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HomeMy WebLinkAbout0628 MAIN STREET (OST.) - Health �62�=1llain Street Osterville A 141 059 een Se September 14, 2006 �L Ocry Thomas A. McKean-Director rr o n med BARNSTABLE HEALTH DIVISION 200 Main Street Hyannis, Massachusetts 02601 RE; Hazardous Waste Site Cleanup 628 Main Street Osterville, Massachusetts Mr. McKean: This letter is written to inform you that Green Seal Environmental, Inc. (GSE) and Atlantic Environmental Technologies, Inc..(AET) have completed a.Immediate Response Action (IRA) at the above referenced property in Osterville, Massachusetts. A release of oil - or hazardous materials.,was. -reported to the Massachusetts Department of Environmental Protection(MA DEP) and issued a Release Tracking Number(#4-19315). GSE and AET conducted a IRA at the site, which has been cleanup to a point where Licensed Site Professional Toivo Lamminen, Jr. is able to issue a Class A-2 Response Action Outcome. This means that there is no longer a significant risk of harm to human health or the environment from the incident. A copy of the IRA report is available through MA DEP or GSE. If you have any questions or require additional information regarding this matter, please call. Sincerely, GREEN SEAL ENVIRONMENTAL, INc. Terry F. Bauer, PG - Chief Operating officer C ` Main Office New Hampshire Office 28 Route 6A, Sandwich;MA 62563 "' 301-baniel Webster Highway,Merrimack,NH 03054 Phone: (508)888-6034•Fax: (508.)888-1506 www.gseend.com Phone:(603)424-3004•Fax: (603)424-3241 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: .PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZfppltCatton for Mtgpogal *pgtem Comarurtton Vermtt Application for a Permit to Construct O Repair X) Upgrade O Abandon O ❑ Complete System ❑Individual Components Location Address or Lot No. v j ONc�,,; Sm a4erqM1 Owner's Name,Address,and Tel.No. Assessor's Map/parcel ` OS Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �v 14S A c9 i t ,Ale Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 'ReO cce L tN e C, SdM oom,, 3D sepbc_ Tew Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by th.i5lavard of Health. , Signed 1 Date Application Approved by Date Application Disapproved by: Date for the following'reasons Permit No. �' Date Issued No._ Fee THE'(C,OMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes .PUBLIC HEALTH DIVISION. - TOWN OF BARNSTABLE, MASSACHUSETTS - -" Zlpp icat oOkfOr Mi5po5al *p5tent Congtruction Permit r Application for a Permit to Construct O RepaITX) Upgrade O Abandon O ❑ Complete System ❑Individual Components r ' A a4C(Q% Location Address or Lot;No�� 4�a S'C' 11P Owner's Name,Address,and Tel.No. As Map/patcel Installer's Name,Addree`ss,and Tel.No. Designer's Name,Address and Tel.No. Type of B`uiiding: Dwelling 1... No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other \ Type of Building No.of Persons Showers( ) Cafeteria Other Fixtures j Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date - Title Size of Septic Tank 1 Type of S.A.S. Description of Soil + Nature of Repairs or Alterations(Answer when applicable) _R�pk C{f' L a Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewagerrdisposal system in accordance with the provisions of Title 5 of the Environmental Code.,and not to place the system in operation until a Certificate of Compliance has been issued by thiopard of Health. x i �'♦ Signed e �� el 117 o Al-A.- Date Application Approved by //f/ 1 lry fi7 r/.f �_ I Ul__ Date Application Disapproved by: y Date for the following reasons Permit No. �� Date Issued G/1� ' THE COMMONWEALTH OF MASSACHUSETTS N. BARNSTABLE, MASSACHUSETTS 1 Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired Upgraded ( ) Abandoned( AA)by ,S at G a b,tJ (il ` has_been con tructed'In rdance with the provisionsof Title 5 and the for Disposal System Construction Permit No. D dated Installer De10 e`1 G S 1�(OyJ/�3 Designer #bedrooms Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the syste,Lrtrwi4.1,func io cis esigned. Date ?� �� � Inspect( --------��-- f- —'---------=----------- Fee --/X)—-- " THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS 0is pogar *pgtem Construction Permit Permission is hereby granted to Construct ( ) 71N, ir ()C ) Upgrade ( ) Abandon ( ) System located at ro ae /A c�� St 0S ( r 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. I Provided: Construction must be ompl6ted within three years of the date of this t, Date Approved-by � � 1 ,e ^ r _ r c � r COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AF ATPq DEPARTMENT OF ENVIRONMENTAL PROT ��p 1 SOUTHEAST REGIONAL OFFICE 20 RIVERSIDE DRIVE, LAKEVILLE, MA 02347 508-94- - MITT ROMNEY STEPHEN R.PRITCHARD Governor -- Secretary KERRY HEALEY ROBERT W.GOLLEDGE,Jr. Lieutenant Governor S E P 29 2005 Commissioner TOWN OF BAK HEALTH DEPT. URGENT LEGAL MATTER:PROMPT ACTION NECESSARY September 16,2005 Ms.Anne Jordan RE: OSTERVILLE—BWSC 628 Main Street Residential Release Osterville,Massachusetts 02655 628 Main Street RTN#4-18836 NOTICE OF RESPONSIBILITY M.G.L. c. 21E,310 CMR 40.0000 ATTENTION:Ms.Jordan -` On. September 12, 2005 at 10:20 AM the Department of Environmental Protection (the "Department")received oral notification of a release and/or threat of release of oil and/or hazardous material at the above referenced property, which requires one or more response actions. It was reported that an unknown volume of#2 home heating oil (fuel oil)was released at the above referenced property. After an inspection conducted on September 14, 2005, it was confirmed,that fuel oil was released which impacted surrounding soils and possibly groundwater. The Massachusetts Oil and Hazardous Material Release Prevention and Response Act, M.G.L. c.21E, and the Massachusetts Contingency Plan(the "MCP"), 310 CMR 40.0000, require the performance of response actions to prevent harm to health, safety, public welfare and the environment which may result from this release and/or threat of release and govern the conduct of such actions. The purpose of this notice is to inform you of your legal responsibilities under State law for assessing and/or remediating the release at this property. For purposes of this Notice of Responsibility,the terms and phrases used herein shall have the meaning ascribed to such terms and phrases by the MCP unless the context clearly indicates otherwise. The Department has reason to believe that the release and/or threat of release which has been reported is or may be a disposal site as defined by the M.C.P. The Department also has reason to believe that you (as used in this letter, "you" refers to Ms. Anne Jordan) are a Potentially Responsible Party (a This information is available in alternate format.Cali Donald M.Games,ADA Coordinator at 617-556-1057.TDD Service-1-800-298-2207. DEP on the World Wide Web: http:/Avww.mass.gov/dep 0 Printed on Recycled Paper I 2 VRP") with liability under M.G.L. c.21E §5, for response action costs. This liability is "strict", meaning that it is not based on fault,but solely on your status as owner, operator, generator,transporter, disposer or other person specified in M.G.L. c.21E §5. This liability is also "joint and several",meaning that you may be liable for all response action costs incurred at a disposal site regardless of the existence of any other liable parties. The Department encourages parties with liabilities under M.G.L. c.21E to take prompt and appropriate actions in response to releases and threats of release of oil and/or hazardous materials.By taking prompt action, you may significantly lower your assessment and cleanup costs and/or avoid liability for costs incurred by the Department in taking such actions. You may also avoid the imposition of,the amount of or reduce certain permit and/or annual compliance assurance fees payable under 310 CMR 4.00. Please refer to M.G.L. c.21E for a complete description of potential liability. For your convenience, a summary of liability under M.G.L. c.21E is attached to this notice. You should be aware that you may have claims against third parties for damages, including claims for contribution or reimbursement for the costs of cleanup. Such claims do not exist indefinitely but are governed by laws which establish the time allowed for bringing litigation. The Department encourages you to take any action necessary to protect any such claims you may have against third parties. At the time of notification to the Department,you retained Bennett& O'Reilly,Inc. to oversee the following response actions which were approved as an Immediate Response Action•(IRA): • Determine the horizontal and vertical extent of fuel oil contaminated soil. • Investigate the potential impact to groundwater. • All Remediation Waste must be properly stored/handled and disposed of within 120 days from the date of generation per 310 CMR 40.0030. On September 16, 2005, the Department provided verbal approval to Bennett & O'Reilly, Inc. to remove up to 5 cubic yards of fuel oil contaminated soil to better access the full impact of the release. ACTIONS REQUIRED Additional submittals are necessary with regard to this notification including,but not limited to,the filing of a written IRA Plan, IRA Completion Statement and/or an RAO statement. The MCP requires that a fee of$1,200.00 be submitted to the Department when an RAO statement is filed greater than 120 days from the date of initial notification. Specific approval is required from the Department for the implementation of all IRAs, pursuant to 310 CMR 40.0420. Assessment activities, the construction of a fence and/or the posting of signs are actions that are exempt from this approval requirement. In addition to oral notification, 310 CMR 40.0333 requires that a completed Release Notification Form(BWSC-103, attached)be submitted to the Department within sixty(60)calendar days of September 12,2005. You must employ or engage a Licensed Site Professional (LSP) to manage, supervise or actually perform the necessary response actions at this site. You may obtain a list of the names and addresses of these licensed professionals from the Board of Registration of Hazardous Waste Site Cleanup Professionals fA 1 3 by calling (617) 556-1145 or visiting http://www.state.ma.us/IM. The Department has David Bennett with. Bennett&O'Reilly,Inc.as the LSP of record for this release. The Department prepared the Homeowner Oil Spill Cleanup Guide to assist homeowner's in understanding the legal requirements and step-by-step cleanup procedures of the MCP. The Guide will familiarize you with the terminology, parties involved, cleanup technologies etc. The Guide is available at the Regional Office or at http://mass.gov/dep/bwsc/files/homeownr/homeownr.htm. Unless otherwise provided by the Department, potentially responsible parties ("PRP's") have one year from the initial date of notification to the Department of a release or threat of a release,pursuant to 310 CMR 40.0300,or from the date the Department issues a Notice of Responsibility,whichever occurs earlier, to file with the Department one of the following submittals: (1) a completed Tier Classification Submittal; (2) a Response Action Outcome Statement or, if applicable, (3) a Downgradient Property Status. The deadline for either of the first two submittals for this disposal site is September 12,2006. If required by the MCP, a completed Tier I Permit Application must also accompany a Tier Classification Submittal. This site shall not be deemed to have had all the necessary and required response actions taken unless and until all substantial hazards presented by the release and/or threat of release have been eliminated and a level of No Significant Risk exists or has been achieved in compliance with M.G.L. c.21E and the MCP. If you have any questions relative to this Notice,please contact Michael Whiteside at the letterhead address or at (508) 946-2704. All future communications regarding this release must reference the following Release Tracking Number: 4-19315. Very truly yours, Richard F.Packard,Chief Emergency Response!Release Notification Section P/MCW/ 4-19315/NORdoc Attachments: Release Notification Form;BWSC-103 and Instructions Summary of Liability under M.G.L. c.21E Department's guide to hiring a Licensed Site Professional. ec: Barnstable-Thomas McKean healthgtown.barnstable.ma.us Barnstable-Town Council councilna,town.bamstable.ma.us fc: Barnstable-Fire Department ATTN:Fire Prevention 508-362-8444 I Health Complaints 04-May-06 Time: 11:30:00 AM Date: 5/4/2006 Complaint Number: 18785 Referred To: DAVID STANTON Taken By: TINA FONTAINE Complaint Type: NUISANCE CONTROL REG. 1 RUBBISH Article X Detail: UNSANITARY CONDITIONS Business Name: Number: 628 Street: Main Street Village: OSTERVILLE Assessors Map_Parcel: Complainant's Name: Address: Telephone Number: Complaint Description: Corner of Old Mill and Main in Osterville big piles of dirt and dumpsters are located on property since Nov 2004. Caution tape all around house. Actions Taken/Results: YES, VERY GOOD OBSERVATIONS. NO INFO ON COMPLAINANT TO RETURN CALL. NO FURTHER ACTION REQUIRED. Investigation Date: 5/4/2006 Investigation Time: 1:35:00 PM ` 1 BENNETT AT O'REILLY, Inc. Engineering, Environmental & Surveying Services 1.573 Main Street Sanitary 21E/Site Remediation Property Line PO Box 1667 Site Development Hydrogeologic Survey Subdivision Q Brewster,MA 02631 Waste Water Treatment Water Quality Monitoring Land Court 508-896-6630 Water Supply Licensed Site Professional Trial Court Witness 508-896-4687 Fax B005-4411 December 6,2005 Mr. Michael Whiteside,Case Officer MA Department of Environmental Protection,Bureau of Waste Site Cleanup Southeast Regional Office 20 Riverside Drive Lakeville,NIA 02347 RE: NOTICE OF LSP TERMINATION Jordan Residence,RTN 4-19315 r-628'Main Street-Osterville, Dear Mr.Whiteside, In accordance with the provisions of 310 CMR 40.0169(2), and as consistent with the licensing requirements of 309 CMR 4.03(4),BENNETT&O'REILLY,INC.is providing notice that I[David C.Bennett, #4303] am no longer the LSP of Record nor have any further association with the Jordan Site, as referenced above. BENNETT&O'REILLY,INC.,was released from the project by Ms. Jordan through communications with her brother, Robert Harmon. BENNETT& O'REILLY, INC., has been advised by Robert Harmon that Green Seal.Environmental has been engaged and subcontracted the services of Toivo Lamminen, Jr., from Atlantic Environmental Technologies as the Successor LSP(#6846). Under the Terms and Conditions of existing contracts,all project documentation owned and on file with BENNETT&O'REILLY,INC.,will be delivered to Ms.Jordan upon receipt of full payment for all outstanding invoices as presently outstanding and delinquent. Any.use or representation of such information without the expressed written authorization of BENNETT&O'REILLY,INC.,is a breach of legal contract and violation of the law. Please direct any line of questioning on Site status to Ms. Jordan as the Responsible Party or contact Robert Harmon(508)648-3933 as the purported agent for Anne Jordan. This Notice ofTermination shall absolve me personally and BENNETT&O'REILLY,INC.,collectively, from any and all future remedial response performance under the MA Contingency Plan, 310 CMR 40.000. Should you have any questions,or need additional information,please contact me directly VVI& urs, ILLY,INC. C C c l cap c7 u NireTcto ?f nett;LSP < 1 n nviro 'ental Services o : - to I CC. Anne Jordan-Potentially Responsible Party co James Benton III-Hydro Environmental Technologies,Inc.,Consultant to Providence utual I T uratc� Michael Allain-Adjuster to Providence Mutual Greg Worsen,Principal-Green Seal Environmental Toivo Lamminen,LSP COMM Fire Department (Barnstable Health Department t �iPa.4 —nr i ? H Jai. 10 I'm 1 19 DATE 12116105 PROPERTY ADDRESS 628 Main St2eet O'steay.iiie Ma z 02655 AW On the above date, the septic system at the address above was Inspected. This system consists of the following: 6,r 3, /�(J 1., 2-1000 gaUon zept.ic tankz., 2., 2- Diztai&ut.ion Boxes., 3., 4- 7iow d.i�,eusoas 36'X10'X.2' Based on inspection, I certify the following conditions: 4., 7h.iz .is a 7.itie Five zept.ic .3yztem" 5.1 Se/lt.ic Zytem .ins .in /22oRe2 WILk-ing oicdea at the. pnezent time., SIGNATURE A- _a Name: Robert A. Paolini Company: Joseph P. Macomber & Son Inc . Address: P. O. Box 66 Centerville, Mass 02632 Phone: 508-775.3338 or 508-775-6412 JOSEPH P. MACOMBER & SON,. INC. Tan ks-Cesspools-Leachfields Pumped & Instalied Town Sewer Connections P.O. Box 66 Centerville, MA 026.32-0066 775-3338 775.6412 f � COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a DEPARTMENT OF ENVIRONMENTAL PROTECTION - r M TITLE 5 OFFICIAL INSPECTION FORM,.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART-A CERTIFICATION i Property Address: . 628 Main zt2en_.t 0.6 t eity.t PDn Ne7 Owner's Name: 4nn lo2dan Owner's Address: z am e Date of Inspection: 6 0 5 Name of Inspector:(please prin t APa01"9�ni Company Name: P. Nacomlelt An Inc. Mailing Address: en env.c e, a6,3..02632 -� Telephone Number: 5 0 8-7 7 5 3 3 3 8 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: XXXPasses -Conditionally Passes Deeds Further Evaluation by the Local Approving Authority ails Date: Inspector's Signature: 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 sliared'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. 4':+lu c inenoe!tinn rnrm 6/15/2000 page 1 r Page 2 of 11 OFFICIAL INSPECTION:FORM—.NOT- FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE IDISPOSAL SYSTEM INSPECTION FORM � PART A CERTIFICATION(continued) Property Address: 628 Main S:taee.t O,steay.iLee _ Owner:Ann Zo2dan Date of Inspection: 12116105 Inspection Summary: Check A,B,C,D or.E/ LWAV&eomplete,all of Section:D A. System Passes: 'DES NO I have not found any information which indicates1hat 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: Sept-iC 6yatem .is .in 1211012ea woak.ing oadea at .the pae4ent time., B. System Conditionally Passes: NO One or more system components as described in the"Conditional Pass"..section.need tote.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.detenmined(Y,N,ND)in the for the following statements.If"not determined"please explain. No The septic tank is metal and,aver 2Q years old*,or the septic tank(whether metal or not)is.structurally unsound,exhibits substantial infiltration or exfilration.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: NO.' 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: NO_ 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 �J ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:628 Main z t zee;t Owner: Ann to zdan Date of Inspection: 12116105 C. Further Evaluation is Required by the Board of Health: no Conditions.exist which require further evaluation by the Board.of Health in.order Wdetermine 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: n o Cesspool or privy is within 50 feet of a surface water n 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: no The system has aseptic 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. no Theaystem has a septic tank and SAS and the'SAS is`within a Zone I of a.public water•supply. no The system has a septic tank and.SAS and the SAS is within 50 feet of a private water supply well. rLQ_ The system has a septic tank and SAS and the SAS is less than 100 feet.but 50 feet or more front a private water supply well".Method used to determine distance v csua.2 "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 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM !' . PART A . CERTIFICATION(continued) Property Address: 628 Main .st2ee� Oate2vz.P.�e. Owner: ,4nn to zdan Date of Inspection: 7 217 6/0 5 D. System Failure Criteria applicable to all systems:. You must indicate"yes"or"no"to each of the.following.for all inspections: Yes No X Backup of sewage into facility or system component due:to overloaded.or clogged SAS..or cesspool x Discharge:or ponding of effluent to the surface of tht.ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool- . X Liquid depth in cesspool is less than.6"below invert or available volume is less than'h day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. _ X Any portion of cesspool or privy is within 100 feet of a surface water supply.or tributary to a surface water supply. X Any portion:of a cesspool or privy is within al Zont 1,of a..public well. X Any.portion of a cesspool or privy is within 50 feet of a private water supply well. �. X Any portion of a cesspool or privy is less than 100 feet but greater.than 50 feet from a private water _ supply well with no acceptable water quality analysis. [This system.passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution.from:that 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 fort.] NO (Yes/No)The system fails.I have determined that one or more<:ofthe above failure.,criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owneruld 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 1.0,000 gpd to 15,000 gpd• You must indicate either"yes"or`.`no"to.each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply _ X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant.threat,or answered "yes"in 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 5ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 628 Main S12eel- 04tzAv.ixie Owner: 4nn Jo zdan Date of Inspection: 12116105 Check if the following have been done.You must indicate"yes"..or"no"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal.flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of th sinspection? X _ Were as built plans of the system obtained and examined?(If they were not available#tote as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up X _ Was the site inspected for signs of break out ? X _ Were all system components,excluding the SAS;located on site?. X _ 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? X _ Was the facility owner(and occupants if different from owner)provided with Information on the proper maintenance of subsurface sewage disposal systems? 00 The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X Existing information.For example,a plan at the Board of Health. X _ 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)j 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTIO.N FORM � PART C SYSTEM.INFORMATION Property Address: 628 Na-in Staeet U:3tenv e Owner: Ann 7oadan Date of Inspection: 12116105 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): <3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): n o Is laundry on a separate sewage system(yes or no): n o [if yes separate inspection required]. Laundry system inspected(yes or no): n o Seasonal use:(yes orno): no 2004=32, 000ga2.eonz qPD=87., 67 Water meter readings,if available(last 2 years usage(gpd)):2 0 0 5=3 2, 0 0 0 ga.e 2 0 n.6 G P D=8 7 6 7 Sump pump(yes or no): n o Last date of occupancy:/21 e..s ent . COMMERCIAL/I1)DUSTRIAL Type of estab.�i� nt: N/A Design flow(lased on 310 CMR 15.203): gpd Basis of dbsigp`flow(seats/persons/sgf,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: 1/5/0 3 ma ini 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. X Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool —ivy _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: -cnzt a,eied 1999 Were sewage odors detected when arriving at the site(yes or no):_a o 6 Page 7 of 1 l OFFICIAL INSPECTION FORM-NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION(continued) Property Address: 628 Main Staeet Me.M eze Owner: Ann loadan Date of Inspection: 12116105 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction:—cast iron X40 PVC—other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): ao cnt s aR�ea2 t caht NO e-akagg Vyn.tyr/ Ihnniinh hn116.Q SEPTIC TANK: y ee 4locate on site plan) 2-10 0'0 ga.2.2 o n .tank z Depth below grade: 12" Material of construction: X 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:8'.6"X5 ' 8"X4' 10" Sludge depth: t2 ce Distance from top of sludge to bottom of outlet tee or baffle: t a a c e Scum thickness: t a a c e Distance from top of scum to top of outlet tee or baffle: t a a c e Distance from bottom of scum to bottom of outlet tee or baffle: t z a c e How were dimensions determined: m e a z u a e d Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid.levels as related to outlet invert,evidence of leakage,etc.): Pua42 lank a e ?Ii 3 ii2n4 c Za.eet ou t i eit t e e A oay iwalazaro Tank .i s .3btuctuaai.2q zound -- GREASE TRAP: 2 o(locate on site plan) Depth below grade:— Material of constructiom 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.): G2eahe taaI2 is not paesent 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS. SUBSURFACE.SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART.0 SYSTEM.INFORMATION(continued) Property Address: 628 Main Owner-Ann 7o zdan Date of Inspection: 12116105 TIGHT or HOLDING TANK: no (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass . . polyethylene other(explani): 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.): tight o121t hoed.ing .tankz ate not Raesent DISTRIBUTION BOX:y e (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.): Boxe.6 ate 2evei - Kave 4 &tezaf.s , No AnAid rnanyouon nn Oaa/r,,, a in 02 out o aox.' PUMP CHAMBER:n o (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.): lumI2 chamgea is not Raeaent 8 f Page 9 of 11 OFFICIAL.INSPECTION FORM—NOT.FOR VOLUNTARY ASSESSMENTS. SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 628 Na-in Si-age-1- Owner: 4an loadan - - Date of Inspection: 12116105 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Located see Rage 10.- Type leaching pits,number:_ 7—leaching chambers,number:-4—T 2 o w D i�/u z o a a z 3 8'X 10'X 2' 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.):. Loamy nand To goney dine •sand. No .sings o� jeiaeaAe oa oad.in -3 o.c .6 aice ay.- Vegetation 1-6 noama t CESSPOOLS: no (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: PAW Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes nr no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): ce6.6Roo.2.6 aae not ?ae.6ent PRIVY: n o (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 i Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i PART C: SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. ��Y } I I 104V s" d- i I. 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:6.28 Main Staeet Oz.teitv.i .Pn Owner:Ann loltdan Date of Inspection: /9 6/ 5 SITE EXAM Slope Surface water Check cellar Shallow wells d Estimated depth to ground water ,4 feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: y e.3 Observed site(abutting property/observation hole within 150 feet of SAS) h Checked with local-Board of Health-explain:a s B n,!,P t sand - no Checked:with local excavators,installers-(attach documentation) Accessed USGS database=explainh t i/2:t o wn.,&a a n:a to 8.$e.,ma.-u.a You must describe how you established the high ground water elevation: llsed : Cape Cod Comm.is.ion idatea 7atte Codtou2z And /uliic Ugtea Supply Veil head paotect.io-n aaeas mad , Sept 1995 _ klatea aezouaces 0;12.ice cane cod comm.ts.'on --Top of Cround Leaching ' Pit 4`UI_eet. Groundd: Feet Below Bottom;of Pit. High Groundwater Adjustment 1.8 ft per Fnmpter Method Therefore,the vertical.separation distance between the bottom of the leaching pit and the adjusted groundwater table is feet. 11 . - •AM1*N+•r.st7��17��7Rs-aRO.fwR�+r.R IAAOf411IM11111111104111111 ' JA7Rlr!.4rtr.tr••t TOWN OF „DaRNS7 BLE BOARD OF 11$A•16TII SUBSURFACR SEWAUH DISPOSAL SYSTEM IIrSPECTION FORM - PART D CERTIFICATI10N •••an-T•:-t:t`t 7nw•tETnNrpnn•RnFlrstr!/�.►+w'1111'17T••anrs � Vr11oT••1'►-.fit•rr• —TYPE OR PRINT CLEARLY— PROPERTY INSPECTED STREET ADDRESS 628 Main Staeet �. ASSESSORS MAP, DLWK AND 'PARCEL # OWNER's NAME Ann jo2dan. PART D CERTIFICATION . NAME OF INSPECTOR e,et P.a.o"n i COMPANY NAME ;o aaph 'P., Racomiel?V Son Inc " COMPANY ADDRESS Box 66 Cen�eav,11.1a Mazz 02632 ' Str'ed�• Town-or City State LIP COMPANY TELEPHONE ( 508. ) 7.5 - 3338 FAX (' 508' 1190 1578 CERTIFICATION STATEMENT I certify that. I have personally .i.nspeoted ..the sewage 'digposk. system at I address and that tfrd information reported .is true,. s.OcUra•tev slid omplete as of the time ..qf inspection..• The inspection was performed and any tions regard.in upgrade, •ma•intenanee,• abd repair .are• oon$is'tent with my trainipg and experience in the proper futrcti,•on• and maintenance of on- site sewage disposal systems . Check one: XXXX � • System PASS*D The inspection which -I have •condugted has ,,n-at found any information which indicates that the systm fails to ' adequately. protect .publiv _ health or the enviropment as defined in. .310 CMR. 1$•i-30.3-, Any failure criteria trot' evaluated are as stated in the FAILUR:R CRITERIA .seati`on o•f this form. System FAILED* The inspection which I have con ted 'has .'•found that the System fails to protect the public Health And the envIronmen•t ' in acvo•rdance with Title 6 , 310 CMR 16 . 303, and as • specifical..ly noted on .PART-0 -. FAILURE CRITERIA of this Inspection form. Inspector Signature' Date ' ;On6 copy of this eeirtifi.cat•i .'n must •tie provided 'to the .QWNER, t BUYER' where appl koa•ble) a►nd t.hl 13PARD Or HEALTH. * If the inspection FAIL'Z-bj thb ,owne`r' .ox�operator -whall . uptrade'•the system. within one year of the da't•e of the i,nspection, unless. al•lowsd Qr, requi;red nf.harw{se as Provided in* q;10 CMR 16 ,306 , DATE : 12/23/02 PROPERTY ADDRESS:628 Main Street _ _ Osterville,Mass_--- G 02655 On the above date, I inspected the septic system at the above address. This system consists of the following: 1 . 2-1000 gallon septic tanks. 2. 2-Distribution boxes. 3. 4-Flow diffussors. 36 'X10 'X2 ' <�6 •� Based on my inspection, I certify the following conditions: ✓AN 4 . This is a title five septic system.,._Installed 1999 TOwN 2 �ZQQ3 t5. the -septic_ the presentstimem is in proper working order at NFq ti�psTge( 6. The flow diffussors are presently dry. T F 7. Pumped 1 -1000 gallon tank at time of inspection. Second tank did not need to be pumped. � '/e-�Z SIGNATUR5A I Name:_ J .— P . —Macomber—jr . Company:lg5.tph Pam_ M�Dgomttr & Son, Inc . Addr4ss :__BQ; _rzf------------- -_Q_enS2rYiUP-,_Ma-_QZ_632-0066 Phone : 5 0 8- 7 7 5- 3 3 3 8 --------------------- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tanks•Cesspools•leachflelds Pumped & Installed Town Sewer Connectlons P.O. Box 66 Centerville, MA 02632.0066 775.3338 775.6412 -\ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 0 TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 628 Main Street Osterville,Mass, Owner's Name: Anne Harmon Owner's Address:Same Date of Inspection: 1 2/2 3/0 2 Name of Inspector: (please print) ,7osenh P_ Macnmher Jr. Company Name: J.P.Macomber & Snn Inc. Mailing Address: gc)x 66 rente—d 11e,Mass. 02632 Telephone Number: 5 0 8—7 7 5—3 3 3 8 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 traiping 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 Is Inspector's Signature: Aw Date: The system inspector shal ubmit 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 I time.This inspection-does not address how the system will perform in the future under the same or different 4 conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 628 Main Street Oster ville.Mass. Owner: Anne Harmon Date of Inspection: 1 / /0 2 Inspection Summary: Check A,B,C,D or E/ LALA WAYS complete all of Section D A: S stem Pass 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 5.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: - ThP septic system is in proper working order at -hp nracont- time_ 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. 4�L 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 existifig 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 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 628 Main Street Osterville,,Mass. Owoer:Anne Harmon Date of lospectioc: 1 2/23/02 C. Further Evaluation is Required by the Board of Health: All 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 determioes In accordance with 310 CMR 15.303(I)(b) that the system is not fuoctioning in a maooer wbich will protect public bealtb,safety and the envirooment: 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. S'Nstem 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: X10 The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or rributary to a surface water supply. .+',? The system has a septic tank and SAS and the SAS is within a Zone I of a public water supple. .(�l7 The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. •fld The system has a septic tank and SAS and the SAS is less than 109 feet b 150 feet or more from a private water supply well, Method used to determine distance 1� $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 nirrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criieria arc rriggered. A copy of the analysis must be anached to this form. 3. Other: JJ 3 Page 4 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:628 Main Street OStE.,rville,Mass Owner: Anne Harmon Date of Inspection: 1 2/2 3 0 2 D. System Failure Criteria applicable to all systems: You must indicate"yes" or "no" to each oftife following for all inspections: Yes N� ackup 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 distribut-t7io�n box bove outlet invert d_ue to n overloaded or clogged SAS or _ / cesspool ti�,��� /ndiV fJ dr5 e- Liquid depth it.c.esspea}is-less than 6 below invert or available volume is less than h day flow Required pwnping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped ) /✓arty 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. �/_ /arty portion of a cesspool or privy is within a Zone I 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. jTbis 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/No)The system fails. 1 have determined that one or more of the above failure criteria exist as described in 310 CMR 15.103. 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• 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 d no the system is within 400 feet of a surface drinking water supply _ fle 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 11 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 sh)uld contact the appropriate regional office ofthe Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 628 Main Street Osterville,Mass . Owner: Anne Harmon Date of Inspection: 1 2/2 3 /0 2 Check if the following have been done. Yoo 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 components1,'4'"1uding 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 ? 2— 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 /n0 � 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 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 628. Main Street Osterville,Mass, OwnerAnne Harmon Date of Inspection: 12 23 02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): '�7 Number of bedrooms(actual): .3 DESIGN flow based on 310 CMR 15.203,(for example: 110 gpd x # of bedrooms). X Number of current residents:�'/r� ' ,t Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system,�yes or no): � (if yes separate inspection required) Laundry system inspected( es or no): Seasonal use: (yes or no)-, ' Water meter readings, if available (last 2 years usage(gpd)): 20001 —96, 000 gallons—263, 02 GPD Sump pump(yes or no): X)o 2002-63, 000 gal lons-1 72. 61 GPD Last date of occupancy: iK&4V COMM ERCIAL/INDUSTRIA L Type of establishment: Design flow(based on 310 CMR 15.203): 0 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):'�,z Water meter readings, if available: 16)4 Last date of occupancy/use: 44 OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: pumped 1 tank at time of inspection. Was system pumped as pan of the inspection (yes or no): If yes, volume pumped: 1AW gallons -- How was quan try pumped determined? jf Reason for pumping:Heavy scum & solids layers were presen TY SeOF SYSTEM Septic tank, distribution box, soil absorption system Single cesspool ,,aOvcrflow cesspool Privy Shared system(yes or no)(if yes, attach previous inspection records, if any) �lnnovative/Altemative 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 �0_ Other(describe): 1 Ap2=imate age of all com onents, date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):-e,20 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: 628 Main Street Osterville,Mass. Owner: Anne Harmon Date of Inspection: O 2 BUILDING SEWER(locate on site plan) . A' Depth below grade: T#/ ���� Materials of construction: cast iron _. 40 PVCy�other(explain): Distance from private water supply well or suction line: is. Comments(on condition of joints, venting, evidence of leakage,etc.): Joints appear tiaht.No evidence of leakaae.System is vented the house vents. 1 SEPTIC TANK: (locate on site plan) Depth below grade:% /,air�� .J .f BN Material of construction:_knfroncreteA/=metal ,.) fiberglass polyethylene ,tJ other(explain) A>o If tank is metal list age:0 Is age confirmed by a Certificate of Compliance(yes or no)i0 (attach a copy of certificate) ) /�)) l Dimensions: 'V6 n.(Ly y�d if/}4 X�i vr'j7'�//�l Sludge depth 2u d Distance from top,�Dludge to bonom of outlet tee or baffle:/, Scum thickness: f Distance from top of scum to top of outlet tee or baffle:A4d Distance from bonom of scum to bonct of outlet to or baffle: How were dimensions determined: �c'il�s'(ll7°� Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,,evidence of.leakage;-etc.):.— —. - Pump the septic tanks every 2-3 years. !'nlet & outlet tees 'arP in pl ace_ThP tanks arP stru _t- tra-1 1 y Gound and shows no evidence of leakage. GREASE TRA914eflocate on site plan) Depth below grade: Material of construction:,jconcrete,�ametah&�2fiberglass/l,&olyethylene,,g.4other (explain): ,dze2 Dimensions: Scum thickness: AIA 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: 2' Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Grease trap is not present. Page 8 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Add ress:628 Main Street Os vi 1 1 �,Mass_ Owner: Anne Harmon, Date of Inspection: 1 2_/9-1 f n 2 TIGHT or HOLDING TANIG A4e(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: .,)14 Material of construction:Z.2-concrete,64 metal fiberglass 4Y polyethylene,fe/4other(explain): Dimensions: Capacity: allons Design Flow: gallons/day, Alarm present(yes or no): _ Alarm level:V_ Alarm in working order(yes or no): AA Date of last pumping:_40— Comments(condition of alarm and float switches,etc.): Tight or holding tanks are not present. DISTRIBUTION BO*Z(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:.!/l] 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.): Eagh di st-ri htfti on hox has one 1 atera 1 No PytdPnrP of soli cis Carr near Nn avi aenr-e of leakage into or of the box- PUMP CHAMBEP &(,(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.): Pump rhamhPr i s nnt- prPSPnt 8 I Page 9 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:628 Main Street Osterville,Mass, Owner: Anne Harmon Date of Inspection: 1 2/2 3/0 2 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) 4—Flow diffussors in series_ 38 'x10 'x2 ' If SAS not located explain why: Located: See Page 10 Type A-Dleaching pits,number: 49 leaching chambers, number: 106 leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: Q V0 overflow cesspool,number:0 ZF innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Loamy sand to boney fine sand No signs of hydraulic failnrP or Pondina.Soils are dry Flow d' ffussors are dry at the nrF+aant time. Vegetation is normal. CESSPOOLS (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: O Depth—top of liquid to inlet invert: ,(J 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.): Cesspool s arp nnt prAseni- PRIVY(locate on site plan) Materials of construction: Dimensions: J _ Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy is nest nrPsPnt _ 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: 628 Main Street Ostervill_e,Mass _ Owner:Anne Harmon Date of Inspection: 1 2/9 3/n/n 2 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. r oV dU 1'%W 610 • I L F7 •C 2'91MM U/ �I 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: 628 Main Street Osterville,Mass. Owner: Anne Harrnnn Date of Inspection: 1 2 //9-1 /n 9 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: yF SS Obtained from system design plans on record -If checked,date of design plan reviewed: 12 2 3 0 2 YF.S Observed site(abutting property/observation hole within 150 feet of SAS) yFZ Checked with local Board of Health-explain: Obtained as built card YFS Checked with local excavators, installers-(attach documentation) http: town,barns tble.ma.us. ye&Accessed USGS database-explain: NA You must describe how you established the high ground water elevation: Jsed: Gahrety & Miller Model, 12/16 /94 Ground water elevations above sea level. Jsed: URGS- Qhservat-i nn well data.June 1992 Jsed: Usr�s Technical bulleyin 92-000-1 Plate #2 Annual ranges of around water etavim,Nu hunnjann;;ry 1c3A2 Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per FrimP ter Method Therefore,the vertical separation distance between the bort Of the leaching pit and the adjusted groundwater table is feet. 11 ' ]•PrtnTw�niTTr•.TTrf►ra.RY.TeRJf�nR rinrt*trr.7e+t.R►t1.r*l.mn Rs•rwZ/1�sllt�rtwT �, Barnstable TOWN OF BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION •••rr�ter••r.: —r..��.-rninr.+n•rr.Tn r+.�asrrn'•.err.Tra��vrne�sr.m•�r n � I -TYPE OR PRINT CI.EAALY- ..�.T-•.-. PROPERTY INSPECTED STREET ADDRESS 628 Main Street Osterville,Mass. ASSESSORS MAP, BLOCK AND PARCEL # 141 -059 OWNER's NAME Anne Harmon. PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J•p.Macomber & Sory incrl. COMPANY ADDRESS Box 66 Centerville,Mass. 02632 Stravt Town or My St at• LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 1 790 -1 578 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 omplete as of the time of inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one: System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 16 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have con tcted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 310 CMR 15 , 303, and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature 0, s� Date ' — .�,=,F Xne copy of tills rt.ificationmust be prov ded to the OWNER, the BUYER here applicable ) and the I30ARD OF HEALTH. * If the inspection FAILED, the owner or" operator shall upgrade ' syste within one year of the date of the inspection, unless allowedorthe requiredm otherwise as provided in 3.10 CFIR 15 . 3 05 . partd .doc CENTERVILLE-OSTERVILI.E-MARSTON s MILLS FIRE DISTRICT 9875 ROUTE 28 CENTERVILLE, MA 02632 (I (508)790-238OBFAX#!(508)790-2385 f OIL/HAZARDOUS MATERIAL RELEASE FORM It F.A.#� - I IILOCATION:ADDRESS OF RELEASE:, Ji j DATE OF RELEASE: 9 I PRODUCT REL.EASED: ,,. ESTIMATED QUANTITY:• CORRECTIVE ACTION TAKEN BY RESPONSIBLE PARTY: rl r ' NOTIFICATIONS: IFIRE DEPARTMENT: YES( t 1AO( ) DATE:, TIME: (Pr_l NATIONAL RESPONSE CENTER YES(,-f'NO( } 'DATE: `'' krl1&_ DEPT. OF ENVIRONMENTAL PROTECTION YES( �NO( } DATE: ;Z_ ,TIM OIL SPILL COORDINATOR: YES( ) NO(c,,j" DATE: `TIME TOWN BOARD OF HEALTH: YES(V4)-NO( ) DATE: —117. TIME: t a17 TOWN HARBORMASTER: YES( ) NO(vr DATE: TIME:_Y___-,__,_ OTHER AGENCIES: COMMENTS: :2. ? f�. , .-...d:.�w.'..ww�.Jr ,,.;r .f...�.�+rs,,: MK.�i.. •!?•f. ,y..di.,i i. no ,. ! 0 `n�_.d.'� .a�a�1/.r�'..6f j .�a�.`" ` '1� ! ryr rr '� u9..�/`•o � f /M ..+r �.Z �}•.^ n�i"J� � REPORTED BY: DATE. I� WHITE COPY-FIRE DEPARTMENT YELLOW COPY-D.E.P. PINK COPY-BOARD OF HEALTH i C-O-MM FORM#!58 i 1 1 I 1 i I r F_ ik All fm&4% if ■ , �� �' #M�'■ ��. �. Y� / r .�y�«.. }��,fir,�� .. � r '� u + �r �. � 111 � •� F 1 Y I•� k s r d� dTrL7A s 1 4 y t 41 ui 7 r i 1 i�� � � > R � •�'% r �. � t. — �,� 4�' F' �; �: b �`� 6 «' .a �s�. �w �-.? .t , �!� � -r� '�'� �eP' ,��a - � � ,: ''��, �r J�� n + 3.'_.. �, _ ,f .. �!- ���. � ,. .' �. y t,: �+Y � 71 A �� G �4• q; i �, E i �� - - - y �,, 7w ;� u _.. ,.: Yi � � `�3� 1 �1; y1F _*� S � - ti' �. m - � �� - - ; ��� r.�� :�'r '�✓ � s � . �, � 1� � i ., +i - �` � y :fir 5 'm" '�� � f �� u�. N- '- ,. ""x •.��' .a: �� i 6 "q.. r • T - A. ii��" .. *�� i •� e'f dial � 1.� a i y - ♦ ,. 9 _ _ is t •. ". • y - i� i fed • •. • o Lin y � . t b . y J $ y. -lam �_ ' SEP It u SEP 12 . 3 �;..: `, �,� � ,, .: -. _ , , � =� ,:r .: v. :�R �. '.may.... � { s i. .,a'.sAr� �' -.,� ;i a. `e '�� } �� � - - ,, f � r _.V� i` - �P a .. F a. i ' t '•' i• i- . a i z } T I� f, M. a !,!Il7A I E — tt *. Tq " kY �'i Health Complaints 15-Sep-05 Time: 10:22:00 AM Date: 9/12/2005 Complaint Number: 18454 Referred To: DONNA MIORANDI Taken By: SHARON CROCKER Complaint Type: ARTICLE XXXIX HAZARDOUS WASTE Article X Detail: UNSANITARY CONDITIONS Business Name: Number: 628 Street: MAIN ST Village: OSTERVILLE Assessors Map_Parcel: I 1 = AL Health Complaints 15-Sep-05 They are afraid there will be an explosion and/or fire. Therefore the occupants are without heat and hot water. Occupants are moving next door to Anne's mother's house, Mrs. Harmon. Michael Whiteside of DEP is going to site on 9/14/2005. David Stanton shall be giving.him the pictures and copy of this report.Q09/1 /22005=-MefMichael-Whiteside-of DEP on site`and-also'Rick'Summersail-ofi. -3 Riedell. Fire Dept. has allowed a temporary line in order to have hot water. Basement is to be lined with poly as well as the ceiling to prevent fumes from going up into house. Fans are also being utilized. Meeting with the insurance company on 9/16/2005 to see if it will help and may do so if there is a groundwater impact. To be determined by Bennett&O'Reilly who was also on site. APPEARS TO BE MORE THAN 10 gallons but may be as much as 50+ gallons. Previously it was noted that the last delivery was in April but now they are saying it was June 2005. Investigation Date: 9/12/2005 Investigation Time: 2 SEWAGE INSPECTIONS {F LOCATION 628 Main Street DATE 12/23/02 `.VILLAGE Osterville,Mass. ASSESSOR'S MAP & LOT 141 -0 5 9 JNSPECTOR Joseph P.Maccomber Jr. SEPTIC TANK CAPACITY 2-1 000 gallon tanks 2-Distribution boxes LEACHING FACILITY: (typc)4-F1 ow Di f f ssors (sizc)3$'V1 O 'X2 ' NO. OF BEDROOMS 3 BUILDER OR OWNER Anne Harmon OWNER MAILING ADDRESS Same �jpwr it / /�2 e 1 T-7 / L3 1 w I= i OiD 1M+LL 2oAD TOWN OF BARNSTABLE. LOCATION %�� S7, SEWAGE # 99—/c VILLAGE Ov ��/c'v�/ t ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) I ekgr 9/�y c'!J '— r]� (size) 1d NO.OF BEDROOMS BUILDER OR OWNER D .,PERMITDATE: /t7r/ "�l��7 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) Feet Furnished by IL _ ZY !=► pS -�5�� 7 --- No. — � - ; Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓/ Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Migogaf *p5tem Construction Permit Application for a Permit to Construct( )Repair(k-rupgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.col -,x S,T Owner's Name,Address and Tg 1.No. os env,1Ie 46r`t'"Qe\ Assessor's Map/Parcel '76Z ©iTe,-,l 1c 5-6)6S Installer's N%ne,Address,and Tel No. Designer's Name,Address and Tel.No. ,ce.J�aca lIT? 9? Pona 5T ya8-55a 9 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Re airs or Alterations(Answer when applicable) 4 D f) �L S 1._F 0, to e tA& S;TiA x � L n 3 i e,1 L, 't-1Qw �, ��3C23 n.� \a`k 6t w tkJX t�T%%c Syrrc �i� 07 aT 1t1dt S(,ne — eou-c LZ T�t 3�c9it5:-nC: plc rh/1 '1 Ti (( e XIJ i,, �l�S 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 issuo by=th' oard o th. + Signed Date 4/tf/o? /9 9/ Application Approved by — Date ? —1 Z Application Disapproved for the following reasons Permit No. l2 Date Issued - - - - -- - - - - - - - ...•ash. .. . .... - .. .. ,. - __ _. . . - - .. , No. Fee y r THE COMMONWEALTH OF MASSACHUSETTS Entered in computgr: s Yes PUBLIC-:HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pprication for jigpogar *Otern Congtruction Permit Application for a Permit to Construct( )Repair(k/lUpgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.tpza 1B P� n. S 1 Owner's Name,Address and Tg1.No. Assessor's Map/Parcel /7/_ O e 7��( {�t i) h S j. a S I e,- 1 1� S c Installer's Ngne,Addre s,and Tel No. Designer's Name,Address and Tel.No. �. vet ;vs anc el'r , Q7 �un 57- I1d9-s5 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank - Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) A D i) _b �i.7 o x\o e roc -, .S i is--J1- w�)i 7 0t 'ld � ��icnc - � s Date last inspected: j 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 issu d by th•s oard o Ith. , Signed Date Cff/,;z 9 Application Approved by Date . —/z Application Disapproved for the following reasons }Permit No. q�2 Date Issued � '�" THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance j g p y ( )Repaired (�Upgraded( ) THIS IS TO CERTIFY that the On-site Sewage Disposal System Constructed Abandoned( )by at 608 Mai it Si . 0_5 c — flr7aP vie y ha been constructed in accordance with the provisions of Title 5 ah the for Disposal System Construction Permit No. dated Installer �vc� CuC� /'S � Designer The issuance of this permits al Ab cconst ued as a guarantee that the ky {e w11 function as desig. ed. ` Date Ul Ci . Inspector zs�" ? ,fi lI�1 -�-r`11114 j, __ ____ r Fee V THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Big ogala pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair(Upgrade( )Abandon( ) System located at "8 AAi,1 Si cis%P�v,/�� — fhi21JJCW 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. A Provided:Constructi n must be complet�d within three years of the date of this permit. 1. ; Date: 3 //":s ` < ' Approved by 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, cwce Mcccq ``,s 1�� , hereby certify that the application for disposal works construction permit signed by me dated t`[►);c-vi a 1 cic�5 , concerning the property located at 02 8 l`�� iw S7. a S l tc""O t✓ meets all of the following criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There are no wetlands within 100 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S.will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surfac y levation(using GIS information) 1 8 f 5 1 B) G.W.Elevation +the MAX.High G.W. Adjustment.3B3 = DIFFERENCE BETWEEN A and B SIGNED : DATE: /'c C.A/ IoZ c�iQq [Sketch proposed plan of system on back]. q:health folder:cert i i` �c - loo d I 0 � W � f v J ` � I J -------__ _---------------------------- _ $= 1� Permit Number: Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location: 1��� MA1,1 Sr osi—truA Lot No. Owner: -�/arnM(In b.h Address: Contractor: Address: Notes: STEP 1 Measure depth to water-table to nearest 1/10 ft. ............ .Date / ''• .................................................................. month/day/Year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OAppropriate index well.................................................... MIW�9 OB Water-level range zone ..................................................... 3 STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth toM1hl water level for index well ........................... month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), i and water-level zone (STEP 2B) 3,3 determine water-level adjustment .......................................................................................... STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) i from measured depth to water �•3 levelat site (STEP 1) ............................................................................................................. -------- — TOWN OF BARNSTABLE LOCATION 6�8 ic1 S7. SEWAGE # 9/0—/ ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY a�_ LEACHING FACILITY: (type) /Z/d 4-4 22i (size) 3 6 l o NO.OF BEDROOMS BUILDER OR OWNER 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 facility) Feet Furnished by 1 r. + 7­71 �Z 203 499 050 US Postal Service Receipt for Certified Mail No Insurance Coverage Provided. Do not use f r International Mail See reverse Sent t bar P Off te,& IFaC Postage Certified Fee Special Delivery Fee Restricted Delivery Fee u) Return Receipt Showing to Whom&Date Delivered Return Receipt Slowing to Whom, Date,&Addressee's Address 0 TOTAL Postage&Fees Postmark or Date / r CLL 0 a Stick postage stamps to article to cover First-Class postage,certified mail fee,and charges for any selected optional services(See front). 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attached, and present the article at a post office service window or hand it to your rural carrier(no extra charge). LO 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the Q) cc return address of the article,date,detach,and retain the receipt,and mail the article. LO 3. If you want a return receipt,write the certified mail number and your name and address rn j. on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article a- RETURN RECEIPT REQUESTED adjacent to the number. Q 4. If you want delivery restricted to the addressee, or to an authorized agent of the addressee,endorse RESTRICTED DELIVERY on the front of the article. Goo 5. Enter fees for the services requested in the appropriate spaces on the front of this, E receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. ti I!f 6. Save this receipt and present it if you make an inquiry. t 025s5-s7-s-0i 45 a i h `t oFEt Town of Barnstable STAB Department of Health, Safety, and Environmental Services BAMM '� Public Health Division �Eo�AO�� P.O. Box 534, Hyannis MA 02601 Office: 508-862-4644 "Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health January 14, 1999 Mr. Theodore S iharm'on _.�C r 716 Main Street Osterville, MA 02655 NOTICE TO ABATE VIOLATIONS OF 310 CMR: 15.00 THE STATE ENVIRONMENTAL CODE TITLE V: MINIMUM REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF SANITARY SEWAGE, AND 105 CMR 410.00 STATE SANITARY CODE H - MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION. The property owned by you located at 628 Main Street, Osterville listed as .Parcel 141 on Assessor's Map 059 was inspected on January 12, 1999 by Jerome Dunning, Health Inspector for the Town of Barnstable, because of a complaint. The following violation of 310 CMR 15.00, the State Environmental Code, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage and 105 CMR 410.00 State Sanitary Code H - Minimum Standards of Fitness for Human Habitation was observed: REGULATION 310 CMR 15.02 (207)AND 105 CMR 410.300: Overflowing sewage onto the ground. This violation is a serious public health hazard. 1) You are directed to hire a licensed septage hauler to pump the overflowing cesspool within twenty-four(24) hours of receipt of this letter. 2) You are also directed to keep the on-site sewage disposal system pumped as many times as necessary to keep from overflowing onto the ground. 3) You are further directed to contact and hire a licensed Disposal Works Installer within seven (7) days of receipt of this letter in order to repair this system or connect to town sewer. You may request a hearing before the Board of Health if written petition requesting same is received within seven (7) days after the date the order is served. ` Non-compliance could result in a fine of up to $500.00. Each day's failure to comply with an order shall constitute a separate violation. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean Director of Public Health '7 Al 6'T o 4Z�� PA o a e. 5 Sr NOTICE TO ABATE VIOLATIONS OF 310 CMR: 15.00 THS STATE ENVIRONMENTAL CODE TITLE V• MINIMUM REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF SANITARY SEWAGE AND 105 CMR 410.00 STATE SANITARY CODE II - MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION. The property owned by you located at 0/a S' I a.wi,Sr 6 .w listed as Parcel I I on Assessor's MaP6j-?, was inspected on /- I!),-7 y , 1 9 , by D u,,�.V"",g , Health Inspector for the Town of Barnsta a because of a complaint. The following violations of 310 CMR 15.00, the State Environmental Code, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage and 105 CMR 410.00 State Sanitary Code II - Minimum Standards of Fitness for Human Habitation were observed: REGULATION 310 CMR 15.02 (207) AND 105 CMR 410.300: Overflowing sewage onto the ground. This violation is a serious public health hazard. 1) You are directed to hire a licensed septage hauler to pump the overflowing cesspool within twenty-four (24) hours of receipt of this letter. 2) You . are also directed to keep the on-site sewage disposal system pumped as many times as necessary to keep from overflowing onto the ground. 3) You are further directed to contact and hire a licensed Disposal Works Installer within seven (7) days of receipt of this letter in order to repair the system. You may request a hearing before the Board of Health if written petition requesting same is received within seven (7) days after the date the order is served. Non-compliance could result in a fine of up to $500.00. Each day's failure to comply with an order shall constitute a separate violation. PER ORDER OF THE HOARD OF HEALTH Thomas A. McKean Director of Public Health Health Complaints 12-Jan-99 Time: 9:42:47 AM Date: 1/12/99 Complaint Number: 1676 Referred To: JEROME DUNNING Taken By: LS Complaint Type: TITLE V SEWAGE Article X Detail: Business Name: Number: Street: OLD MILL AND MAIN STREE , Village: OSTERVILLE Assessors Map-Parcel: Complainant's Name: ANONYMOUS Address: Telephone Number: Complaint Description: HOGAN RESIDENCE NEXT TO HARMON PAINTING HAS AN OVERFLOWING SEPTIC SYSTEM THAT RUNS DOWN THE DRIVEWAY INTO THE ROAD AND FREEZES. Actions Taken/Results: Investigation Date: Investigation Time: 1 PAR ] Real Estate System - General Property Inquiry] Help [ ) Parcel Id: 141 059- - Account No: 77295 Parent : Location: 628 MAIN ST OSTERVILLE Neighborhood: 30BC Fire Dist : CO Devel Lot : Lot Size : . 27 Acres Current Own: THEODORE S HARMON INC State Class : 101 716 MAIN ST No. Bldgs : 1 Area: 2700 Year Added: OSTERVILLE MA 2655 Deed Date : Reference : 1226/55 January 1st : THEODORE S HARMON INC Deed MMDD: 0000 Deed Ref : 1226/55 Comments : Values : Land: 44800 Buildings : 79000 Extra Features : 400 Road System: 628 Index: 953 (MAIN STREET (OST. ) ) Frntg: 115 Index: ( ) Frntg: Control Info: Last Auto Upd: 050695 Status : C Last TACS Update : Land Reviewed By: Date: 0000 Bldgs Reviewed By: Date : 0000 Tax Title : Account : Taken: Account Status : Hold Status : Cancel [ ] Press XMT for more data Next screen [PAR ] Action [ ] Owners Name [ ] Road Index [ ] Road Name [ ] Parcel Number [141] [060] [ ] [ ] [ ] m SENDER: I also wish to receive the V ■Complete items 1 andfor 2 for additional services. rn ■Complete items 3,4a,and 4b. following services(for an ■Print your name and address on the reverse of this form so that we can return this extra fee): .. card to you. m ■Attach this forth to the front of the mailpieoe,or on the back if space does not t. ❑ Addressee's Address permit. $ ■Write'Retum Receipt Requested'on the mailpiece below the article number. 2. ❑ Restricted Delivery to •The Return Receipt will show to whom the article was delivered and the date a C delivered. Consult postmaster for fee. 0 „ 3.Article Addressed to: 4a.Article Number cc a 4b.Service Type d ❑ Registered J*Certified IE ❑ Express.Mail ❑ Insured S ❑ Return Receipt for Merchandise ❑ COD 7.Date of Delive z / .. i p 5.Received By:(Print Name) 8.Addressee's/Address(Only if requested W and fee is paid) t fr t— g 6.Signat re:(Addressee or Agent) �. X IT :PS FdrM 381it Decembei 1994 i { 102595-97-B-0179 Domestic Return Receipt UNITED STATES POSTAL SERVICE First-Class MailPostage&Fees Paid LISPS Permit No.G-10 O Print your name, address, and ZIP Code in this box O Public Health Division Town of Barnstable P.G. Box 534 flya^ais. Massachusetts 02601 fi "111i11�i�.1��l1�t 11IIII���t 111-1�1I111�-'1i111'{1t111�i1'�1�1" J i Health Complaints 03-Dec-99 Time: 1:30:00 AM Date: 11/22/99 Complaint Number: 2154 Referred To: GLEN HARRINGTON Taken By: GLEN HARRINGTON Complaint Type: NUISANCE CONTROL REG. 1 RUBBISH Article X Detail: Business Name: Number: b'o � Street: corner Main &Old Mill Rds Village: OSTERVILLE Assessors Map-Parcel: Complainant's Name: anonymous Address: Telephone Number: Complaint Description: dumpster is overflowing and a mobile home is poarked there along with an unregistered vehicle. Actions Taken/Results: GH - I checked property at corner and next door where camper and roll-off dumpster was. The dumpster was not overflowing and the camper was not being used. There were no electrical lines or water hoses connected to camper. There was one unregistered vehicle on the corner property. They are allowed one unregistered vehicle per property. Investigation Date: 11/22/99 Investigation Time: 3:30:00 PM 1 ip TOWN OF .BARNSTABLE 5 Ordinance or Regulati®n f WARNING NOTICE t 5: Nam :07 e-of: n'of !' E . ` 1 . <� 1.; Address :of Offender ' � ;: > ' ,�' ea , , MV/MB Reg # Village/State/Zip ' f' : ,, : '` { �° •: k t s - ' t .Business Name amp/pm; on 2 ) f ` Business ,Address :' �.rk�� t `as Y' Signature of Enforcing Officer ' Village/State/Zip ' Y Location of Offense f , ' T h"D 1 � � Enforcing Dept/Division . Offense, Facts 11� ?'# tr�1L '� '� f /\ '}✓ r✓ `This; will= serve only a Am s a warning •'At this time no legal action has: been taken It is the goal of ;Town agencie's, ,to ,..acheve volvi untary compliance of Town Ordiiianees, Rules : and, Re.gulationS. Education efforts- and. warning; notices `are attempts'_'to gain,: voluntary compliance Subseguent, violations will result in apprgpriate .legal :action by the. Townv � F„� {k IWO TOWN Op BARNSTABLE ` .., Ordinance or Regulation' '` WARNING NOTICE fi { Al Name of Offender/Manager. d' Address of Offender ` }A >» R < "' � ' x MV/MB Re- . ,. Village/State/Zip ; � _ ;" '' � ,. k a' w., Business Name C am/pm; on Z � 20 " t B, mess-Address Signature of Enforcing Officer Village/StateJZiF:° '` JJ location of Offense � Q ,' . ' Enforcing Dept/Division{ Offense 4Y C. ,. e �`3 y�^`s F� r" �.;;' d Facts .1; eF, ° t s i 1 tynF .. r`_ ' r ;#' ¢ .,. ¢ !�° r 4 r1 ; "m- �{c- . • • _ cti,- A t.l Y.,MK�...._.. Y `1'a+.9 '" x° n `-` V I( : U a.r��'$..--,{ "Thin will.' serve on'ly,"-As a. warning. At. this'."time`.no�;legal` action has been taken It is ..the goal'° of Town agencies--� to. achieve`° voluntary , compliance',,of Town t O inaAnce's, Rules ,and Regulations Education ,efforts,.and warning- notices ,are. attempts " to .g 'in'`voluntary compliance : Subsequent violations wial ;result, in aPPropriate legal action by ,the Town � ' f:z1 M S +r,t.i`'Y x"�.. b ate:.1. ij y ,r, < 4r,.'�? .•- r r ,: 7"'i $ARNS:TABLE "BAR-W � 'Ordinance .or Regulation x J WARNING NOTICE Name.-of• Of fender/Manager - -- � ..F' T! rF P.ddress of Offender ` ", l '. - 3/� ; r� # ,, ,' o li , (._ r, > MV/MB Reg' # Village/State%Zip n i•/� .+k° Y1, '� . Business. Name ' Wim t/ , on p Busin ess ,,Address , F Y. :t u. . 1 Signature ofE`nforcing Officer Village/State/Zip •d Location of Offense Enforcing Dept/Division Of f e.n s e FaC.tS r r / ✓f 1� r �} r( ., .F� r I�`•,i i ♦ ! > d . �5 J(— This will serve 'only a,s a'warning. At this time no le-gal action has been-taken it_# is the 'goal'' of ` Town agencies'- to• achieve .. Voluntary compliance' of,.'.Town' Ordinances,'- Rules and Regulations, on efforts And warning notices are attempts to gain voluntary compliance:-.r3Subsequent vioFlatio s will re,suit. 1h appropriate legal action by the Town. WHITE OFFENDER CANARY ORD/REG PROG PINK ENFORCING OFFICER GOLD ENFORCING D/EPT . A J }�'.- ...,,.,.a.,,�;..Ze a._ 4 {'. h-.`-.k k...<. .� .. ... .......:�.,.,�i...:':.n.5��? ..sk:. xf .r.,r.A,,.z,x m t:.,+,. tl. a...:..,.� a,,..:>kx,xr�•ee.w..;L.,Ys,st ...,....__ ...,.: ..i,,..^t.:.n a, .,,..... .,.e„s...... .. ._, ,n A.., ..r ,4 a...a. �.o„�r,,,�..y��Yjeos� •sy�,v.,�i,.4 �y,£,.� i3§'s 6 y'-"�L�7.s 3,�"'� {y �. „g ePi.��r', 4t__'1+'�'G�tz�:-d" r�s���{y'lR,y';4i ..: ,z y'� �•L.,,,; A�>$ q xrw-a. �tsr- n 1� +•�.: . �^--,,,� '� r� &_ � �c.- � � f t� Y(� f a..,,q ,r �t i rr,s x -TOWN OF BARNSTABLE T' 77 -Ordinance u f`�or Regulation + yr. R Y•. � b •i' �r WARNING,.VOTICE � Name of Offender/Manager °{ �+ C �� ri 44 dob 5 Address of r '` d. r� s, ,MV/MB Reg # Village/State/Zip s`. ,. ..,.: fi ' y, ., .,., ? ,.. SS#` a, `Business Name t am/pm on; Business. Address y 7 ``Srgiiature of"•Enforcing° Officer �.. x c 4 Village/S.tate/Zlp Location of Offense ^f Enforcing rD,ept/Division tit4Offense .Facts This will "serve only.as `A warning ';At;'.this time •no legal- action `has been ,taken is the goal of . Town agencies, to achieve voluntary compliance • of Town _;Ord nances,; 'Rules. and" Regulations Educition .efforts -and warning notices arer. .`attempts to gain voluntary compliance Subsequent violations will result in appropriate legal. action .by .the Town A rt .k WHITE OFFENDER CANARY ORD7REG PROG� PINK ENFORCINGOFFICER � GOLD ENFORCING DEPT {� t,;•:g.,.xui:ro.. „r.>,.s-".apt .�d..- A .........: ..:.w:i�i ;+..,...<.:::. . .x,. .±'a s- , .w_,:,.«.:F.s.a .7„N.a.._..,_9.;.s,:t...;�^R ...% .�'�.. .::xr.�.. se k,..{p to...-33?., z..... 3 y.:, _,:....,n N5 i.;r".a•.,.A.l...,.,... y " TOWN OF BARNSTABLE Ordinance or Regulation WARNING -NOTICE Tv Address of Offender Odri�T/MB Reg '# r Villa e/Stave/Zip t �,t1lr l . t � _ :�t s 4: ' " ( 2 Business. Name am pm on J. Business- Address S ' ature of'Enfgrc�ing-Of,fice.r'. Village/State/Zip- � �- J Location of Offense '' .�p � 1 `, ! Enforcing Dept//:Division ;:Offense V f 10A" 1 Facts P f d 'This'_will - serve qn1 ;:As a warn ng.,':At- this time no legal actiohn has 'been "'taken. It is the goal °of ;.Town : agencies- to ..achieve `;volunta'ry compliance of Town. rdinances,._..Rules. And''.Re.gulations Education-"effo=ts, and warning' noticFes "are e attempts to gain:'voluntary compliance .>:. Subsequ.enfi.- violations -will ' result'a in appropriate Iegal action by the Town s __: 1 TOWN OF' BARNSTABLE `z'�x3 ffi ' t Ordinance or. Regulation = WARNINGS NOTICE' � 4l i Namef o Offender/Manager " ` + f, • - i + f'..Addr.ess of `Offender, ' # �. � t � HMV/MB Re t` u s w k� �1tK Ilia ge/ tate'/Zip IF .r �� �w, + �. ��,r L= r u `Business Name RL1rt rr a 'aIIl/plilj OCl '�3i s i�..ai � ,r �v a BuSlmess .rAddresS i 3 F r >` { ° Signature of Enforcing, O-, ' t r f t3te/Z1 'g Villa e/S �h � 3 � f Location. +of Offense + rJ 18 � p Enforcing Deptf/Division x" r r � ,� J ' Ns} � � �`''��r"� ,,�+�'�� �,,.x�:-� ��, �•� 4 a,.a� '+y r�.h � � � �� �,, ..;�t/1,,. Offense .G ~.a,� v0 .. «r•'.4 +'" X * �`Lt�: r;,�+°4 ,F rF .`} • "C act }'k 1% �1 3�'. .a��?�0. �`� `� f...�..,�- # &'z. .�'.�. sx d ,.ql u,+ {� s � .rs's {�t§ "w�,,$+, "`' +. "°" rrF B "'.gY '�Jr � ,,r �' +' r� a 1�'fi ar'�:+ ,,rlr �� 2J� ' ,ri 5 s,km r 6 Skit e ,f 3 $,b i2'*.-.h:...rr��' 1,r+ u i..it # ,r. t .9 ' This°`:will, serve only" as a ,warn"ing �A,t this time: no legal Action tias been taken goal of Town -',agencies °;`to achieve Y' volunt" ,compliance of t . `brdinances,r Rules, and.`-Regu5lations Education of orts and warning `ono tces ,pare `s attempts" to',gain .voluntary compliance Subsequent -iviola.tions will' res'ultin a ro riate 'le aI actionx by the Town °�. P o-P ��� g w son������i�� �r�i�1� * -ip i •J COMPLETE • s Complete items 1,2,and 3.Also complete A. ignature item 4 if Restricted Delivery is desired. X ( ❑Agent ■ Print your name and address on the reverse ❑Addressee so that we can return the card to you. B. Rec v d by(Printed Name) C. D e of elivery ■ Attach this card to the back of the mailpiece, / 6 or on the front if space permits. fo D. Is delivery address different from item Yes 1. Article Addressed to: If YES,enter delivery address below: ❑ No C3T i 3. Service Type Certified Mail ❑ Express Mail �A^ ❑ Registered ElReturn Receipt for Merchandise ! JV ❑ Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number (Transfer from service label) WOO J 09v DD/ 3 qO 6 q/D PS Form 3811,August 2001 Domestic Return Receipt 102595-01-M-2509, UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid USPS Permit No.G-10 • Sender: Please print your name, address, and ZIP+4 in this box • I � "Llblic Health ofifft Town of Bams 200 Mahn St Hyanft,Mms*mft 02601