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0400 MAIN STREET (OST.) - Health
400 MAIN STREET Osterville A= 165 -088 0 I ' 0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 400 Main St. r„I M SV 6 0 Property Address �* Lane Owner information Owner's Name is required for a: every page. Osterville MA 02655' 5/9/18 - City/Town State Zip Code. Date of Inspection E; r7i Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Frank Nunes III 4 Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 Cityrrown State Zip Code 508.272.6433 13010 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5/9/18 Inspector's ignatur Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design-flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 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. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 t5ins.doc-rev.6/16 O P 9 P Y 9 Commonwealth of Massachusetts a v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 400 Main St. Property Address Lane Owner information Owner's Name is required for every page. Osterville MA 02655 5/9/18 Cityrrown State Zip Code : Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. - Comments: 3 - w B) System Conditionally Passes:.' 0 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. hx *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. ❑ N ❑ ND (Explain below): J t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Mt 400 Main St. Property Address Lane Owner information Owner's Name is required for every page. Osterville MA 02655 5/9/18 Cityfrown- State Zip Code Date of Inspection B. certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y -❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain'below): ❑ The system required pumping more than 4 times a year due to'brokeri or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17. I , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 400 Main St. - Property Address Lane Owner information Owner's Name is required for every page. Osterville MA 02655 5/9/18 CityTrown 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: r 4. 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 El due to an overloaded or clogged SAS or cesspool ® Static liquid level in the distribution box above outlet invert due to an overloaded 1:1or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M yVOy`t 400 Main St. Property Address Lane Owner information Owner's Name is required for every page. Osterville MA 02655 5/9/18 City/Town' State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. El ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen,is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No El 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 1 ❑ 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.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 400 Main St. Property Address Lane Owner information Owner's Name is required for every page. Osterville MA 02655 5/9/18 Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑; ® Were any of the system components pumped out in the previous two weeks? ®; ❑ Has the system received normal flows in the previous two week period? Ell ® Have large volumes of water been introduced to the system recently or as part of this inspection? . Z ❑ 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? 1 ® ❑ 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 p,❑ ® 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): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage,Disposal System Form-Not for Voluntary Assessments M ° 400 Main St. Property Address Lane Owner information Owner's Name is required for every page. Osterville MA 02655 5/9/18 City/Town State Zip Code Date of Inspection D. System Information Description: .p y i e Number of current residents. 4 Does residence have a garbage grinder? ❑,Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection , information in this report.). ❑ Yes ® No Laundry system inspected? °' ❑ Yes ® No Seasonal use? El Yes ® No Water meter readings; if available (last 2 years usage (gpd)): ' Detail: Sump pump? ❑ Yes ® No Last date of,occupancy: occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design.flow(based on,310 CMR 15.203): Gallons,per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.'): ' Grease trap present? ❑ 'Yes ❑ -No . Industrial waste holding tank present? ❑' Yes ❑ No Non-sanitary waste discharged to the Title 5 system? - ❑ Yes ❑ No 4 Water meter readings, if available: t5ins.doc rev.6/16 9 k. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 400 Main St. Property Address Lane Owner information Owner's Name is required for every page. Osterville MA 02655 5/9/18 Cityrrown 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: Pumped 2yrs ago per owner 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 t, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments- wM , 400 Main St. Property Address is Lane Owner information Owners Name is required for every page. Osterville MA 02655 5/9/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Existing tank , new d-box and chambers 2007 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ® No.. Building Sewer(locate on site plan): 2'6" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10'feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) Outlet cover raised to 3" of grade, tank appears to be structurally sound If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No i Dimensions: 1000g Sludge depth: t5ins.doc-rev.6/16. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments, 400 (Wain St. Propery Address Lane Owner information Owner's Name is required for every page. Osterdille MA 02655 5/9/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) S3ptic Tank(cont.) >12" Ustance from top of sludge to bottom of outlet tee or baffle Scum thickness trace-1/2" D stance from top of scum to top of outlet tee or baffle D stance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): P-imping suggested every 3 years to prolong the life of the system Grease Trap (locate on site plan): Depth below grade: feet Material of construction: f ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): D.mensions: " Scum thickness Dstance from top of scum to top of outlet tee or baffle D stance 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 : Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 400 Main St. Property Address _ Lane Owner information Owners Name is required for every page. Osterville MA ' 02655 5/9/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): r Tight or Holding Tank(tank°must be pumped at time of inspection) (locate on site plan): Depth below grade; s Material of construction: •`❑ concrete, ❑ metal; ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: f , Capacity: gallons Design Flow: gallons per day• Alarm present: ❑ Yes ❑ No " k Alarm level' ,' Alarm in working order. ❑ Yes 'El- No Date of last pumping: a 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 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 400 Main St. Property Address Lane Owner information Owner's Name is required for every page. Osterville MA 02655 5/9/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): 01. Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box is 4' below grade, cover raised to18", no adverse conditions 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.): t * If pumps or alarms are not in workingorder, 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 400 Main St. Property Address Lane Owner information Owner's Name is required for every page. Osterville MA 02655 5/9/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers. number: 3 ❑ 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.): Chambers were video inspected and are damp at this time, no indication of past hydraulic failure 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 . t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 400 Main St. Property Address Lane Owner information Owner's Name is required for every page. Cisterville MA 02655 5/9/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic,failure, level of ponding,condition of vegetation, etc.): Soils are compact and dry 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.): t t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Assessing As-Built Cards Page l of 1 TOWN OF BARNSTABLE LOCATION /I c/C�c.-e SEWAGE#-WtP7 3J"'SI VILLAGE_¢t1%11„12CI C ASSESSOR'S MAP&PARCEL J YY INSTALLERS NAME&PHONE NO. gd•r . SEPTIC TANK CAPACITY - /000 LEACHING FACILITY:(type) 3 -5U0 4, C (size) /o�yc i t NO.OF BEDROOMS I/ OWNER .41;v PERMIT DATE: 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 Wctland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY _ 0 0�� . ov f}.-c- �.�a.� � fie.(, r�z•v r=y9 R . http://towrLbamstable.ma.us/Assessing/HMdisplay.asp?mappar=165088&seq=l 3/12/2012 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 400 Main St. Property Address Lane Owner information Owner's Name is required for Osteruille MA 02655 5/9/18 every page. City/Town State ' Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high round water: feet p g g 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: 2007 NGW 132" Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health'-explain: 2007 compliance Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: TOPO mapping . S . You must describe how you established the high groundwater elevation: Chambers are at 24'msl nearby surface water is 6'msl } 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , 400 Main St. Property Address Lane, Owner information Owner's Name is required for every page. Osterville MA 02655 5/9/18 Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist fi. ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System"Page 17 of 17 i CENTERVILLE—OSTERVILLE—MARSTONS MILLS FIRE DISTRICT 1875 ROUTE 28 CENTERVILLE, MA 02632 I (508) 790 2380/FAX#(508) 790— 2385 OIL/HAZARDOUS MATERIAL RELEASE FORM F,A,# LOCATION: ADDRESS OF RELEASE: ��,,t}__ , — -, }; ► o T dt M dc��f'� +4 4='S R 4a!+��-•f'.lrsri��!r't:(-•! i�'�r�—ems DATE OF_RELEASE: PRODUCT RELEASED:�, ���: ,; ESTIMATED QUANTITY:' CORRECTIVE ACTION TAKEN BY-90ROBLE PARTY: faoe�v�afe s-, N�� NOTIFICATIONS: FIRE DEPARTMENT: YES( NO( ) DATE: a zz 4i� TIME:_ NATIONAL RESPONSE CEN YES( ) NO( ) DATE:" TIME: DEPT. OF ENVIRONMENTAL PROTECTION YES( ) NO( ) DATE TIME: OIL SPILL COORDINATOR: YES( ) 0( ) DATE' TIME: TOWN BOARD OF HEALTH: YES( NO( ) DATE; TIME: 00 TOWN HARBORMASTER: YES( ) NO( ) DATE. 'TIME. OTHER AGENCIES: COMMENTS: - r �.rrims �rsl� fiyla+rr a4ie�avn�+n'rE4+�iw �oa:'.�+ 1 REPORTED BY: ��'b4�Q 14 DATE, - -n�-- WHITE COPY-FIRE DEPARTMENT YELLOW COPY-D.E.P, PINK COPY-BOARD OF HEALTH C-+'J-MM FORM #58 1 PF 11 ;Spiee:Lane Ostervilt:. A= 165 -- 108 I E i o I I 0 1 t v vv u va �aa uaiaovac � Regulatory Services 5 Thomas F. Geiler, Director Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 pF.INE l� * BARNSPABLE,.'* 9 MASS. FINAL ORDER June 5, 2007 Mr. William Laverty 11 Spice Lane Osterville,MA 02655 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 11 Spice Lane, Osterville, MA was last inspected on January 20TH, 2007, by James M. Ford, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: Back up of sewage into facility or system component due to overloaded or clogged SAS. Cement tees were present. The liquid level was even with the outlet invert. Recommend risers be installed to bring covers to grade. You were informed that you had 60 days on receipt of notice to bring your failed system into compliance with the guidelines of 1995 TITLE 5 (310 CMR 15.00). We have not been informed that you have taken any steps to bring your failed system into compliance. Any person who shall fail to comply shall be fined not less than$10.00 nor more than $500.00. Each day's failure to comply with an order shall constitute a separate violation. You may request a hearing before the board of health, a written petition requesting a hearing on the matter, within seven days after the day this order was received. BARNSTABLE HEALTH DEPARTMENT l Thomas A. McKean, R.S., C.H.O. ��cQ_ Agent of the Board of Health I Town of Barnstable CF IME Tp� Regulatory Services BARNSfABLE, : Thomas F. Geiler,Director 9�ArFo �p,�� Public. Health Division Thomas McKean,Director 200 Main Street,Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 March 16, 2007 Mr William Laverty . 11 Spice Lane Osterville, MA 02655 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE. 5 The septic system owned by you located at 11 Spice Lane, Osterville, MA was last inspected January 201h9 2007 by James.M. Ford, a certified septic inspector for the.State of Massachusetts.. The inspection of your septic system after further evaluation"Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: Backup of sewage into facility or system component due to overloaded or clogged SAS. Cement tees.were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage. Recommend risers.be installed to bring covers to grade. You have 60 days from the date of the system failure to bring the system into compliance... If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. aoma ABLE HE H DEPARTMENT.A..McKean,.R.S.;C.H.O. Agent of the.Board of Health Town of Barnstable GF 1HE 1p� o Regulatory Services snxxsrns Thomas F. Geiler, Director MASS.9� ••� Public Health Division �fD MA'S A Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 March 16, 2007 Mr William Laverty 11 Spice Lane Osterville,MA 02655 • I ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system owned by you located at 11 Spice Lane, Oasterville,.MA was last inspected January 201h, 2007 by James M. Ford, a certified septic inspector for the State of Massachusetts. The inspection of your septic system after further evaluation"Fails" under the guidelines of 1995 TITLE 5.(310 CMR 15.00) due to the.following:. Backup of sewage into facility or system component due to overloaded or clogged SAS. Cement tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage. Recommend risers be installed to bring covers to grade. Recommend risers be installed to bring covers to grade. You haver r frroym the date of the system failure to bring the system into compliance. If there are any ue�tions about this reminder,please feel free to contact the Barnstable Health Department. BARNSTABLE HEALTH DEPARTMENT Thomas A. McKean,R.S., C.H.O. Agent of the Board of Health 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: /l Sfo pice Lane / 6 j Osterville, MA`02655 Owner's Name: William Laverty Owner's Address: Date of Inspection: . .January 20, 2007 Name of Inspector: (Please Print) Janes M" Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 s CERTIFICATION STATEMENT w I certify that I have personally inspected the.sewage disposal system at this address and that the information eported below is true,accurate and complete'as of the time of the inspection. The inspection was performed based on-iriy training and experience in the proper function and maintenance of on site sewage disposal systems;I I am a.DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: .0, Passes c _ . Conditionally Passes , ZFa Further,Evaluation by the Local Approving Authority C.) 4 ✓ 3� M <<� Inspector's Signature: Date:. January 30, 2007 The system inspector shall sub 't 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` 6/15/2000 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: 1 Spice Lane Osterville, MA Owner: William Laverty Date of Inspection: January 20, 2007 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 breakout 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 i Page 3 of 11 OFFICIAL INSPECTION-FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: I Spice Lane Osterville, MS Owner: William Laverty Date of Inspection: January 20, 2007 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to detennine 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 toy 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: 3 I Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: I Spice Lane Osterville. M4 Owner: William Laverty Date of Inspection: January 20, 2007 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 groundwater 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.] Yes (Yes/No)The system fails. I have.determined that one or more of the above failure criteria exist as described in 310 CMR 15303,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 m 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 4 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: 1 Spice Lane' Osterville, M,4 Owner: William Laverty Date of Inspection: January 20, 2007 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 backup? ✓ _ 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: I Spice Lane Osterville M,4 Owner: William Laverty Date of Inspection: January 20, 2007 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3' DESIGN flow based on 310 CMR.15.203 for example: 110 d x#of bedrooms • ( p. gP ). 330 Number of current residents: 0 Does residence have a garbage grinder (Yes or no ):. n/a 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)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIALANDUSTRIAL 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 orno) 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: Unavailable ,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 gM. 1973-per info 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: 1 Spice Lane Osterville, MA Owner: William Laverty Date of Inspection: January 20, 2007 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: 22 p 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: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness:. 2rr 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.).. Cement tees were present. The liauid"level was even with the outlet invert There did not appear to be any signs of leakage Recommend risers be installed to bring covers to grade. 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 Page 8 of T1 j OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 Spice Lane Osterville, MA Owner: William Laverty Date of Inspection: January 20, 2007' 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: Qallons/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 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): Alarns in working order(yes or no) Coimnents.(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: IS Rice Lane Osterville, MA' Owner: _ William Laverty Date of Inspection: January 20, 2007 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits.,number: 1 -6'x 6'(1000 val.) leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Continents(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegewtion,.etc'): The leach pit had 6"of liquid on the bottom The scum line was up above the inlet nine, Signs of past failure., The cover was 24"below Qrade. The bottom to Qrade was 9' 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): Continents:(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: I Spice Lane Osterville, MA` Owner: William Laverty Date of Inspection: January 20: 2007 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. } G A(A S G3 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: 1 Spice Lane Osterville, MA Owner: William Laverty Date of Inspection: January 20, 2007' SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 20+/ 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: Using Barnstable topographic and water contours maps, the.inaps were showing g 20'+/ to groundwater at this site. l This report has been prepared only for the septic system and components described herein. This septic system has been inspected and failed 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 septic system, the inspection,this report and/or any components of the septic system which have not been located and inspected. 11 a• TOWN OF BARNSTABLE LOCATION ,6,,� SEWAGE#-J00?— XJ—Y ill ILLAGE ca,rYpW—y © ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) w X yo 0 t X NO.OF BEDROOMS OWNER PERMIT DATE: P-11L1• &q COMPLIANCE DATE: 111710 Separation Distance,Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility.(If any Wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY fL 7 P d 0 � V t d r c� i=sz•® r sq.� q. TOWN.OF BARNSTABLE `` LOCATION I Sp1C� I�Q/1t, SEWAGE# c) .VILLAGE rV,l(k ASSESSOR'S MAP&PARCEL 0 INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY //0 90 LEACHING FACILITY:(type) G�,� (,� (size) Iwo NO.OF BEDROOMS 3 OWNER L4UC/ PERMIT DATE: 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 facltity) Feet FURNISHED BY Zits �G ,iM r0r IIX L07 I 3g ay G ArA 4- �3 .•�.�r t;- a.l,. .. ..,o, y.r...rsl...�'�, .-r '.i .`T,..'1v, r-'�Y No. Fee ZOO THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppYtcatton for Mtgpogar *pgtem Congtructton Permit Application for a Permit to Construct( ) Repair(1;/1U1"P,grade( ) Abandon( ) ❑Complete System 2Individual Components Location Address or Lot No. // J� A//� Owner's Name,Address,and Te n Tel.No. /���i�7 /�L��✓r` US�y'-4ICY. /'i,,, P6s�f /r�aLC Assessor's Map/Parcel Installer's Name,Address,and Tel.No. /"� T/ Designer's Name,Address and Tel.No. LlPd J Type of Building: Dwelling No.of Bedrooms L/ Lot Size 17j `7a y sq.ft. Garbage Grinder ( � Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures l Design Flow(min.required) �i 6 gpd Design flow provided ��y gpd Plan Date .Td" 2rj, 74 Number of sheets Revision Date Title 5_ 5',4 )6�_-ry /) :ioc ' 11`/c ®S' y',1lr' Size of Septic Tank clj(� (SAL L%(.3A&l? Type of S.A.S. 3 - 5-zlo stir L L,rc4 C/,-,r, , Description of Soilol Nature of Repairs or Alterations(Answer when applicable) Y i/` ?c 4m, — 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 t nvironmental Code and not to place the system in operation until a Certificate of Boa, Compliance has been issued by this Bo f ealth. Si ed 4 �� Date /-Q' Application Approved b Date < !U7 Application Disapproved by: Date for the following reasons Permit No. �? 3✓�{ Date Issued �' -y,�.•w-...�...:.-°.�.� _�,�� � ,_i ..`•..,-.+`+i'�` .....•..i``.'.-.... "-n.r_ .t�;�.....�,,.a+Y�;-. .. .v -mac,. ��+.. y ai . t No. Fee E '"THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �. PUBLIC HEALTH DIVISION-- TOWN.OF BARNSTABLE, MASSACHUSETTS Yes r TippYication for Oiopogar 6pgtpmc Cow5truction Permit Application for a Permit to Construct O Repair(grade,( Abandon O ❑ stem Complete S /p y ©Individual Components"*,. . . Location Address or Lot No.�� J��G t' K Owner's Name,Address,and Tel.No. Assessor's Map/Parcel I�j S' l$ [ Installer's Name,Address,and Tel.No.57ry J//1' Designer's Name,Address and Tel.No. &UW O �v`� /�S" g9 ( �1�1• �/ SZcI -3b2-N�5'/ �anwr4,,�.�� ��- Type of Building: L l Dwelling No.of Bedrooms / Lot Size sq. n. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures -Design Flow(min.required) 6 gpd Design flow provided yyy gpd Plan Date Tv— 2F,-7o //-7 Number of sheets / J Revision Date Title �_ S tSize of of Septic Tank l)Gr�o Anna L C14o)1ih7 Type of S.A.S. 3 - ft-o Lac b Description of Soil Nature pf Repairs or Alterations(Answer when applicable) /Gt7 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 nvironmental Code and not to place the system in operation until a Certificate of Compliance has been issued•by this Boar o ealth.. Si. tiedf Date t \ Iq .I_Q Application Approved by, r. Date 'R, M 7 Application Disapproved by: Date for the following reasons e9 Permit No. ,,.)F t t' Date Issued l� --� — — -- — --- — —=—----- - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance -- THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (✓) .Upgraded ( ) Abandoned( )by �� 416/`/1�/, 6,1,f/,-1- 1Ca J at A/c ,- L.n rYdy, t has been constructed in accordance )) / with the provisions of Title 5 and the for Disposal System Construction Permit No.Aq�0 dated !1 Installer /�G,� Yr��/I"J�, Goer 1��i��7 ir,✓ Designer;�A.) #bedrooms Approved design flow ��//� / _ gp/d The issuance of this permit shall not beconst uedsass a guarantee that the system wilt.] as designed Date _h (� � / Inspector % .. �" ———————--- . -- / r—�------- -- -----�—" -----�No. a)—7 Fee 1/00 . THE COMMONWEALTH OF MASSACHUSETTS PUBLIC.HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS lwt!5po!5a[ *p.5tem CongtrUction Permit Permission is hereby granted to Construct ( ) Repair (A,_) Up/grade ( ) Abandon A ( ) System located at / /c ` H Y•� S�`.�,;, , 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 pe r"it. Date �� y/ Approved bye,,. _ '� FROM :down cape engineering inc FAX NO. :15083629880 Aug. 28 2007 12:17PM P1 u7-,3� To'%m of Barnstable Regulatory Services - " Tbomas F. Geiler.Director NAM.�v Public Realtb Dhision Tbomas'MGl-eon, Director 200 Main Street,Ryannis. MA 02601 l Office: $09-962-4644 Fax: 509-790-6304 Installer d Des' er-Ce-tifiention Form Date: -o-7 Smage Permit# " 3s- Assessors MaplParcel Design er. ' � U /►ZE! Installer: 4�G✓ �r1 ( �-i ��. Address: "ZI n cf Address: On 9.1 y O-7 wms issued a permit m install a septic s<'Sttm a r C,4. based on a desi�ii dwmAm by (address) Owlti ' a — (dbsi r} X 3 aertif' that 'the Sep tic. syste referenced above was installed substantially; according to the design, �rriich may inclu a minor appxoved ci�an=s such as lateral. relocation of the distribution box an&or septic tlnk; . I certify, that the septic s}'st referenced above was installed with major changes (i.c. �reaier than 1 W lateral -re)ounor of the SAS or any verb Cal relocation of any compone-at of the se system) but in a cordame v�'Ith Szzte &: Local Re-ulations. Plan revision or ce-t d -built by designer to follow. OJALA civil. (Itistallwr'S Signature) -0 No 30792 {off% (Designer`s aziature) (Affix Designer's Stamp Here) ., PLEASE RETURN TQ BARNST BLE FV9LI 14r-ALTH nT\9SiQN. CERTIFICATE OF C MPLIANCE WILL N4T BE S 'ET) UI�"I1L T3a H V411S FORM N AS-BUILT CARD ARE RE LI I)BY TH 13AR TABLF, LIC H'LALTH D1'\'IS1 . TH.A!`K Y()U. - - . -- Cl:}lealthlScnuclDcsi er Cenifit-Rion Form -26-04.doc t � ll Cl o Sty �y 7, rU Liu 4 G L 4 IN No......�.1...---...... Finc............................_ THE COMMONWEALTH OF MASSACHUSETTS J �� BOARD F HEA TI-r 14 � _ 1101�,................OF...... .. .... Appliration for %iVosal Worka Tomitrurtiou Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal systY;* •�,,/ � - . -..- ocation-Address or Lot No. --- . . - ----- ---- ---- - - -- ------------- ----- ---- jO Ad ress nsta ler Address ' Type of Building . . r Size Lot----/_j .............Sq. feet Dwelling—No. of Bedrooms: S---.-} .�...............l.____Expansion Attic ( ) Garbage Grinder Pk Other—Type of Building ----- No. of persons..........s�-______ Showers (� Cafeteria ( ) a - L . -'i ------- ----------------- Other fixtures .....................4) _____ W Design Flow_ ____________________________ gallons per person per day. Total daily flow------------------------------------------ ,99 WSeptic Tank 1 Liquid capacity.; allons Length................ Width---------------- Diameter-------------•-- Depth--.------=------ x .Disposal Trench—No.:................... Widt .__....___..... Total Le Total leaching area--------------------sq. ft. Seepage Pit No._....__..-:°:_:____ Diameter_._,_: . epth belowmlet- ......... .'Total leaching area------------------sq. ft. Z Other Distribution box ) osing tank ( ) aPercolation Test Results Performed by-------------------------------------•--------------------- -------- Date---------------------------------------- Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water__-______-_____-__------ t% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water._-_-___•___-___---.___. O Description of Soil------ C . ---- ----------- U - W UNature 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beetistWiey b of h. .... .................... ......// Da e Application Approved By..... �............. Zate Application Disapproved for the following reasons:............................ -••-•--•--- --•-•-----•-•••••••-•--•-•----•-•---------••-----•------•------•-••--•-•---------------------••------.....----•--•--•--•------••--------•--•--•-•-- ........................................... Date PermitNo......................................................... Issued----- •--- ... ------ ,.3?............... D e ,r. No....:: _ F�:c .................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliration for Disposal Iforks TOnstrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Systeyat* IV it 3 i ocation.Address or Lot No, +ni .............. . -- `... ---........---- ---- ---- -------f 1 Own . • , ` + , Address .... J' ` . v------Z - . ; ref_�. 1..' -- ` -''� �--=�-22�---•-- Installer �v,, I Address y� 1l"`1 F� Type of Building Size Lot----.d__/f ------Sq. feet Dwelling—No. of Bedrooms______________5 ......... pansion Attic ( ) Garbage Grinder p`,,, Other Type of Building x> -- f No. of persons - Showers ( t '- Cafeteria ( ) Other fixtures ............ i-- --- W Design Flow............................ .:.:. ....gallons per person per day. Total daily flow............................................. t1"'�'.....__gallons. WSeptic Tank Liquid capacit _��. �allons .Length-_----__•__-•--- Width----- --------- Diameter____.-_.--_-____ Depth__..._....._._Disposal Trench—No..._._..:.. ++f'' _. dth=.... :_/ otal Len __ .....__. . Total leaching area--------- •_-__sq. ft. . Seepage Pit No......... ......... Diameter_ ;�"�-_ 'XI belo filet........__.......... Total leaching area------------------sq. it. z Other Distribution bo ( ) Dosing tank ( ) a Percolation Test Results Performed by...........,............................................................... Date---------------------------------------- Test Pit No. 1................minutes per inch Depth of Test Pit---------------------Depth to ground water_---___--_-__-___------- (i Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ / -•---- _ O Description of Soil------- =- - - x W ................... •-----••------------------------ .................................. U Nature of Repairs or Alterations—Answer when applicable................................................................ .._. ----------------------------------------------•---•••••----•••-•-••-•--•--•--------•-••--_.._...•••-•-•--••--•-----------------•-•-•-••-••--•••-..... ................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance-with, the provisions of Article XI of.the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue y�the beard.of h / SignE ....................&.................. ------ .. Application Approved By........ /j '` �� f � ------------- . --------a { � e -_'------- Application Disapproved for the following reasons:..............................------------------------------------------............=.......................... ^: Date PermitNo................................................:........ Issued.- - = E' -- ------------to THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... ..........................OF................ . .... ...........:................................................. if irate tre THIS IS TO CERTIFY, That t Individual Sewage Disposal System constructed ( or Repaired ( ) b =-- ------------•... .................••-•-•••--•... -•------•--•--------•--_-----•--- .. _.. 11 at...... .. .--_.--- � !S .. --------•-------•------------------- 1 has been installed in accordance�vith the provisions of Article XI of Th State42tary Code as described in the application for Disposal Works Construction Permit No---------4:............. ... .f..... dated-........ . . ..__ 7.-___--.___.. f� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE PISTRUE® AS A GUARA' E� /E_ THAT THE SYSTEM WILL FU CTIOI* SATI$.FACTORY. ; r DATE- 72 f Inspector-'"' ; 1 `r THE COMMONWEALTH OF MASSACHUSETTS y BOARD OF HEALTH tom(............OF..:.... . .." NO' f� o FEE----••---- �� hipppal Works. 0 onatrurtion rrrmit Perniis"sion is hereby'granted- -: •. ..................... -- '- ....................................... to HI Constru ( or Repair ( ) an ndivi uaewa isosa .. �=�-�..•a.*1+1�-•'t, ?;� -G,�w st�r2=>�' ---------- at --y as shown on the application for Disposal Works Coris ruction Permit`No..... ... .........mated_: ___ ._..___ ___ ___........ . o. ��. (oath -------------- DATE - --- ............................... ,1 ',�- - - -- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS L ji IN ......... E_ ......... L __J_ I r 1 14_ze- _ __ _ _ __ r _ ____�__ _ _ I i i t I --------------- ........... �C [ 1 _! C _� __ -----I_-_i_ _ I - -- ---------- ..... ......... _ __ �_ _ — _ _� __. _____�_ _ _ _l__ _ _a __ —C _ _______� —_ ____C_ __� _ _� ILL ............. _ _ _ _ _ -- �_,Lr ............ 7 Tj r r 4ks .......... Z ----------------- _.. _. _. --- . 1-.. I- I -- - .. . - ..I_R-. �jf - ___!__�.._ - --- --- -- -1.. -- - -- .__l - -4---. !-. _-r-__i I I i I i - -4- __-—..-..---I --�'_---__-.F.!_t__-.-�__I_r-._-.__�_!C___--_- -...-..___ L -1 .. I! I _.._-.....-.II_I--_--.:--A 1�C3- f - !--!-- - ..,::. 41 ........... F7 771—7-1 tn 6-C.4 ----------- 4-- 4- 7' Kevin Howard Licensed & Cell:508-360-5461 'Insured ......... . OUND S j BUILDING. & REMODELING CAPE COD,MA 4 cl 140[ k _4 s 570 Teaticket y. Business: 508-457-1133 Fax: 508-457-1550 �._.-i--�. ---- leatichet, MA 02536 ....... fjt------_..-. . __--- -- I- -------ii__----- ---I�.....-I !I----..-._—_._-.I- - II —i - . I._...-._�' ,I_-_ . .. -;r- _-..---Ii--- _.�- -iI-- _I--..._-I _ --i 1_ L—_._..-� --------- -A Division of Sound Home Builders Inc., J _-T _ i ALL SYSTEM COMPONENTS SHALL BE NOTES SYSTEM PROFILE MARKED WITH MAGNETIC TAPE OR TOP FNDN. AT EL. 35.0' COMPARABLE MEANS FOR FUTURE LOCATION. ACCESS COVERS TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE) ACCESS COVER TO WITHIN 3" OF FIN. GRADE 1. DATUM IS APPROXIMATE NGVD s�o^ / ACCESS COVER (WATERTIGHT) TO 27.0' MINIMUM .75' OF COVER OVER PRECAST /r WAIN 6" OF FIN. GRADE 2. MUNICIPAL WATER IS EXISTING 2X SLOPE REQUIRED OVER SYSTEM 24.0 ' INSTALL INLET RUN PIPE LEVEL 2" DOUBLE WASHED PEASTONE 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. O *EXISTING TEE 1" ABONE FOR FIRST 2' OR GEOTEXTILE FABRIC OUTLET INVERT 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHfl **EXISTING 1000 H- 10 25.50 t EXISTINGT s SUMP 21.0 GALLON SEPTIC TANK GAS k20.34' 5. PIPE JOINTS TO BE MADE WATERTIGHT. • BAFFLE 20.51' � 0 � � 0000 r2O.2' 0 0 0 0 0 kED = afo;n "t6" CRUSHED STONE OR MECHANICAL0 0 0 � 0 0 O 0 O6. CONSTRUCTION DETAILS TD BE IN ACCORDANCE WITHCOMPACTION. (15.221 [2]) 0 0 0 0 0 0 0 0 ED 0 18.2, MASS. ENVIRONMENTAL CODE TITLE V. DCUS OF DEPTH O FLOW �' 3/4" TO 1 1/2" DOUBLE WASHED STONE 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO TEE SIZES: � BE USED FOR LOT LINE STAKING OR ANY OTHER PURPOSE. INLET DEPTH _ 1� OUTLET DEPTH = 14" (2f-X SLOPE) ( 1 X SLOPE) 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. { FOUNDATION EXISTING SEPTIC TANK 19' D' BOX 16' LEACHING 5,2' 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED FACILITY WITHOUT INSPECTION BY BOARD OF HEALTH AND PERMISSION *THE INSTALLER SHALL VERIFY THE **THE INSTALLER SHALL CONFIRM MIN. OBTAINED FROM BOARD OF HEALTH. LOCUS MA LOCATIONS OF ALL UTILITIES AND ALL SEPTIC TANK SIZE AT 1000 GALLONS AND 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING SCALE: 1" = 2,000't BUILDING SEWER OUTLETS AND ELEVATIONS ITS SUITABILITY FOR RE-USE DIGSAFE (1-888-344-7233) AND VERIFYING THE LOCATION PRIOR TO INSTALLING ANY PORTION OF BOTTOM, TH-1 EL. 13.0' OF ALL UNDERGROUND & OVERHEAD UTILITIES PRIOR TO ASSESSORS MAP 165 PARCEL 88 SEPTIC SYSTEM COMMENCEMENT OF WORK. LOCUS IS WITHIN AP OVERLAY DISTRICT 11. EXISTING LEACHING FACILITY SHALL BE PUMPED AND +fC REMOVED OR PUMPED AND FILLED WITH CLEAN SAND, 12. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE REMOVED 5' BENEATH AND AROUND THE PROPOSED LEGEND LEACHING FACILITY. 100.0 PROPOSED SPOT ELEVATION AREA OVERGROWN WITH o 6 HOLLIES AND RHODYS rn s3; SYSTEM DESIGN: / \ +100.00 EXISTING SPOT ELEVATION ;oIm �,( \ GARBAGE. DISPOSER IS NOT. ALLOWED 100 PROPOSED CONTOUR 10 � N � hAVED �, \ DESIGN FLOW: 4 BEDROOMS 0 110 GPD = 440 GPD 100 EXISTING CONTOUR G� � �,R �0) DRIVE N / \ USE A 440 GPD DESIGN FLOW (00 CA cs CA SEPTIC TANK: 440 GPD (2) = 880 GRAVEL **_ \ RE-USE EXISTING 1000 GAL. _SEPTIC TANK PARKING/ T 2 � 8.0 � \ LEACHING: . 1 \� H (LAGARAG)E \ SIDES: 2 (40 + 10) 2 (.74) = 148 GPD H 4 G N BOTTOM 40 x 10 (.74) 296_ GPD TOTAL: 600 S.F. 444 GPD BENCH MARK - CORNER OF � \ USE CONCRETE SLAB EL. = 29.4 (3) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL) Iv ' WITH 4 STONE AT ENDS AND 2.6 AT SIDES AND TEST HOLE LOGS \ �'` Qk,G 3.25' BETWEEN UNITS ENGINEER: DAVID FLAHERTY, R.S. O „3 h / y MA WITNESS: DONNA MIORANDI, R.S.. �� APPROVED DATE BOARD OF HEALTH DATE: DUNE 21, 2007 \ ti� •a STING PERC. RATE _ < 2 MIN/INCH +\�� EXI4 BR }- TOP OF FNDN EL 35.0 y / TITLE- 5 SITE PLAIN CLASS I SOILS P# 11806 OF 11 SPICE -LANE (OSTERVILLE) BARNSTABLE ELEV. ELEV. ELEV. ELEV. 4 24.0' Q" � 25.8' � q3 24.0' �' � 25.8' MA Dc 1�6O S�O�� � PREPARED FOR 24' FILL 22.0' 1.8" FILL 24.3' 24" FILL 22,.0' t8" FILL 2.4.3' LOT 85 6'�' 17,924E SF � BORTO'LOTTI CONSTJ A A A 0.4E AC. , LS LS Ls LS WILLIAM LAVERTY 1OYR 3/2 1OYR 3/2 1OYR 3/2 1OYR 3/2 y° 26" 21.8 26" 23.6' 26" 21.8 26' 23.6' �;� B B B B DATE: JUNE 29, 2007 LS LS LS LSr „ 1OYR 6/6 20.3' &/6 1OYR 6/6 34" tOYR 23.0' 44" 10YR 6/6 20.3' 34" 23.0' / � �tNOFd�ss �(NOF O� ARNE H. ARNE��� EEC off 508-362-4541 / o �c o OJALA R+ �`� n, fax 508 362-9880 pm CIVIL OJALA v I 1p 3079 o �4 .No.2ssa8 down cape, engineering, inc. MS MS MS MS 1 °FF 10 Scale:1 132" 2.5Y 7/3 13.0' 120" 2.5Y 7/3 14.8' 132" 2.5Y 7/3 13.0' 120" 2.5Y 7/3 14.8 "= 20' � �oN L ENG\ p� vE�CEt C/1�/L ENG/NEERS �t aaG7 LAND SURVEYORS 939 Main Street - YARMOUTHPORT, MASS.NO. GROUNDWATER ENCOUNTERED NO GROUNDWATER ENCOUNTERED 0 10 20 30 40 50 FEET' DATE ARNE H. OJALA, P.E., P.L.S. DCE #07-031 07-031 BORTOLOTTI_LAVERTY.DWG (DDF)