7� C.t_J/Tn• O l-1 ee Page 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued CESSPOOLS: (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc.) rimM n 1' d J -o,.0 aj c'f T&9 C A- ,►4 PRIVY: {�1� (locate on site plan) materials of cons ruction dimensions depth of solids Comments: (note condition of s il, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations maintenance or rep irs,etc.) page 6 I} SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.N7 PART B SYSTEM INFOR]IATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: XEn2 SY JT�wt include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' ?iT 1 N-Zo . 1 4 ) pi DEPTH TO GROUNDWATER (,,depth to groundwater method of determination or approximation: 0 N p.9 (�B page 6 8 SUBSURFACE SENVAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: 7 include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' N D LUJ4E! � I N A' �z ��` 747b�l _ PST �of 7, S pow,v 3 DEPTH TO GROUNDWATER OS6J 6r, T41FV• 28 , t 1 _ � t depth to groundwater .�o �m lam'" o 19,7- 7 3 27 method of determination or approximation: 6roap W,99� btl-- —. � s � Page 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not) /00 Backup of sewage into facility? Lo Discharge or ponding of effluent to the surface of the ground or surface waters? /Uo Static liquid level in the distribution box above outlet invert? bo Liquid depth in cesspool <6" .below invert or available volume< 1/2 day flow? NO Pumped 4 times or more in the last year? number of times pumped — Vo Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: bO below the high groundwater elevation? Vo within 50 feet of a surface water? No within 100 feet of a surface water supply or tributary to a surface water supply? Y No within a Zone I of a public well? NO within SO feet of a bordering vegetated wetland or salt marsh? within SO feet of a private water supply well? vv less than 100 feet but greater than SO feet from a private water supply well with no acceptable i analysis? P water quart} If the well has as been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate to nitrogen. i G page 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector Ronald J. Cadillac Inspector Number Registered Sanitarian No. 1060 Company Name Ronald J. Cadillac, PLS, RS Company Address Box 258, W. Yarmouth, MA 02673 (508) 775-9700 Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. Check one: I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15.303. Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. _ I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15.303. The basis for this determination is rovided in the FAILURE CRITERIA section of this form. Inspector's Signature Date JY 5 Original to system owner Copies to: Buyer (if applicable) proving authority 05/25/1995 13:49 506-428-3508 0.-.0.MM. WATER DEPT PAGE 02 KEY NUMBER <700 > NAME <REGAN, STEPHEN, C > B-C 1 B-C 2 STREET 9 KINGSWOOD ROAD $-C 3 B-C 4 CITY NEWTON ST 14A ZIP 02166-1013 REF 1 REF 2 PHONE ( 617 ) 965-1082 REF 3 REF 4 METER N0.< 20> DATE READING CONS STREET <MAIN ST NO. 338> 12/31/94 106 75 CITY OST 0 ST LOC 06/30/94 31 17 PHONE ( } - 12/31/93 14 59 ROUTE NUMBER 11 10/06/93 0 010�06/93 1341 45 SERVICE DATE 03/26/43 0630/93 1296 11 METER DATE 10/06/93 12/31/92 1285 20 CAPACITY 7 06/30/92 1265 8 STYLE T10 SIZE 1 RATE SCHEDULE KEY PIT PLASTIC NOTE RR RIGHT SIDE ADDITIONAL CONS 0 ALTERNATE MIN 0 ,r -- TOWN OF ARNSTABLE LOCATION 3�J SEWAGE ,$ VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER FUIT DER OR OwwFR DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: +�orad srd� ✓4 sP a TOWN OF BARNSTABLE vA ,�,��� 5-i- ga�k �� 'I'OCATION SEWAGE # VILLAGE O ST(v& ASSESSOR'S MAP & LOT I C�S 030 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /OM GA. 14-aO LEACHING FACILITY: (type) �� (size) L�x 3� �►� NO.OF BEDROOMS (t! BUILDER OR OWNER —70k/� �A)I01r\ PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility.(If any wetlands exist within 300 feet of leaching facility) I� Feet Furnished by Ford Se jG /ts '6� /ti Loo l 4 Ai- PIP +a Aa- +co co ao" AS- 3y,'�* z,- Sys+;tm c TOWN OF BARNSTABLE LOCATION 0 1�fa�✓1 �- SEWAGE # 'VILLAGE 0S"re(Vi�� ASSESSOR'S MAP& LOT ��S 03D INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1 UW GA). LEACHING FACILITY: (type) T (size) yX(o ' 3,S OAk NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) J_ Feet Furbished by r Ss T.G 1 rt S/ec��an Y �Al aatI 019 A 1 93 - a3 Aa- 3ti 132- ay'�•' Fon,' , , la " o �� AS- �- 3a MAIA w S Sf�M r • y TOWN OF BA:RNSTABLE LOCATION M Ain SEWAGE # VILLAGE 0 ASSESSOR'S MAP & LOT �6 0 3 0 Y INSTALLER'S NAME&PHONE NO. rr SEPTIC TANK CAPACITY CJlrO I� 'a d LEACHING FACILITY: (type) �'T ��6� (size) NO.OF BEDROOMS BUILDER OR OWNER T�'� PAI I c^ PERMTTDATE; COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted,Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching Lfacility) l Feet Furnished by �r1&Q U'Un �01 a�'►/6,� A' �AU� lo O T a RO ao 0 3 3 31 yo TOWN OF BARNSTABLE LOCATION M/ I,n �' SEWAGE #:QUO G VILLAGE O STt,f Vi h ASSESSOR'S MAP & LOT 6 Z 010 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �UO LEACHING FACILITY: (type) 3 (size) �/0�,x 33� (��• NO.OF BEDROOMS BUILDER OR OWNER PERMPTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching.Facility(If any wetlands exist witlin;300 feet of leac ng facility) Feet Furnished by n S�G t, t on _r'0 rC' i f I a i 3 o 3 a Y ASSESSORS MAP N0: f� No....I — 6 PARCEL NO: ........................---------------- ........z:.. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .......---°... ..'.O F........ /'� �$_ije.................................... Applirution for Uhipwial Work�To $�`u iuu rruti# Application is hereby made for a Permit to Construct ( ) orepair ( ) an Individual Sewage Disposal System at: Say/--- 04 `�--.-.. .s .. _- - =.. : ' ..............................................r ........................... Location•Address or Lot No. p f Address4. a Installer Address Q Type of Building Size Lot../°. ...... U Dwelling—No. of Bedrooms----.__—--.--_-.--•-----------------Expansion Attic ( Garbage Grinder A Other—Type of Building . No. of persons......_`................... Showers — Cafeteria aOther5xtures ........................................:.............•----•----•-•. .._....---•-------•------. Desi n Flow.... .................................... allons er erson e da . Total d '1 flow.��® ° -?° _� --gallons. W g �r �e��� g P P ;",r d y y���3'., ,. WSeptic Tank—Liquid capacityi� _..gallons Length._/e/...... Width__-�.�_._._. Diameter-_._-_ ...... Depth.__.._.. x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. _ -_ . Diameter.._..__.1v2 Depth below inlet..- __rs_..' Total leaching area_��//9 s ft. � Seepage Pit No.------ - - -- ------- �Pe,� -- •---• g -=f--- --•--- 9• Z. Other Distribution box (j4 Dosing t k V1 �. Percolation Test Results Performed by...��( _..�.1�'��._.. •_......... Date..../�7� .=. ._.__.. minutes er inch Depth of Test Pit...... Depth to round water ?./d/ .-'I1, Test Pit No. 1_...___��..-_--- P P � --------- P g /� '---- �-� (z, Test Pit No. 2.......Zt,...minutes per inch Depth of.Test Pit-----/��...... Depth to ground water........................ •----...••-•-•................................................................................................... Description.of Soil.....= •. ���'??__.Y._ �.. .21......•--••-•• ..............................................................................••... W ...................................... .-�14 1.129..----...✓"P-_h .........-•---•---•••......-••---....._ W ----------------------------------------•---•---••-------------------•-------.._....--•----------••--•-••---------------------.-----•••-----•-•-•••-••-•------••------••------..........._.......•----- VNature of Repairs or Alterations—Answer when applicable................................................................................................ ...................-•-----•....................•--......----•-•---------------------_.._.._...........•---•--•-----•-------••-•-•-••-••--•-•-----•------•---•--....._...-•-•..........---••--•--...... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iI'= 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has en issued y the board h . Signed., f - � .. - Date Application Approved BY--------•a'nz 7—i . ............................................................. Application Disapproved for the f of ing reasons-----------------------•-------------.------------------------------------- .................Date•---•---...--- ..................................•••-------------•_......._.------------.........--•-••-•.._--------.....---------------•-------•---------------------- ---------- ------- - -------- -- - Date Permit No.._: -)' _SZ� ------ Issued....--•---•--------------- ......... . ......... ......... Date 2_1 No.... Fimic............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .Oq le.. . ................... .....................0 F........ . ........ Appliration for Disposal Works Tonstrurtion Prrmit Application is hereby made for a Permit to Construct 'or Aepair an Individual Sewage Disposal System 4 e­� .. 0 3 .......3 . .. A­�_/­ ...... ... /11V­ .�....L) ....................... .... . .......................................................................... Location-Address or Lot No. ............................. ...... ... t Address -------- ---------------- ­ ------ -------- ---------------------------------------------------------- I------------------------ Ow f .. .........00­ Installer Address CA Type of Building Size s Garbage Grinder Dwelling—No. of Bedrooms....../----------------------------------Expan. ion Attic P4 Other—Type of Building ---------_----__------- No. of persons............................ Showers = Cafeteria P4Other fixtures ........................................................................................................ Design Flow..../ .......__gallons. .......­.................f�c.......gallons per person her day. Total daily flow.m 1:4 Septic Tank—Liquid capacitygallons Length Width.............. Diameter-_--_....... Depth.4U....... W irm_ ­;`V---------- Disposal Trench—No.------_---_----- Width_....____....___._._ Total Length.........._......,.._ Total leaching area....................sq. f t. Seepage Pit No........4......... Diameter.._....- Depth below ......... Total leaching area."/1 _191...sq. ft. Z Other Distribution box (Vol Dosing t nk Percolation Test Results Performed by...*.,. ............ .... ......... Date__ /007 n.w;w........ 7......... .. Test Pit No. I......X.....minutes per inch Depth of Test Pit-----le�....... Depth to ground wate]Vdt..AW4,00 Test Pit No. 2.......Z-...-niinutes per inch Depth of Test Pit......�X...... Depth to *ground water........................ ---------- ..............0 Z. ............... ------------------------------------------------------"---------------------4 /.. ..............A..................................................................................Description of Soil­&�'t�.�.. t..�__- W ..................................... .......... -------_--_- ------------------------------ ----------- ---- -------------------- U ...............I........................................................................................................ ................................................................................ U Nature of Repairs or Alterations—Answer when applicable............I................................................................................... ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system V� " th ystem in operation until a Certificate of Compliance has been issued b;y th board, .1i �e.44 V S, .. . ..... igned.- .. ....... ....................... Date Application Approved By.._.. .... . ......... ... 4.n.g....... ....................................--------------------- ....................D a.t e ------------- 10 i Application Disapproved for the fo reasons:................................................................................................................ .....................................................................................................................................................................................I................... Date Permit ....................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......... OF...... ................................ ...... (9rdifirate of Tontpliattrr THIS TO CERTLFY, That the Individual Sewage Disposal System constructed Or Repaired by---------------- .............. ......................................................................................................................... Install ............I ........................................at......3 .......... ......... --------------_------- has been.installed in accordance with the provisions of TITTF 5 Gf The State Sanitary Code as described in the K .57� 7).application for Disposal Works Construction Permit No—P 1-— 111-111-11-1-- lb ............. 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 ( !.........OF ...oc", ..................................................... FEE. ................... Disposa Nor s Tonstrurtion "trutit 0r Permission is hereby granted........ ... ............ ...... --------------------------------------------------------------------- !n4dividual Sewa IT, em to Construct 0C) or Repair an I. . .......... M-46 UL)Z p�os at No..2.3..1. "+�JJ........... ------------------------- --------- ------------ ....... Street as shown on the application for Dispbsal Works Construction Per it No.fl:: -Dated....... ...... ............. .......... . - - ------------------------------------ DATE............. .............. B66rd !��l ........................... ......................... FORM 1255 HOBBS & WARREN. INC., PUBLISHERS As-Built `' Page 1 of 2 TOWN OF BARNSTABLE LOCATION 33,57 SEWAGE # (� - VILLAGEA / ASSESSOR'S MAP& LOT INSTALLER'S NAME & PHONE NO. b !(>YQYI d yZrf=;35 a SEPTIC TANK CAPACITY / .(Sbd "Z LEACHING FACILITY:(type) r 0 (sfze) (9/we2z e4 NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER U �G BUILDER OR OWNER )4A]',Pf R !eT OwAe r DATE PERMIT ISSUED: 6-'p26 --('7 DATE .COMPLIANCE ISSUED: S- )Li - SS 2 VARIANCE GRANTED: Yes No / 1i� � f use http://issgl2/intranetipropdata/prebuilt.aspx?mappar=l65030&seq=1 10/11/2017 TOWN OF BARNSTABLE LOCATION .3 G�%r� u SEWAGE # -VILLAGEAl/e/Ville- ASSESSOR'S MAP & LOT :INSTALLER'S NAME & PHONE NO., oy SEPTIC TANK CAPACITY LEACHING FACILITY(type / y' (size) b1WQal Ca . NO. OF BEDROOMS PRIVATE `WELL OR PUBLIC WATER U �G BUILDER OR OWNER 4"A Te 9J/ e DATE PERMIT ISSUED: DATE .COMPLIANCE ISSUED: S' - IL, VARIANCE GRANTED: Yes No �� v � 1 4 i l � J 1 _ i �11 vS� l .I 4-1 MS-�r: �edro0m C:. Z U g ,moo X 170 meat I cn ! Pa,! c t 7 5c -- —!n- 9 i 00 I yam•,,,.. - I •i I I ----------------- � I I I I � I I � 44 I I. ct I ► � I 1 . i l II I � Q•.k ii hl.l t w cn Q I � I i 1 . —— -- -- --- - O I� 03 a 4-1 2 OI I c 00 •� I I �I ti I I , 1 � j . •s �tAw t. A xt5T1.1.2 tic.:C .zS G�D4.r1 �o J3 C S?tiG.G -i ?��+1-t'G(Q t= ►--t~E C{ �h1 t 5 4><c;� v' . t 07 b= 444 U-n L1 t 1 e25 IFT-k0 E-704. b i cp ,_�. 46 9 r - zr - N Zx1wTS) 7DMt5 LATA LET Y �C1s i►��5 ►tit t ASUtZ _ ugg A: -tt Y Cx�sntiit� 5`t� � Td 3r Y - _,,Fg OT,u !\ld r„e�, �l ttW �j-- �3 M w iT�� Iwo i=xts�l�E, SY>i S !`� ��" 46 6 : 3385,Mla,li �, Z?Gr ��.111pCk, #2 t:;)A1 LY FLCW I i o k 5C /o,cQ 66U 4g.ov''� : , 4-7- =��' > .0 �Ai. =ra r.�i� --sirs,-�:� i •�...� : ► k,�zr+�� , — `. 471. I� �4t._ � 5,tsr�-rri 2 .�r+�,.{ 1<, � 46.to 1b!5 two 5 'PIT � Use % ! - _ - . .: ..�?j � ,G7.4Ot...R�t=� F_,r?�..t-'t'S'(ST�7�s ,,` ...._ .9_5• 9-._ .4 z, L 4b. woo Z ZCo I- =1a= LAMJO N �"T"t F"t N Z M1 N ©� �- P rt R G: :• -F':�2rjt'a i2 -ZZ-81^o S SULLivAllJ 2 L GO fJo ��73� -'. 1, . Q,GG.-::+5. .►Z a ..vR!�.T31 ._�2..''_Cr C .Y_5.1 ►-+�._' .. '�o �F�s >r `'a- gG,2. �5�Er1n' Svc�M I o �QN,a�EN I d d L-7 = '4 8�(�. 5%(SiE+nn 2: . - 42•-7 G ao q„ 5c t�'• SST, t Nt/ GOAL• �t3,�. 44, FIT WI Y` L u ��( TH 37 TANK, I NV i 10,to wjnw\ � r 5'TaNE.. �` �t�,/ �9•$ SyS�µ I - 1� CAA L 3 �'' 3 . . �.1• s'rs a�.L - rx�o �� C '1 O7' Eb,O �7 3 38 Scac�Ty. F u ST j L.� 1J0 C.h�LE - i1A� f t }�a�t�.a.. : . ER. - lzYEjr t _ '• TQ. ti .00 I C©. r . , I '•� l �.1 �� ' '' t i 1. .., ! ! ' t s ►$1•r S H O v 0 0 0 -P n1 O Dog Pen v uo ASSESSORS REF.: 0-----0---_. Map 165, Parcel 30 OVERLAY DISTRICT.• AP — Aquifer Protection District A w s Shown on Plan Entitled "Revised Groundwater Protection Overlay Districts" — -April, 1993 ZONE: 1 RC (Resource Protection Overlay District) Area (min.) 87,120 SF Fronts a (min) 20' Width min) 125' 9. 4' Setbacks: Fron t 20' Side 10' Rear 10' 1 ' sty w/f Garage FLOOD ZONE: y, Zon e C Community Panel No. � #250001 00016 D July 2, 1992 \ 6 _ 0 WNER: I ,-+- (u' I\ John T. Jr. & Patrice B. F'611on � r 338 Main Street C.n i 1 Osterville MA 02655 C_ ) X- I I � oo C) z / N n, ,l \ 00 Existing(oprox) Septic System Cb Cb I . I I I I � I 17.8' \ I Cb i \ Cb L-OT S Z L ,- 1.Li(o SAC. Q� \ I I _I N) v 5 9can NOTES I _ T to - ELE •• �� 2 sty w/f � EST HOLE. Water Supply ForThis Lot is Municipal Water PROPOSED DEPTH• 0 4 ' v 1.W PP Y \ I A LAYER 0Y � I �3/3 Are Apprax. ADDTITON i D well in g 2 Location of utilities Shown on This hEw ton For i \ I DARK BRowN At Least 72 Hours Prior to Any 4-' 338 I I io" SANDY Lc�AM ►I5:2 Project The Contractor Shall Make The Required _ / B LAYER 10YR y/(e Notification to Dig Safe(I 8 88 ]] I 3. The Contractor is Required to Sec Constrpuction tee DhRK YEII.DWISN SRN. Permits From Town Agencies I COARSE SAND Defined byThis Plan. ' to Within 12� of � ( I sb 41.3, 4: Install Risers as Required ,. I C1 LAYER 2 5Y (ofij Finished Grade. ( OLIVE Y6CLOW 5.All Structures Buried Four Feet or More or Subiect �'j�••.: •• I i Vehicular Traffic lobe H-20 Loading. ••.,• •- I I COAK5F SAND to -- �eep xis i g(aprox)�':' � I I �0 40.Z' & Septic System to be Instal ledin Accordance With — t► System CZ LA`l�R 2.5Y(o�(� 310 CMR 15.00 Latest Revision And The TownofI I OLIVE YFt-Low Barnstable Board of Health Regulations tO 7. All Piping lobe Sch.40 PVC. 0 ;`NOTE'Existing Septic Syst''' I I FINE SAND to be Removed I I PROPOSED I I SEPTIC SYSTEM I I Ito W "'E 3c� DESIGN DATA 4 Bedrooms 12. 4' i Daily Flow=440 GPD Septic Tank:440 GPO x 200%=980 GPD Use 1500 Gallon Septic Tank is 0 a tZ=to' I I Leachi�a T 440 GPDF0.74=595 SF Required Sidewall=2(12.83'+33.512=185 SF Bottom Area-12.83'x 33.5'-430 SF 615 SF Totol Provided 3- ' Leaching Chamber Design CBID H All Pipes to be Schedule 40.Use 10� W ` s-500 Leachk*Chambers in a Fn d s 8 •�s'2 " 0 5r 1"-- 23'-te-Washed Stone Field as Shown 1 D .23' Brick Walk 18 J0 Asphalt _ _Walk ._._— Brick rifii"tij 1 t 76.97 9 5,35' S 81 .50 , VI/,10, Edge of Pavement Flnish Grade Y�k YX YX yl��Yllx Fabric 'Compacted Fill •N AA Pea Stoll Tw F.G. q C F.G. y(�' Leaching Li nn Chamber N Double Washed Ei 3.z Stone EL. 4. 1500 Galion Top El. q4.f EL:44 OF Septic Tank Et•43.8 Bot.El. 41. ' �J F ��N y c�::� Z - 12'-10" Note:If Encountered Remove&Replace RICH str� p _ r., ,�..:. EL 3. •4' All Unsuitable Soils Within 5'of the 8 R' Bedding as 5.z Outer Perimeter of the System. suuivNI LHEUREUX CROSS SECTION OF CHAMBER M°• No. Pe{Title 5 pYlt. �,� Io M LOT J. . E L 3to NOT TO SCALE. s '�fsis �`��' NO WATEq DELVELOPED PROFILE OF PROPOSED SEPTIC SYSTEM Not to Scale ' Prepared For: . PREPARED BY Ptle: Notes/1?evis1on: JOHN FALLON Cb 338 MAIN STREET Sullivan Engineering, Inc. CVapgsa� ui SITE PLAN The property line information shown was compiled OSTERVILLE, MA PO Box 659 7 Parker Road PROPOSED_ SEPTIC UPGRADE from available record information and does not Osterville, MA 02655 Osterville MA 02655 AT represent an on the ground survey. (508)428-3344 (508)428-3115 fax (508)420-3994 (508)420-3995 fax 338 MAIN ►STREII T OSTERVILLE MA The topography shown was obtained V field: KIHK MOH Draft: 10 ' from the Town of Barnstable G.I.S. " MDH RRL o s 10 Zo �;, � 1 Comp.: MDH Review.: RRL -t Date: Scale: , Proj ifC-477 Drawing # C47T91 —� Mdy 18, 2001 1 =10