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HomeMy WebLinkAbout0862 MAIN STREET (OST.) - Health 862 Mm:N s'm{ 5-< -OSTERVILLE- y A - 117 077 k I, No. �a l 7 Fee G'� 1'2 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: f+'"'� PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes =` 0[ppliLation for 30isposal *pstrm Co ULtion Permit ` Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ❑Complete System 2 Individual Components Location A dress or Lot No4 I fts4r% tSVTt .&- Owner's Name,Address,and Tel.No. Assessor's Map/Parcel — U Installer's Name,Address,and Tel.No. Designer's Designer's Name,Address,and Tel.No. Type of Building: ) Dwelling No.of Bedrooms I" ��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) ?%-d—Ti f✓M e✓L sat, 0 CE.S R►[t ,�«�ia�4 + � "ul C- 1P'tnyJ' #—n dl' C gS4 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_C.o&and not to place the system in operation until a Certificate of a� Compliance has been issued by this Board of He Sign Date D'S1 I a`,`� Z� Application Approved by Date Application Disapproved by Date for the following reasons Permit No. — 7 Date Issued jj NO. a . . .F� Fee ! .J I s t-Z THE COMMON„,WEALTH OF MASSACHUSETTS Entered in computer: PUBLIC'HEALTH DIVISION -,TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplication for 3019poBal 6pBtrm Cott ULtion 3perttlit Application for a Permit to Construct( ) Repair( ) Upgrade.(')' Abandon( ❑Complete System [Individual Components Location Address or Lot No.g�L jhc,�R ,.S c-QA k— Owner's Name,Address,and TeL No. LU_ Assessor's Map/Parcel � IZNZ p,c E�? Installer's Name,Address,and Tel.No.}o 1,�C►�-r Designer's Name,Address,and Tel.No. ;Ate' %c-ry.'Ct e- r1 L/ Type of Building: t Dwelling No.of Bedrooms . �" Lot Size sq.ft. Garbage Grinder( ) Other " Type of Building No.of Persons Showers( ) Cafeteria( ) i Other Fixtures X 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) ��,.�=� C-Ma vt� 'k^1, 03o44ft '1^ Jr +-�► "C_ �-� � "�`t, x" C QS c t7e�i �. � Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of , Compliance has been issued by this Board of Hea t�i! Signed :, Date DS+ 14 2 Q Application Approved by t ,, Date Application Disapproved by Date for the following reasons i Permit No. Date Issued n j f d�� � THE COMMONWEALTH OF MASSACHUSETTS Sr 11) ( BARNSTABLE,MASSACHUSETTS �`��J f Certificate of Compliance ( � THIS IS °O CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) l Abandoned V� 46 � ( Y n.. G` i! at L 11c�,4�. p,S•rt [ .tt`l L: has been'o.structed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ,._2o,2 I- ),2 dated Installer All) , Designer #bedrooms v A/I A Approved design flow JV . gpd The issuance of this permit shall not be construed as a guarantee that the system will ft n Lion ash designe Date 16 j Inspector ( (� ------------------------------- 1 ----. --------- --------- No. U a I - -7 �` Fee 7.J{ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS disposal 6pste tt Construction �PrtTClt Permission is hereby granted to Construct Repair( ) Upgrade( )' T'Abandon - System located at '—M t� e and as described in the above Application for Disposal System Construction,Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constructs n must be completed within three years of the date of this permit. ' Date �7, 7/a / Approved by �(-� ti`� Commonwealth of Massachusetts 0 Title 5 Official Inspection F o rrn ^i Subsurface Sewage Disposal System Form -Not for Voluntar Assessments y I j � 862-864 Main Street Property Address Osterkent, LLC Owner Owner's Name information is required for every Osterville " MA 02655 3/14/2021 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form, Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important;When A. Inspector Information filling.out forms h on the computer, use only the tab .lames Ford key to move your Name of Inspector cursor-do not Ford Septic Services LLC use the return - key;: Company Name P.O. Box 49 rab Company Address Osterville MA City/Town 02655 State Zip:Code 508-862--9400 S 12482. Telephone Number License Number- B. Certification certifythat: I am a DEP a �4-' approved system in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on:my training and experience in the proper function y and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ ,Conditionally Passes 3, El Needs Further.Evaluation by the Local Approving Authority 4. ® Fails 3/1912021 Insp t is Signature Date The ter inspector shalt 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 form.should".be sent to,the system,:owner and copies sent to the buyer, if applicable,`'and the approving,authority. Please note: This report only describes conditions at the time of in 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: t5insp.doc-rev.7!26/2618 Title 5 Official Inspection Form:Subsurface Sewage Disposal System'+page 1 of 18 Commonwealth of Massachusetts w Title 5 Official Ins ection Form Subsurface Sewage Disposal S st p y em Form-Not for Voluntary Assessments ' 862-864 Main Street Property Address Osterkent, LLC Owner Owner's Name information Is required for every Osterville MA 02655 3/14/2021_ page. City Town State Zip'Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5"86tl all ofi4 and'6. 1) 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: *'The Title 5 system passes. **The single cesspool fails 7. 2) System conditionally Passes ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved',by the Board of Health, will pass Check the box for'"yes", no or not determined (Y, N;.*ND),for the following`statements. f"not determined," please explain, z The septic,tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration.o,r 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 he"tank is less than-.20 years old is available. Y ❑ N ❑ ND (Expiairi below): t5insp.doc•rev,7/26/2018 `Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 18 r Commonwealth of Massachusetts F Title 5 Official Ins P.ection Form Subsurface Sewage Disposal System Fo m - Not for Volunta "Assessm/ ry ents 862-864 Main Street •tip .. Property Address Osterkent LLC Owner Owner's Name information is required for every Osterville MA _02655 3/14/2021 page. City/Town State ` - Zip Code Date of Inspection C. Inspection Summary (cont.) - 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarims'not operational. System will pass with Board of Health approval if pumps/alarms are repaired:, ❑ observation of sewage backup or break out or high static water]evel.in the distribution box due to broken or obstructedpipe(s) or due to a broken settled or uneven distribution box..'System will , pass inspection.if(with approval of Board of Health).- broken pipes)are replaced ," ❑ Y ❑ N ❑ ND (Explain below): . *. El obstruction is removed ❑ Y,;. ❑ N ❑ ND (Explain below)El : distribution box is leveled or replaced ❑ Y ❑ N ` ❑ ND (Explain below): ❑ 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(sj are replaced ❑ Y El N ❑ ND (Explain below): obstruction'is+removed ❑ Y,. ET N ❑ ND'(Explain below): 3.) Further Evaluation isAequieed by the Board of Health: t ❑ Conditions exist which.require further evaluation by the Board of Health in order to determine if the system is.failing to protect public health safetyor the environment. f a. 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: 15insp.doc•rev.7f2872018 T Ue.5 Official Inspection'Form:Subsurface Sewage Disposal System Page 3 of 18 r Commonwealth of Massachusetts_ _ Title 5 Official Inspection Form to Subsurface Sewage Disposal g p sal System Form -Not for Voluntary Assessments . V, 862-864 Main Street Property.Address Osterkent, LLC Owner' Owner's Name information is OStervllle required for every MA 02655 3/14/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (coat,) 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 b. 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: El 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 taW and SAS and the SAS is,withirt a Zone 1 of a public water supply. The system has aseptic 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, C. Other: z 4) System Failure Criteria Applicable to All Systems:. You must indicate"Yes"or"No to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool tSinap ifoc-rev.7/28/201 8 Title 5 Official Ipspection Form:Subsurface Sewage Disposal System-page'4 or 18 Commonwealth of Massachusetts` Title 5 Official Inspection Fora. < Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 862-864 Main Street Property Address Osterkent, LLC Owner Owner's Name information is OSterville required for every MA 02655 3/14/2021 page. CitylTown State Zip Code Dated Inspection. C. Inspection Summary (cont:). 4) System Failure Criteria Applicable to All Systems:`.(cont) Yes No ® Static liquid level in the distribution box above outlet invert'due to an overloaded or clogged SAS or cesspool ® Liquid depth in cesspool>is less than 6",below invert or available volume is less than Y2 day flow ® 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. 0 ® Any portion of;a cesspool or privy is.within a Zone 1 of a public water supply well. EJ ® Any portion of a cesspool`be 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.] E3. The system `is a cesspool'serving:a,facility with a design flow of 2000 gpd 10,000 gpd' ... 0 :Z 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. 5) Large Systems: To be considered a large system the system must serve a facilitywith a design flow of 10,000 gpd to 1 5,000 gpd. For large systems,you must indicate either"yes"or"no"to each of the'following, in add itIion to the questions in Section CA. Yes No- 0 1z 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 LI of a public water supply well t5insp doc•rev:7l2812018 TiOe 5 Official Inspection Form:Subsurface Sawage Disposal System•Page @ of 18 e r Commonwealth of Massachusetts. f Title 5 Official Inspection f=orrn Subsurface Sewage Disposal System.Form - Not forVoluntary Assessments l� 862-864 Main Street Property Address Osterkent, LLC Owner Owner's Name information is required for every Osterville MA 02655 3/14/2021 page. City/Town State Zip Code Date of Inspection: C. Inspection Summary (coat.) If you have answered "yes"to any question in Section;C'.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a'significant threat under Section C.5 or.failed` under Section CA shall upgrade the system in accordance with 310.CMR 15.304:The system.owner should contact the appropriate regional,office of the Department. 6. You must indicate "yes"'or"no"for each of the following for a//inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant; or.Board of Health R 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? El Have large volumes of water been introduced to the system recently or as part of this inspection? Z El 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 fors0sn of sewage back up?1 Was the site'inspected for signs ,f_break'out? ' ® ❑ Were all'system components,`excluding the SAS; located on site? ® ❑ Were the septic tank manholes uncovered; opened, and pthe 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? El Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? -The size andaocation of the Soil Absorption System (SAS) on the site has <I;een determined based on: ®' ❑ Existing information. For example, a plan at the Board of Health.. Determined, in the field (if any of the failure criteria related to Part C is at issue approximation.of distance is unacceptable) [310 CMR'15.302(5)) sl t5insp.doc•rev:7126/2018 Title 6 Official Inspection Form:Subsurface ewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts` Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments 862-864 Main Street Property Address : Osterkent, LLC Owner Owner's Name information is OSterville required for every MA 02655 3/14/2021 page. CltyfTown State Zip Code, Date of Inspection D. System Information 1. Residential Flow Conditionsr Number of bedrooms desi n :. Na ; n/a ( g ). Number,of bedrooms(actual): DESIGN flow based on,310 CMR,15.203 (for example 110 gpd x#`of bedrooms): n/a Description: t Number of current'residents Unknown Does residence have a garbage grinder,?,., El .Yes o' No Does residence have a water,treatment,unit? ❑ Yes No If yes, discharges to; Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ .Yes ® No Laundry system inspected? ❑ 'Yes ® No Seasonal use? . Yes Z No. Water meter readings; if available`(last 2 years usage(gpd)). Detail: unavailable :..: Sump pump?: ❑ Yes ® No Last date of occupancy:. currently. Date t5insp.doc•rev.7/28/2018 Us 5 Official Inspection Form:subsurface Sewage Disposal System-Page 7 of 18 I , Commonwealth of Massachusetts Title 5 Official, Inspection Form Subsurface Sewage Disposal System Form=Not for .Voluntary Assessments 862-864 Main Street U Property Address Osterkent, LLC Owner Owner's Namer information is required for every Osterville MA 02655 3/14/2021' page. City/Town State Zip Code Date of Inspection D. System Information (Pont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: :`retailloffice Design flow(based on 310 CMR.15.203): n/a Gallons per dpy(gpd) Basis of design flow (seats/persons/sq.ft., etc:): n/a Grease trap present? ❑ Yes No Water treatment unit present? - ❑ Yes Z No If yes, discharges to: Industrial.waste holding tank present? ❑ Yes No Non=sanitary waste discharged to the Title 5 system? ❑ Yes No Water meter,readings, if available: unknown Last date of occupancy/use: currently „ Date Other(describe below 3. Pumping Records:'`. . Source of information: unknown: " Was system pumped as part of the inspection? : � r. ® Yes [I No , . If yes, volume pumped. : 1500 gallons -- How was quantity pumped determined?: Reason for pumping; maintenance t5inep.doc•rev..7128/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 018 Commonwealth of Massachusetts Title 5 Official inspections Fora Subsurface Sewage Disposal System Form-.,Not for.Voluntary Assessments ti 862-84 6 Main Street Property Address Osterkent, LLC Owner Owners Name _ t information is required for every Osterville MA 02655 3/14/2021 page. CitylTown State Zip-Code Date of Inspection D. System Information (cont.) 4. 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 l/A.system by system;operator tinder contract 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 3/27/2001 Were sewage odors detected when arriving at the site' ❑~Yes 0 No 5. Building Sewer(locate on`site plan): Depth`below'grade:` feet Material of construction: ® cast iron 040 PVC [] other(explain): Distance from private water supply.well or suction line: feet Comments(on condition'ofjoints, venting;evidence of leakage,,etc:); t5insp.tloc•rev:7126l2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 r Commonwealth of Massachusetts P Title 5 Official Ins ection P o rrn t Subsurface Sewage Disposal System Form -Not forVoluntary Assessments .� 862-864 Main Street Property Address Osterkent LLC Owner Owner's Name information is required for every Osterville MA 02655 3/14/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont:) 6. Septic Tank(locate on site plan): Depth below grader 16" feet Material of construction: ® concrete ; ❑_metal, , ❑fiberglass D polyethylene []other(explain) I If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) , Yes M No Dimensions: 1500 gal. Sludge depth: 1 Distance from top of sludge to bottom of outlet tee or baffle 24 Scum thickness Distance from top Of;scum to top of outlet tee or baffle " Distance from bottom of scram to bottom of outlet tee or baffle 14, How,were dimensions determined? ' measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition,.structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tee's were present. The inlet steel cover was to grade. The tank was pumped after the inspection. y t5insp.doc rev.,7Y16/201e Title 5 Official Ihspection Form:Subsurface Sewage Disposal System•Page 10 of 1e Commonwealth of Massachusetts Title 5 Official Inspection 'Forml w Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments 862-864 Main Street` Property Address Osterkent, LLC Owner Owner's Name information is required for every Osterville MA' 02655 3/14/2021 page. Cityrrown "State Zip Code Date of Inspection D. System Information.(cont) 7. Grease Trap (locate on site.plan): Depth below grade: feet Material of construction: : a ❑ concrete ❑ metal - : ❑fiberglass,: ❑ polyethylene ❑ other(explain): N/a Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: . "Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition; structural integrity, liquid levels as related to outlet invert;evidence of leakage;'etc.); 8. Tight or Holding Tank(tank mtast be"pumped,at time'of,inspection) (locate on site plan).- Depth below grade: Material of construction: L El concrete` ' ❑ metal ❑.iiberglass. ❑ polyethylene ❑other(explain): N/a Dimensions 'Capacity: gallons Design Flow: gallons per day t5irisp.doc•rev.7/26/2018 r Title 5 OFficiW Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Fo rrn Subsurface Sewage Disposal System Form Not for Voluntary Assessments 862-864 Main Street Property Address Osterkent, LLC Owner Owner's Name_ isrequired for every Osteryille .MA 02655 3/14/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: J, ❑ Yes ❑ No - r Alarm level: Alarm in`'working order- El Yes ❑ NO Date of last pumping: Date- Comments(condition of alarm and float'switches,.etc.): N/a Attach copy of current pumping•contract(required). Is copy attached. ❑;Yes ❑ No 9. Distribution,Box(if present must be opened).(locate on site:plan): Depth of liquid level above outlet invert : Ewen Comments (note if box is level and distribution to outlets equal any evidence of solids carryover;any evidence of leakage into or out of:box; etc.): The D-box was normal. The cover:was 13" below r t5lnsp.doc•rev:7/2612018` Title 5 Official lbspection Form:Subsurface Sewage Disposal System-page 12 of 18 T Commonwealth of Massachusetts _ Title 5 Official Inspection Form p Subsurface Sewage Disposal System Form -Not for Vol untaryAssessments a� II .862-864 Main Street Property Address Osterkent, LLC Owner Owner's Name — information is required for every Osterville MA 02655, 3l14/2021 page. City/Town ;State Zip Code Date of Inspection D. System Information (cont.) 10. 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:): n/a * If pumps or alarms are not in working order, system is a conditional pass: 11. Soil Absorption System(SAS)(locate on site plan, excavation not required): .. If SAS not located,.explain why: { Type: leaching pits number.r. 1- 1000 gal. ❑ leaching chambers ` number. ❑ leaching galleries number: ❑. leaching trenches number, length: leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system } Type/..name of technology: t5insp;doc•rev:7/26/2018 Title 5 Official Ihspection Form:$ubsuiface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Ins ection F®rrn c p Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments - 862-864 Main Street Property Address Osterkent, LLC Owner Owner's Name information is required for every Osterville MA 02655 3%14/2021 page. CitylTown state:., Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont:) Comments(note condition of soil,.signs of hydraulic failure,-level of ponding, damp soil,,condition of vegetation,etc.): The pit was dry and clean.There was no si n of failure from the pit The cover was 18" below. 12. Cesspools(cesspool,must be pumped as part of inspection) (locate orr.site-plan): Number and configuration 1 single Depth top of liquid to inlet invert' Depth of solids layer Depth of scum layer Dimensions of cesspool, Materials,&construction Indication of groundwater inflow El Yes. ® No Comments (note condition-,of soil, signs of hydraulic failure, level of pond!ng,condition of vegetation, etc.): - . . _ _ �� This cesspool was part of the original,system that failed',backon 2f1272001.A new-system-was. installed on 3/27/0 , butthis:cesspool,was..not rempv ed.,A bathroom,fl'ows.to..this. It,needs-, be,' ~�- removed and re-piped the newer,system. t5ins ..doc•r .. er p_ 7/2t3/2018 '.. Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 14 of IS Commonwealth of Massachusetts q . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form—Not for Voluntary Assessments 862-864 Main Street Property Address Osterkent LLC Owner Owner's Name information is required for every Osterville MA 02655" 3/14/2021' page. City/Town State Zip,code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan); Materials of construction: .':N/a Dimensions Depth of solids Comments.(note condition of soil,"signs.of hydraulic failure, level of ponding condition of vegetation, etc.): w 1 t5msp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18. i Commonwealth of Massachusetts _ Title 5 official Inspection Form Subsurface Sewage Disposal S st em F . 9 p y ,. Form Not for Volunta Asses sments ssments v 862-864 Main Street Property Address Osterkent, LLC Owner Owner's Name information is required for every Osterville MA 02655' 3/14/2021 page. - CitylTown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch,in the area below . ❑ drawing attached separately � t� SySie,M" � 0 rtMn��d �S6 � o • } l ! y iq L3 t5lnsp.doc'•rev.7/26I2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 ' ' Commonwealth of Massachusetts Title 5 Official lnspection ,Forrn Subsurface Sewage Disposal System.Form -Nqt for Voluntary,Assessments. 862-864 Main.Street Property Address " Osterkent, LLC Owner Owner's Name information is required for every Osterville MA 02655 3/14/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. .Site Exam: ❑ Check Slope c ❑ Surface water ❑ Check cellar t❑ Shallow wells Estimated depth to high ground water: . 351 r feet Please indicate all methods used:to determine the high ground water elevation: ❑ Obtained from system design plans on record, If checked—date of design plan reviewed: Date Observed site(abutting property)observation.hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Topo and water contours maps Checked with local excavators, installers-(attach documentation) Z. (❑ , Accessed USGS database-explain: You must describe how you established the high groundwater elevation see above _ Before filing this Inspection Report, please see Report Completeness Checklist on next page. . t5hsp4oc-rev.7/26/201$. Title 5 official Inspection Form:Subsurface Sewage DisposaiSystem•Page 17 of 18 Commonwealth of Massachusetts � � � —►� Title 5 Officia l Inspection i®n Fo rm m Subsurface Sewage Disposal System Form - Not for Voluntary Assessments " 862-864 Main.Street. Property Address Osterkent, LLC Owner Owner's Name information is OStervllle required for every MA 02655 3/14/2021; page. City/Town Stats Zip Code Date of inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this.section. ® B. Certification Signed &;Dated,and 1, 2 3 or 4 checked ®` C. Inspection Summary: 1, 2; 3, or 5 completed as appropriate , 4 (Failure Criteria)and 6(Checklist)`.completed. D: System Information: . For 8: Tight/Holding Tank=Pumping contract attached For 14: Sketch of Sewage Disposal;Systerh drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included i f; i t5insp.doc-rev.,7/26/2018 Title 5 official Ihspect on Form:SuDsuriace Sewage Disposal systemr Page 18 of 1 t3 r oF�"r:ram, Town of Barnstable Inspectional Services Department R►MSrAB MASS. Public Health Division 1639. �0 ec► 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4987 8180 April 2, 2021 OSTERKENT LLC C/O MAYNARD K DAVIS, MANAGER 5357 RAVEN STONE ROAD CROZET, VA 22932 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 862-864 Main Street, Osterville, MA was inspected on 03/14/2021 by James Ford, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Single Cesspool fails. - You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH T�roma Mc eari,`i*,F-� Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\862-864 Main Street Osterville.doc Town of Barnstable BARNSTAMASS. r &679. Inspectional Services Department rtmen Public Health Division 200 Main Street, Hyannis MA 02601 Off ice: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CI10 Feb 6, 2007 Rev. 4/26/19 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An "x"' marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ❑ Structurally unsound septic tank or SAS ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box is above the outlet invert due to an overloaded or clogged SAS or cesspool ❑ A portion of the SAS, cesspool, or privy is below the high groundwater elevation ❑ A portion of the cesspool is located within a Zone 1 to a public well ❑ A portion of the cesspool is located within SU feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). T O 2 YEAR DEADLINE CRITERIA Single Cesspool ❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Cl 5. Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 862-864 Main Street ' Property Address Osterkent, LLC r A Owner Owner's Name information is required for every Osterville MA 02655 3/14/2021 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information SIB !S all�I on the computer, use only the tab James Ford key to move your Name of Inspector cursor-do not Ford Septic Services, LLC use the return - key. Company Name P.O. Box 49 4:1 � Company Address Osterville MA 02655 City/Town State Zip Code r � 508-862-9400 S 12482 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ® Fails 3/19/2021 )nspr nature Date 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 16 Commonwealth of Massachusetts Title 5 Official Inspect"on Form Subsurface Sewage Disposal System Form - Not for Voluntary<� st F Assessments 862-864 Main Street Property Address Osterkent, LLC Owner Owners Name information is required for every Osterville MA 02655 3/14/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: "*The Title 5 system passes. **The single cesspool fails 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): 15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 862-864 Main Street Property Address Osterkent, LLC Owner Owner's Name information is required for every Osterville MA 02655 3/14/2021 page. CitylTown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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 broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) 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. a. 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: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts v p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 862-864 Main Street Property Address Osterkent, LLC Owner Owner's Name information is required for every Osterville MA 02655 3/14/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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 I 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. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 862-864 Main Street Property Address Osterkent, LLC Owner Owner's Name information is required for every Osterville MA 02655 3/14/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® 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 water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 1a I l I Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u � 862-864 Main Street Property Address Osterkent, LLC Owner Owner's Name information is required for every Osterville MA 02655 3/14/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health.. ® EJ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 862-864 Main Street Property Address Osterkent, LLC Owner. Owner's Name information is OSterVille required for every MA 02655 3/14/2021 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): n/a Number of bedrooms (actual): n/a DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a Description: Number of current residents: Unknown Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: unavailable Sump pump? ❑ Yes ® No Last date of occupancy: currently Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 7 of 18 f Commonwealth of Massachusetts P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 862-864 Main Street Property Address Osterkent, LLC Owner Owner's Name information is required for every Osterville MA 02655 3/14/2021 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: retail/office Design flow(based on 310 CMR 15.203): n/a Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): n/a Grease trap present? ❑ Yes ® No Water treatment unit present? ❑ Yes ® No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: unknown Last date of occupancy/use: currently Date Other(describe below): 3. Pumping Records: Source of information: unknown Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Reason for pumping: maintenance t51nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 862-864 Main Street Property Address Osterkent, LLC Owner Owner's Name information is required for every Osterville MA 02655 3/14/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: installed 3/27/2001 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: t feet Material of construction: - ® cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts 6 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 862-864 Main Street Property Address Osterkent, LLC Owner Owner's-Name information is required for every Osterville MA 02655 3/14/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 16" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal. Sludge depth: 1 F Distance from top of sludge to bottom of outlet tee or baffle 24 Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 5 Distance from bottom of scum to bottom of outlet tee or baffle 14 How were dimensions determined? measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tee's were present. The inlet steel cover was to grade. The tank was pumped after the -inspection. 15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 9 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments L; 862-864 Main Street Property Address Osterkent, LLC Owner Owner's Name information is required for every Osterville MA 02655 3/14/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene y El other(explain): N/a Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain): N/a Dimensions: Capacity:, gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 862-864 Main Street Property Address Osterkent, LLC Owner Owner's Name information is required for every Osterville MA 02655 3/14/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): N/a *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Even Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The D-box was normal. The cover was 13" below t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 862-864 Main Street Property Address Osterkent, LLC Owner Owner's Name information is required for every Osterville MA 02655 3/14/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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.): n/a *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1- 1000�__ ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 -2 864 Main Street Property Address Osterkent, LLC Owner Owner's Name information is required for every Osterville MA 02655 3/14/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The pit was dry and clean. There was no sign of failure from the pit The cover was 18" below. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 single 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): This cesspool was part of the original system that failed back on 2/12/2001. A new system was installed on 3/27/01 but this cesspool was not removed. A bathroom flows to this. It needs to be removed and re-piped the newer system. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 a ` Commonwealth of Massachusetts Title 5 Official Inspection Form c�; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 862-864 Main Street Property Address Osterkent, LLC Owner Owner's Name information is required for every Osterville MA 02655 3/14/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: N/a Dimensions Depth of p solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a� 862-864 Main Street Property Address Osterkent, LLC Owner Owners Name information is required for every Osterville MA 02655 3/14/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 1 � B old SySie,M . old pipts 9.4 re,Md4�� V_ �S� l O . o a 13 I A B a 3A 3�` � I 3 y► 36 yy � yy i5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 862-864 Main Street Property Address Osterkent, LLC Owner Owner's Name information is Ostervllle required for every MA 02655 3/14/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water , ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 35 fee Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Topo 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: see above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 i ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;. 862-864 Main Street u, Property Address Osterkent, LLC Owner Owners Name information is required for every Osterville MA 02655 3/14/2021 page. Clty[Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate. 4 (Failure Criteria) and 6 (Checklist)completed ® D. System Information: . For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included r t5insp.cloc-rev.7/26/2018' Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 f Commonwealth of Massachusetts J DSO r D�I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 866 Main Street E Property Address 866 Main St. LLC Owner O :f�., wner's Name information is -504 required for every Osterville Ma. 02655 06/24/2016 page. Citylrown State Zip Code Date of Inspection Inspection p on results must be submitted on this form. Inspection forms may not be altered'in,any: way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, 5 144=use only the tab- 1. Inspector: key to move your cursor-do not Michael T Bisienere use the return Name of Inspector key. P Cape Septic Inspections °' �I Company Name OQ 624 Old Barnstable Road �I Company Address Mashpee Ma. 02649 City/Town State Zip Code 508-280-3356 S13938 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 06/25/2016 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""`This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts ti Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •°° 866 Main Street Property Address 866 Main St. LLC Owner Owner's Name information is required for every Osterville Ma. 02655 06/24/2016 page. Cltyrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 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: This building has a H-20 1500 gallon septic tank and a precast leaching pit.The liquid level in the leaching pit was 16 inches below the invert pipe at the time of the inspection. Under the current code this allows the system to pass in the Town of Barnstable B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking,and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 866 Main Street Property Address 866 Main St. LLC Owner Owner's Name information is required for every Osterville Ma. 02655 06/24/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.):. ❑ 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 i e s p p ( )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 broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 f Commonwealth of Massachusetts WE Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 866 Main Street Property Address 866 Main St. LLC Owner information is Owner's Name required for every Osterville Ma. 02655 06/24/2016 page. Cltyrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ' ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *`This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 866 Main Street Property Address 866 Main St. LLC Owner Owner's Name information is required for every Osterville Ma. 02655 06/24/2016 page. Cltylrown 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. ❑ ® An portion y p rt on of a cesspool or privy is less than 100 feet P P Y 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.] t ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. , E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the ' questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 F Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 866 Main Street Property Address 866 Main St. LLC Owner Owner's Name information is required for every Osterville Ma. 02655 06/24/2016 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part.of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 866 Main Street Property Address 866 Main St. LLC Owner Owner's Name information is Osterville required for every Ma. 02655 06/24/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 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? , ❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: ' Office/retail Design flow(based on 310 CMR 15.203): N/A Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Sq. Ft' ' Grease trap present? ❑ Yes ® No Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 6 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 866 Main Street Property Address 866 Main St. LLC Owner Owner's Name information is required for every Osterville Ma. 02655 06/24/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: occupied Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 866 Main Street Property Address 866 Main St. LLC Owner Owner's Name information is required for every Osterville Ma. 02655 06/24/2016 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 36" feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 24" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: standard H-20 1500 gallon i Sludge depth: 311 15ins•3113 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 866 Main Street Property Address 866 Main St. LLC Owner Owner's Name information is required for every Osterville Ma. 02655 06/24/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle apx. 35" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle apx. 5" Distance from bottom of scum to bottom of outlet tee or baffle apx. 12" How were dimensions determined? sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I would recommend the new owner put the tank on a maint. plan with a local septic pumping co. based on the future use of the home.The Barnstable Health Dept has a list of local pumping co Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 866 Main Street Property Address 866 Main St. LLC Owner Owner's Name information is required for every Osterville Ma. 02655 06/24/2016 page. City/Town State Zip Code Date of inspection D. system Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: t p de. 9 Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: El Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): `Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 866 Main Street Property Address 866 Main St. LLC Owner Owner's Name information is required for every Osterville Ma. 02655 06/24/2016 page. Cltyr'rown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert N/A 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.): I ran a camera in the discharge pipe I did not find a D-Box Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 866 Main Street Property Address 866 Main St. LLC Owner Owner's Name information is Osterville required for every Ma. 02655 06/24/2016 CI pa /Town D. Sst 9e. � State Zip Code Date of Inspection y em Information (cont.) Type: ® leaching pits number: One ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection the liquid level was 16 inches below the invert pipe Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 866 Main Stree t Property Address 866 Main St. LLC Owner Owner's Name information is Osterville required for every Ma. 02655 06/24/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): e I t5ins•3/13 Title it e 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 866 Main Street Property Address 866 Main St. LLC Owner Owner's Name information is required for every Osterville Ma. 02655 06/24/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 0 z - 30 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 866 Main Street Property Address 866 Main St. LLC Owner Owner's Name information is required for every Osterville Ma. 02655 06/24/2016 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 14 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: I augered a hole at a lower elevation and shot it with a transit Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 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 866 Main Street Property Address 866 Main St. LLC Owner Owner's Name information is required for every Osterville Ma. 02655 06/24/2016 page. Cltylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on'page 15 or attached in separate file r� e Jv1''Ja /h p� S, A . S, t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION 6 SEWAGE # A 001�--13( VILLAGE ASSESSOR'S MAP& LOT ILI -0 77 INSTALLER'S NAME&PHONE NO. b On L',1."124 SEPTIC TANK CAPACITY i�r©o LEACHING FACILl TY: (type) (size) 6 kC NO. OF BEDROOMS �Q , BUILDER OR OWNER. - PERMUDATE: COMPLIANCE DATE: Z-7Z®/ 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 A1*0 61iP,'1d,'4 el NO. r� 1 �G Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS o ar ent �lConztrurtior� Permit ���Ytcattot� for �tg� �p � Application for a Permit to Construct( )Repair( )Upgrade( Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ��� /"nQ/%� �f - Owner's Name,Address and Tel.No. Assessor's Map/Parcel ✓O // 7 /,Da,rn-t b 'p•6 .�j j�x 7 a, OsfBr✓,'��F �jj f1 Oo2(a$S Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No..S OY� ' ( /Qk/-e_'Su//tV 21ri Pe 1�: e p.p. g ox L.v%'q 7 Per G� Type of Bull ing:Dwelling No.of Bedrooms Lot Size 7 0c,erG ft. Garbage Grinder(1V19 Other Type of Building�' ��4�{10-No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow o9 06 gallons per day. Calculated daily flow O gallons. Plan Date FM ak . ZO O / Number of sheets Revision Date N � Title Pro 1j c,_o(__ .q o ,p S,4s#_i I7 S J�Ixd S Size of Septic Tank /SO 0 �L( X M-C _L Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss d by this oard of Health. Signed TIN Date ?I Application Approved by Date -T//4Zd 1 Application Disapproved for the following reasons Permit No. obQ Date Issued No. I ( G ,. _ Fee l THE COMMONWEALTH 0 MA SACHUSETTS Entered in computer: . , t Yes / PUBLIC HEALTH DIVISION -TOWN OF.BARNSTABLE., MASSACHUSETTS ✓' Application for Miopoml *p.5tem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No: ��, n�� 7 S Owner's Name,'Addiess and Tel.No. ` Assessor's Map/Parcel (�S f�.0 V��r�� �V i6�U D.�' R• ,C�a Y 1S - Installer's Name,Address,and Tel.No. 3ner's:Name,Address and Tel.No. te�'S61/)"v�17 P,�j' Type of Building: Dwelling No.of Bedrooms Lot Size 7 Cs CI Garbage Grinder( /v� Othei.,� w Type of Building�/066 6(.No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow c9 OD gallons per day. Calculated daily flow �OZ. gallons. Plan Date F0-2 20 O / Number of sheets�_ Revision Date N 0 Title Size of Septic Tank C-fi J Type of S.A.S. U Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system ' in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu d by this oard of Health. Signed 0_ �7-'S "1 Date P/ a Application Approved by Date 3 �� Application Disapproved for the following reasons Permit No. 0 /—I?. Date Issued 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 at • S6 a has been constructe in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 7 4V t- 1-S G dated 3y D Installer Designer v The issuance of this permit shall,not be construed as a guarantee that the system Will funct, nta'd'esigned. Date 3>/Z7�G/ g Inspector y '�07_ ——————————————————————————————————————— No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS x1i5potar *p6tem Construction Permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( ) System located at 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 /permit. Date: -3/��/�/ Approved by 117677 OPINE Town of Barnstable * 11AMSZABU, Board of Health 9�'ArF 61 P.O. Box 534, Hyannis MA 02601 Office: 508-8624644 Susan G.Rask,R.S. FAX: 508-790-6304 Ralph A.Murphy,M.D. Sumner Kaufman,M.S.P.H. To: DAVIS,HOLBROOK R Date Monday,March 05,2001 P O BOX 572 OSTERVILLE MA 02655 RE:Underground Tank at 862 MAIN STREET(OST.) Map/Parcel 117077 Tank NO: 01 Tag NO: 01066 The Town of Barnstable Public Health Division records indicate that your undergroud or chemical storage tank is 25 years of age,and has not been tested as required under section 07:(5)of th health regulation regarding fuel and chemical storage systems. You are directed to have each tank and its piping tested within thirty(30)days of the receipt of this notice. Results of the testing shall be filed with the Board of Health and the Fire Department. You are reminded that you shall have the tank and its piping tested during the 10th, 13th, 15th, 17th, and 19th year after installation,and annually thereafter. Failure to comply with this order may result in a fine of up to$300.00.Each day's failure to comply with an order shall constitute a separate violation. You may request a hearing if a written petition requesting same is received by the Board of Health within ten(10) days after this order is served. Per Order of the Board of Health Thomas A.McKean, RS, CHO Health Agent { TOWN OF BARNSTABLE LOCATION SEWAGE # ©d t j 3s VILLAGE ��� ASSESSOR'S MAP & LOT Ill :: 7-7 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /SOD LEACHING FACILrrY: (type) (size) C NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE. COMPLIANCE DATE. z 7�G 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 Teaching facility) Feet Edgebf Wetland and Leaching Facility(If any wetlands exist - within 300 feet of leaching facility) Feet " Furnished.by ---------�--�--------- -------------r � ^ - -�------------------ ----------------- -------------�------------- -------------~--- � - ----' -- - --�-�~~ � , HolhroA R. Davis n 249 ScaPuit Road - Box 572 Osterville, Massachusetts 02655 f'66j -, I z N br June 20, 1992 Town of Barnstable Health Department \ V Linda Leppanen 367 Main Street Hyannis, MA 02601 Dear Ms. Leppanen: Returned herewith are three certificates of registration for oil tanks. Als_o--.h.e:rewith two checks totaling $45. Ce tank with Tag :#-1063 was removed from underground about two years ago and all departments were notified and gave their approval . It has been replaced by an above ground tank which I understand is not subject to a fee. The checks are to c-owe�the other two i .e. one for Tag �#1066',,and one application without a tag number bu:t—ro on parcel #095015. Very truly yours, G Holbrook R. Davis HRD/jl Enc. -U. l