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Home My WebLink About0935 MAIN STREET (OST.) - Health r 93 5 Mairl Street Osterville A= 117— 184 6 cam, Commonwealth of Massachusetts T Title 5 Official Inspection Form Flo Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ca» 935 Main Street V �' Property Address 1.0 Richard Calahan r Owner Owner's Name ; information is required for every Osterville MA 02655 7-23-19 CRICity/Town/Town page. Y State Zip Code Date of Inspection w� 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. OFr � Important:When A. Inspector Information D �� 9 filling out forms p �� o�� . ':�y on the computer, =�:' JAMES (P use only the tab James D.Sears key to move your Name of Inspector cursor-do not Ca ewide Enterprises ':c+ o use the return y;L..�gF:� •' key. Company Name � i�F .... 5 f N 153 Commercial Street r� Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S 1623 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 0,6�_,L4, • 7-24-19 h-96ector'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 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. 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 it Commonwealth of Massachusetts Title 5 Official Inspection Form .W Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w � 935 Main Street Property Address Richard Calahan Owner Owner's Name information is required for every Ostenrille MA 02655 7-23-19 page. City/Town 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 system is a 1500 Gal. Tank D Box and trench 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form �a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 935 Main Street Property Address Richard Calahan Owner Owner's Name information is required for every Osterville MA 02655 7-23-19 page. City/Town 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 935 Main Street Property Address Richard Calahan, Owner Owner's Name information is required for every Osterville MA 02655 7-23-19 page. City/Town 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 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 an d d 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 F¢ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 935 Main Street AV Property Address Richard Callahan Owner Owner's Name information is required for every Osterville MA 02655 7-23-19 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 is less than 6" below invert or available volume is less than 1/z day flow 4- EA&1--<itiG ❑ ® 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 18 i Commonwealth of Massachusetts ,P Title 5 Official Inspection Form Fio Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 935 Main Street Property Address Richard Calahan Owner Owner's Name information is required for every Osterville MA 02655 7-23-19 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. ❑ ® 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)] o 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 935 Main Street Property Address Richard Calahan Owner Owner's Name information is required for every Osterville MA 02655 7-23-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): NA Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Description: 1500 Gal. Tank D Box and trench. Number of current residents: 2 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 El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): NA Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date I t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 I� Commonwealth of Massachusetts ,IF Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 935 Main Street Property Address Richard Calahan Owner Owner's Name information is required for every OSterVille MA 02655 7-23-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No 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: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? . ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Fl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 935 Main Street Property Address Richard Calahan Owner Owner's Name information is required for every Osterville MA 02655 7-23-19 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: NA / New D Box 7-2014. Were sewage odors detected when arriving at the site? • ❑ Yes ® No 5. Building Sewer(locate on site plan): 20" I Depth below grade: 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.): Pipeing is 4" PVC SCH -40. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 935 Main Street Property Address Richard Callahan Owner Owner's Name information is required for every Osterville MA 02655 7-23-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) - 6. Septic Tank(locate on site plan): Depth below grade: 10" 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: 1500 Gal. Precast H-10 Sludge depth: 211 Distance from top of sludge to bottom of outlet tee or baffle 28" 211 Scum thickness Distance from top of scum to top of outlet tee or baffle 811 Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape-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.): Tank at working level. Tank and covers at 10"below grade. Two inlet tee,s w/outlet tee. No sign of leakage or over loading. Note: Tank to be maint. pumped afther inspection.. t5insp.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 F Subsurface Sewage Disposal System Form -Not for Voluntary Assessments <� 935 Main Street Property Address Richard Calahan Owner Owner's Name information is required for every Osteryille MA 02655 7-23-19 page. City/Town 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 ❑ 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 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 ❑ other(explain): 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 c Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 935 Main Street Property Address Richard Calahan Owner Owner's Name information is required for every Osteryille MA 02655 7-23-19 page. City/Town 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.): *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 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-20" below grade w/one line out. D Box is New 7-2014 w/cover at 6". t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 935 Main Street Property Address Richard Calahan Owner Owner's Name information is required for every Osteryille MA 02655 7-23-19 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.): * 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: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 25' ❑ 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 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 935 Main Street Property Address Richard Calahan Owner Owner's Name information is required for every osterville MA 02655 '7-23-19 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.): Leaching is a 25' long trench. Camera out line and prob area. Clean and dry w/no sign of holding water. 12. 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 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 14 of 18 (f\, Commonwealth of Massachusetts Title 5 Official Inspection Form J. Subsurface Sewage Disposal System Form -Not for Vol u ntary'Assessm ents 935 Main Street Property Address Richard Calahan Owner Owner's Name information is required for every Osterville MA 02655 7-23-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 935 Main Street Property Address Richard Calahan Owner Owner's Name information is required for every Osterville MA 02655 7-23-19 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 ek TOWN OF BARNSTABLE LOO,ATION 9.3.3 A A SEWAGE # � VII LAGE- n S�e/P i/�� .2 ASSESSOR'S MAP& LOT JV=4L IN.§TALLER'S NAME&PHONE NO._ �Q C U M ��R 5O/!1 SE:MC TANK CAPACPTY L #C IING FACILITY: (type) I'!yD �LDU C.4/i4MAfAgsize) DD NO::OF BEDROOMS ;2. BUILDER OR OWNER PERMITDATE: Y 9 7 COMPLIANCE DATE: y'7 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Privai6::Water Supply Well and Leaching Facility (If any wells exist oh.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 j Furnished by ... i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 935 Main Street Property Address Richard Calahan Owner Owner's Name information is required for every Osterville MA 02655 7-23-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells N0 Estimated depth t high ground water: 10, 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: 12-14-15 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: T.H.at 9336 12-14-15 10' no G.W.. This lot is 3' higher bottom of field at 3' below grade. Field at T+above T.H. Depth. 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 c Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form Not for Voluntary Assessments 935 Main Street Property Address Richard Calahan Owner Owner's Name information is required for every Osteryille MA 02655 7-23-19 page. City/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 03 v/7oM PC �� 4 L . NU Gw t5insp.doc•rev.V2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered incoinputer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplitatlon for Disposal *, pstem Construction Permit Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. 931S t"L41M Sr 057, Owner's Name,Address,and Tel.No. W f C.(.L*04 ss, P i C.4 4PZC) C4 LL.444V Assessor's Map/Parcel 1 Pa gog S' MA— Installer's Name,Address,and Tel.No. S d2'-14`Z7—n 77 Designer's Name,Address,and Tel.No. d 4#V&C0i DE/A06C-0-7 6 OUa Gig , tj l,' A6 6E Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures i Design Flow(min.required) gpd Design flow provided tv L6= 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) pl 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 He h S t C Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. �(/ ` Date Issued 1 w� No. Ll Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01p pfiration.for -Misposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair(� Upgrade( ) andon( )a. Complete System Individual Components Location.Address or Lot No. C�, S ��(� O S- , Owner's Name,Address,and Tel.No. d � Sr� VOY c-c,t��l. � R.lC�4R� C4LL� Assessor's Map/Parcel1177 Installer's Name,Address,and Yel.No. $09- -77-181�7 Designer's Name,Address,and Tel.No. . C4pc-wla&/tz -<— a ocj--c.0 , tJl�4 t Type of Building: Dwelling No.of Bedrooms LotSize sq.ft. Garbage Grinder( ) Other Type of Building No'of Persons Showers( ) Cafeteria,_( ) r 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 4 e, n Nature of Repairs or Alterations(Answer when agplicable)1,; v Date last inspected:" -' Agreement:. The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in wµw. 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 oard of Health. Si Date Application Approved by Date P . e Application Disapproved by Date for the following reasons q Permit No. 91 [� Date Issued --------------------------------------------------------------------------------------------------------------------- ----------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(V Upgraded( ) Abandoned( )by C—u)(I roerj A nozL ca at g:� IVjAmc,�j ST' 6� has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit Nq-�/q ^�L,flated Installer _ av Designer #bedrooms Approved design flow and The issuance of this perlit shI ll not be construed as a guarantee that the system will nct n As desig Date Inspector - ------------------------------------------------ No. /o —c7-3 L, Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair A) Upgrade( ) Abandon( ) System located at 935 mr61 x) 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:Constructioq must be com leted within three years of the date of this p " it. Date ( Approved by 1 Lavelle, Timothy From: Sousa, Vanessa Sent: Friday, July 27, 2018 11:14 AMw`o To: Lavelle, Timothy wW' too) L �rj`' DJ B� Subject: Point Oil C" Co o �' o OL Hi Tim—I spoke with Savannah and she states Point Oil was sold to "Hop Energy." She says there is no storage of hazardous materials. Her contact number is 978-851-6111. Savannah will not be in on Monday or Tuesday next week, but you can speak to Susan. Thanks, Vanessa Sousa Town of Barnstable Health zoo Main Street Hyannis,MA 026oi rt. ON . S�Ot)cj 1 °F IKE►oq� Town of Barnstable Office:508.862_4644 Public Health Division Fax:508 790 6304 • enRMASSBLE.g` 200 Main Street• Hyannis, MA 02601 039.' TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT Q Business Name: 1 m V4 DI ( Date: Location/Mailing Address: Sf , Dsfe rv,1 I-e— Contact Name/Phone: - a,. 5'0A- T 71 -z32-9 I nventory Total Amount: 12Da4a1��{0 MSDS:low—S�G��o�S)>5 License Tier II : n Labeling: OY**, Spill Plan: �L a, e.t Qost Oil/WaterSeparator: Floor Drains: o Emergency Numbers: Storage Areas/Tanks: Wo Q.&A %l iw diM o o�u v� �,,, ,fig Emergency/Containment Eq_pment: S t� e k _y --�Waste Generator ID: VSog,--1 v5 Waste Product: 01 eicS Date&Amount of Last Shipment/Frequency: 6 30 110 l DO al --- / e SDI ktcs -III 5- Licensed Waste Hauler&Destination: (;,vL M►4 II Other Waste Disposal Methods: LIST OF TOXIC AND HAZARDOUS MATERIALS NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more requires a license from the Public Health Division. Antifreeze Dry cleaning fluids Automatic transmission fluid ?i Other cleaning solvents&spot removers Engine and radiator flushes Bug and tar removers Hydraulic fluid (including brake fluid) Windshield wash koo Motor oils Wgak w kA&At K Miscellaneous Corrosives Gasoline,jet fu I, aviation gas Cesspool cleaners Diesel fuel, kerosene, #2 heating oil Disinfectants Miscellaneous petroleum products: Road salts grease, lubricants, gear oil 4— O[� Refrigerants iZ A W I� Degreasers for engines&garages Pesticides: Caulk/Grout insecticides, herbicides, rodenticides Battery acid (electrolyte)/batteries Photochemicals(Fixers) Rustproofers Photochemicals(Developer) Car wash detergents Printing ink Car waxes and polishes Wood preservatives(creosote) Asphalt&roofing tar Swimming pool chlorine Paints, varnishes, stains, dyes Lye or caustic soda Lacquer thinners Miscellaneous Combustible Paint&varnish removers, deglossers Leather dyes Miscellaneous Flammables Fertilizers Floor&furniture strippers PCB's Metal polishes Other chlorinated hydrocarbons Laundry soil &stain removers r (including carbon tetrachloride) (including bleach) Any other products with "poison labels" L c(a� � ��,,y _ cases (including chloroform, formaldehyde, hydrochloric acid, other acids) VIOLATIONS: ORDERS: INFORMATION/RECOMMENDATIONS: 5vee, 4o ,l1 eo►,k, v.e ao_ 4 a�v�. o a\ 4, a;! s .M.c.,�..c , •t- v�a.�, S�.r� 2 eeS Inoue.- cr-ce.43 yr. O, 1 v- J-LS C9dC+te- nspector:--i -D e— �p �q'�a C S 4J4S-�2 • i c-�a� 2\&a�'��5Facility Representative: Sv%QW�tN ` '1%Clc+%0-%%_W �K. 4.y WHITE COPY- HEALTH DEPARTMENT/CANARY COPY-BUSINESS / Date: 3 /ate/ TOWN OF BARNSTABLE,�, �.�,, I? I TOXIC AND HAZARDOUS MATERIALS RIEROTRATM FORM NAME OF BUSINESS: �DIOr� 01 BUSINESS LOCATION: g3S/�a�n S� , �5-het,. l(� INVENTORY MAILING ADDRESS: TOTAL AMOUNT: TELEPHONE NUMBER: 0$ 1-71 -13 CONTACT PERSON: rjGoh a tv, EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: %Q g�- INFORMATION / RECOMMEND TIONS: �� G o cell of +'�s ' F,I e D t ict: z Jv� inn, f- v,s 3�� I �a a Sac o S,`�� `') �xvkQ L- �-✓1'�►'Vl Waste Tlr�eri¢cor I o 8 13 a+�sportat shipment of hazardous waste: Name of Hauler: C Destination: �G��o�- , ✓V� fl IO°1a Waste Product: way+t o•k oily 50119,5 Licensed . es No M*' ad2,3o37"l7 NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants (go Motor Oils Pesticides ❑ NEW USED 100 auk'- (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives(creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers (including bleach) Spot removers &cleaning fluids (dry cleaners) '�. Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staffs Initials 1 Town of Barnstable m'Q 1 SHE�Q Regulatory Services 11 c� W �.o Thomas F. Geiler,Director Public Health Division sAMSTASLEI Thomas McKean,Director v$ 1 MASS. 1� 200 Main Street, Hyannis,MA 02601 prFD MA't A Phone: 508-862-4644 Email: healthQtown.bamstable.ma.us Fax: 508-790-6304 Office Hours: M-F 8:00—4:30 August 25,2006 Ms.Nancy Mann Point Oil 935 Main Street Osterville,MA 02655 Dear Ms.Mann: Thank you for your time and cooperation during the follow-up hazardous materials inventory and site visit at Point Oil on July 31, 2006. Please note the problems identified at your place of business during the May 1 2006 hazardous materials inspection and their corresponding orders or recommendations listed below and the follow-up information from the July 31,2006. Due to the removal of the 275 gallon tank,the inventory levels indicate that you are not required to obtain a hazardous materials permit for the 2006-2007 year. PROBLEM(May 1,2006): • Drum of waste oil was not properly labeled. ORDER: • Please label your 275 gallon tank of waste oil with"Waste Oil' or"Used Oil". FOLLOW UP (July 31,2006): • The 275 gallon tank has been removed(permitted thru the COMM Fire Department)and replaced with at 110 gallon tank. PROBLEM(May 1,2006): • Three 55 gallon drums not properly labeled with its contents. ORDER: • Please label your 55 gallon drums with"Soiled Solids"etc. FOLLOW UP (July 31,2006): • Contents have been labeled with"Solid Waste". PROBLEM(May 1,2006): • Contingency plan not posted in the shed where the 275 gallon tank of waste oil is stored. ORDER: • Please refer to the Town of Barnstable General Ordinance: Chapter 108: Hazardous Materials, Section 6(A-H). • Post contingency plan near all phones as well as in the shed. This will provide adequate information i.e.telephone numbers and contacts in the event of an emergency spill or release. FOLLOW UP(July 31,2006): • Did not see this posted during the visit,please ensure there is a list posted with emergency telephone numbers and contacts in the event of a spill. PROBLEM(May 1,2006): • Used rags and uniforms are stored in a mesh bag. RECOMMENDATION: • Place rags and uniforms in a metal can with a lid. FOLLOW UP(July 31,2006): • Rag can with lid has been obtained and put into use. On Site Inventory Total The Toxic and Hazardous Materials On-Site Inventory from the follow up visit on July 31, 2006 shows that you have approximately 110 gallons of toxic and hazardous materials being used, stored, generated and disposed of at Point Oil, 935 Main Street,Osterville,MA(Please see enclosed Toxic and Hazardous Materials On Site Inventory sheet). The Board of Health has determined that the using, storing, generating and disposing of over 111 gallons of hazardous materials per month requires businesses in the Town of Barnstable to obtain an annual Hazardous Materials License. The permit for the fiscal year 2006-2007 does not need to be obtained from the Town Offices located at 200 Main Street,Hyannis,MA 02601. If you decide to use, store, dispose of or generate more hazardous materials at this location,please contact the Health Department. If you have any questions about these problems,the orders and recommendations,or you need further information, guidance or assistance,please do not hesitate to contact the Public Health Division. Sincerely, A7lisha L.Parker Hazardous Materials Specialist All orders to correc violations of Chapter 108 of the Town of Barnstable Ordinance: Hazardous Materials shall be co pleted upon receipt of this letter. mas A. Mc ean,RS, CHO Director of Public Health s Enc. On-Site Inventory(copy) Date: 7 /P/ XO�o TOWN OF BARNSTABLE pA5WU TOXIC AND HAZARDOUS ARD MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: - od BUSINESS LOCATION: �� n4 ibk SD2&n, .�(yy i u- 3 A/4A IN MAILING ADDRESS: OTAL AMOU TELEPHONE NUMBER: l 1-7 1 —.032 CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: MSD ? TYPE OF BUSINESS: lV(1 0js�Y� Q INFORMATION/RECOMMENDPjION Fire District: I)Ak imb. r ��1lrb�a I �i Waste Trans portati n: tks Last shipme f hazardous waste: jo_ � Name of Hauler• -Destination-- Waste Product: M241k, oLk Licensed Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the GentraKaws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum Antifreeze (for gasoline or coolant systems) Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor&furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers (including bleach) Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS -71211oV Tj od - FWWY-o? o� OIL WASTE OIL OIL FILTERS ANTIFREEZE WASTE ANITFREEZE GASOLINE WASTE GAS DIESEL FUEL W/W FLUID ATF HYDRAULIC/ MISC. MISC. MISC. MISC. BRAKE FLUID COMMBUSTIBLE FLAMMABLE CORROSIVE PETROLEUM (GEAR OIL/GREASE/ LUBRICANTS) FREON ACETYLENE CAR WASH CAR WASH PAINTS/ WAX DETERGENTS THINNERS SEALANT CLEANING BATTERIES/ POISION/TOXIC CAULK/GROUT SOLVENTS BATTERY ACID FERTALIZERS WASTE SOLVENT MSDS MANIFESTS JA) K )Ak Dja f i Town of Barnstable z ;q oFt r Regulatory Services �► '1� Thomas F. Geiler,Director Public Health Division axxsTas '* Thomas McKean,Director 9�p 63 200 Main Street, Hyannis,MA 02601 r, a. Phone: 508-862-4644 Email: health ,town.barnstable.ma.us Fax: 508-790-6304 Office Hours: M-F 8:00—4:30 May 1, 2006 Ms.Nancy Mann Point Oil f 935 Main Street Osterville,MA 02655 Dear Ms. Mann: Thank you for your time and cooperation-during the hazardous materials inventory and site visit. at Point Oil on April 25,2006. This letter contains information from that visit that will help your become compliant with Chapter 108 of the Town of Barnstable Ordinance: Hazardous Materials. Enclosed are copies of Chapter 108: Hazardous Materials ordinance,the Toxic and Hazardous Materials On-Site Inventory form from the site visit, and a sample Contingency Plan. Please note the problems identified at your place of business during the hazardous materials inspection and their corresponding orders or recommendations listed below. PROBLEM: • Drum of waste oil was not properly labeled. ORDER: • Please label your 275 gallon tank of waste oil with"Waste Oil" or"Used Oil". PROBLEM: I • Three 55 gallon drums not properly labeled with its contents. ORDER: • Please label your 55 gallon drums with"Soiled Solids"etc. PROBLEM: • Contingency plan not posted in the shed where the 275 gallon tank of waste oil is stored. ORDER: • Please refer to the Town of Barnstable General Ordinance: Chapter 108: Hazardous Materials, Section 6(A-H). • Post contingency plan near all phones as well as in the shed. This will provide adequate information i.e. telephone numbers and contacts in the event of an emergency spill or release. n PROBLEM: • Used rags and uniforms are stored in a mesh bag. RECOMMENDATION: :ite Place rags and uniforms in a metal can with a lid. On Inventory Total The Toxic and Hazardous Materials On-Site Inventory from April 25, 2006 shows that you have approximately 305 gallons of toxic and hazardous materials being used, stored, generated and disposed of at Point Oil, 935 Main Street, Osterville,MA(Please see enclosed Toxic and Hazardous Materials On Site Inventory sheet). The Board of Health has determined that the using, storing, generating and disposing of over 111 gallons of hazardous materials per month requires businesses in the Town of Barnstable to obtain an annual Hazardous Materials License. This license has been obtained by you for the fiscal year 2005-2006. The permit for the fiscal year 2006-2007 shall be obtained by June 30,2006 from the Town Offices located at 200 Main Street,Hyannis,MA 02601 (application enclosed). Why are these recommendations being made for Point Oil? • This information is intended to educate you, a business owner/operator in the Town of Barnstable, in order to keep your business operations in compliance with local, state and federal toxic and hazardous materials laws so that you can avoid future regulatory problems. • Complying with the Town of Barnstable General Ordinance: Chapter 108: Hazardous Materials can prevent contamination of Barnstable's existing and future drinking water supply,prevent environmental contamination which can bankrupt site owners, lower or destroy land values, drive out residents and industry, depress local economies and endanger public health. If you have:any questions about these problems,the orders and recommendations, or you need further information, guidance or assistance,please do not hesitate to contact the Public Health Division. AAl rely,a L. Parke Hazardous Materials Specialist All orders to correct A lations of Chapter 108 of the Town of Barnstable Ordinance: Hazardous Materials shall be com leted upon receipt of this letter. Thom s A. McKean,RS, CHO Director of Public Health Enc. On-Site Inventory (copy) Chapter 108 (copy) Contingency Plan (sample) MSDS (sample) Application TOWN OF BARNSTABLE �ate: TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY a NAME OF BUSINESS: BUSINESS LOCATION: FeWl INVENTORY MAILING ADDRESS: it TOTAL AMOUNT- TELEPHONE NUMBER: 5D9 _1?2/ - 034-g Said CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: MSDS, rON SITE? TYPE OF BUSINESS: F 11f INFORMATION/RECOMMENDATIONS1 Fire istrict: ! Wvvd` eb,M Tk Uttk aASW a, _Ar ka"steTnorrati"or � L st shipment of hazardous w ste O Name of Hauler• - Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum Antifreeze (for gasoline or coolant systems) Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides NEWQ7,� USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor &furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers (including bleach) Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS V� ToLk+ v q L9�5 tip —: 05kA V[LU OIL WASTE OIL OIL FILTERS ANTIFREEZE WASTE ANITFREEZE 0�75" x S� +� C p(,IG�S V"V6 GASOLINE WASTE GAS DIESEL FUEL W/W FLUID ATF Jo hh �U 16 HYDRAULIC/ MISC. MISC. MISC. MISC. BRAKE FLUID COMMBUSTIBLE FLAMMABLE CORROSIVE PETROLEUM (GEAR OIL/GREASE/ LUBRICANTS) FREON ACETYLENE CAR WASH CAR WASH PAINTS/ WAX DETERGENTS THINNERS SEALANT CLEANING BATTERIES/ POISION/TOXIC CAULK/GROUT SOLVENTS BATTERY ACID FERTALIZERS WASTE SOLVENT MS MANIFESTS - --t OK fr,s tcfi 6�- r Und Ttiah' 1 6-14 (V ; 3 algaybucies W�t� w� Number Fee 891 THE COMMONWEALTH OF MASSACHUSETTS $100.00 Town of Barnstable Board of Health This is to Certify that Point Oil 935 Main Street, MA 02655� Is Hereby Granted a License FOR: STORING OR HANDLING 111 GALLONS OR MORE OF HAZARDOUS MATERIALS. ------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------- This license is granted in conformity with the Statutes and ordinances relating there to, and and expires June 30, 2006 unless sooner suspended or revoked. - ----------------- ---------------------- PAUL J.CANNIFF,DMD WAYNE MILLER,M.D.,CHAIRMAN February 10, 2006 SUMNER KAUFMAN,M.S.P.H. THOMAS A. MCKEAN,R.S.,CHO Director of Public Health s 0.4/25/2006 13:35 FAX 16002/002 r- COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION FOR IN-STATE WASTE DIVISION OF HAZARDOUS MATERIALS OIL ONLY OR One Winter Street IN-STATE VSO® HW/W0 ' Boston, Massachusetts 02108 Please print or krpa.(Farm designed for use on sifts(12-DI1ch)typewriter.) UNIFORM-HAZARDOUS 1.G nermor US EPA ID No. Manlfast 2.Page 1 Information In the shaded areas WASTE MANIFESTIm r� �4 q L DI e t N p Df Is not required by Federal law. 3..+Generator's Name and Mailing Address 74.G �� r / ' ate 4.Generator's Phone(5�_' 1 e,_�aWzF-� ✓ 4/ s 5,Transporter 1 Company Name 6. . US EPA ID Number rU L_ CYN OIL CORPORATION MAD0612136 LrI 7.Transporter 2 Company Name 8. US EPA ID Number VI C4 S.Designated Fecilily Name and Site Address 10. US EPA ID Number m CYN OIL CORPORATION ^ 1771 WASHINGTON STREET P.O . BOX 01 1 9 tvSTQUGHTON. MA Q2072 bdaiQQ 6 Q B 0 8 V 17 12.Coat Insto 13. 14. - n 11,US DOT Degalption fincludlnq Proper ShipOlnp Narita,HerarOCless,and ID Number) Total Unit .. a No. Type.i Cusntlty Wt/Vol a. IE PETROLEUM OIL COMBUSTIBLE LIQUID a) NA 127Q P (WASTE OIL O l T T V G -� m G b- n w E FA a E H 10 R C. -� CC A is T 3 c 0 a 0 Z to U d r'l � Z d1 � N a E15.Special Handling Instructions and Additional Information p E 24 HOUR EMERGENCY SPILL RESPONSE 781-341-5108 D.O.T. EMERGENCY GUIDE NO. 128 Q y le.GENERATOR'S CERTIFICATION:I hereby declare that the contents of thleconelsnmem era fully and accurately described above try � I proper ehippinp name end are aleeaifled,DSCked,malted,and labeled,and are in all respects In Proper condition for transport W highway 0 standing to applicable International and national government repuletlons. CC If I am a large quentlty generater,I certify that I haw a program In piece to reduce the volume and toxicity of waste generated to the degree I have determined to be economically practicable and trial I have selected the practicable method of treatment,Storage,or dlaDeaal currently avefleble to me which minimizes the present and future threat to human health and the envlron- y Mani;OR,III efh a amag quarnity generator.I havo made a good faith effort to minimize my wests gonaradon and select the boat waste management method the;IS available to me and that I E can aflard. m Date n a�n 1 �lgnahi I Monr par fear 0 CWnf t�JY j y TT 17.Tram ort r Aoknowle ernFie tofMaterials Data 0 A *A n pa me 19nature Mapl Day Year V N �1 c v C.t.� �1. ' i ~ A 18_ n Drter Acknowled ent of Reoel of Maadals Date E Piintetf/rypedNarm ftAoriea Month Dar Year R F 19.Discrepancy Indlostlon Space A C I L 20.Facility Owner or Operators Cardflcatlon of recelpt of hazardous materials covered by this manifest except as meted In Item 1 S. Date T r DeOlysirM Sl Month Dey rabr Form Aglovad OMB No. 50.0039 EPA Fotrn 8700-22( eV.9-94)Previous editions are obsolete. COPY>1 : FACILITY MAILS TO GENERATOR Town of Barnstable-Health Department Page 1 HAZARDOUS MATERIALS INVENTORY SITE VISITS DBA: Point Oil Fax: ..... Corp Name: Mailing Address es _.... Location: 935 Main Street,Osterville Street: ......... .. .. .__.... „ .......... ...................... mappar: City: Hyannis Contact: '';Jim Flannery,GM State: Telephone: 4508)771-2329 Zip: Emergency: Person Interviewed: Nancy Mann Business Contact Letter Date: Category: Miscellaneous Inventory Site Visit Date: 4/25/2006 _..... ..............................................._....--_......._... Type: Follow Up/Inspection Date: ......... _....... ❑d public water ❑ indoor floor drains W outdoor surface drains S6 license required ❑ private water ❑ indoor holding tank mdc W outdoor holding tank mdc ❑ currently licensed ❑ town sewage ❑ indoor catch basin/drywell ❑ outdoor catch basin/drywell expir - - - on-site sewage ❑ indoor on-site syste ❑ outdoor onsite system date: ....................................._ ......... ....___ Remarks:4/8/97 Use truck wash pad owned by Cape Cod Oil Service, compliance: Spedi dry for spills,MSDS sheets. REMARKS: 1999- Satisfactory Recycle"Speedy Dry" 4/25/2006 alp-Absorbent present for releases or spills,No labels on sides of drums,No label on waste oil tank,rags and uniforms placed in mesh bag,Recommend to place all rags and uniforms in metal container with lid. All uniforms are picked up on Tuesdays. Page 2 Town of Barnstable-Health Department HAZARDOUS MATERIALS INVENTORY Chemicals: ❑ Zero Toxic Waste Materials ❑ gty's>25 Ibs dry or 50 gals liquid but less than 111 gals ❑d gty's 111 gals or more ' qa ctescrip4ion SRO: ,gtys un�tof measure waste oil 275 gallons gasoline ( 30 gallons Waste Transporter: Cyn Oil fire District: COMM Last HW Shipment Date: 11/30/2005 Waste Hauler Licensed: Yes ,. V r Number Fee , 185 THE COMMONWEALTH OF MASSACHUSETTS $125.00 Town of Barnstable Board of Health This is to Certify that Point Oil Company 935 Main Street, Osterville, MA - Is Hereby Granted a License For: Storing or Handling 111 - 499 gallons of Hazardous Materials. -------------------------------------------------------------------------------------------------------------------------------------------------------------------- This license is granted in conformity with the Statutes and ordinances relating there to,and a and expires 06/30/2018 unless sooner suspended or revoked. --------------------------------------- PAUL J.CANNIFF,D.M.D,CHAIRMAN DONALD A.GUADAGNOLI,M.D. 07/01/2017 JUNICHI SAWAYANAGI THOMAS A.MCKEAN,R.S.,CHO Director of Public Health P TOw of Ba stable c. atdry Services Richard V. Scali,Director Public Health Division BARNSTABLE y MR,MARM Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 � � Office: 508-862.4644 CW14 -,1Fax: 508.790-6304 �.. APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE HAZARDOUS MATERIALS IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE,C14APTER 108, HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS JULY 1 st—JUNE 3 Oth). APPLICATION FETES CATEGORY 1 PERMIT 26— 110 Callon: $ 50.00 ❑, . CATEGORY 2 PERMIT 111 —499 Gallons: $125.00 CATEGORY 3 PERMIT 500 or more Gallons; $150.00 ❑ *A late charge of$10.00 will be assessed if payment is not received by July Ist. 1. ASSESSOR'S MAP AND PARCEL NO. 2. IS THIS A PERMIT RENEWAL? eATS NO. IF YES,SKIP QUESTION 3. 3. FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS ZONING/BUILDING APPROVAL FOR HAZARDOCS MATERIALS STORAGE/IJSE OF GREATER THAN HOUSEHOLD QUANTITIES(25 GALLONS)? YES NO. 4. FULL NAME OF APPLICANT: 01(U 0 l �- -'l/ 5. NAME OF ESTABLISHMENT: 1 T f ®L 6. ADDRESS OF ESTABLISHMENT: �S� j ca 2 7. MAILING ADDRESS(IF DIFFERENT FROM ABOVE: S. TELEPHONE NUMBER OF ESTABLISHMENT. L`7 9. EMAIL ADDRESS: ILL i�" 10. SOLEOWNER: ES�NO IF NO,&AME OF PARTNER: 11. FULL NAME,HOME ADDRESS,AND TELEPHONE#OF; CORPORATION NAME .N �C PRESIDENT TREASURER ✓�/ CLERK 12, IF PREPARED BY OUTSIDE PARTY: NAME: TELEPHONE#: COMPANY ADDRESS EMAIL: SIGNATURE OF APPLICANT DATE l Q:1Application Fomrs\HAZMAT APP 2017 REV ,doe E0/Z0 39Vd CIO 1NIOd 0EZT8Zb805T Eb:ET LIOZ/50/90 Number Fee 185 THE COMMONWEALTH OF MASSACHUSETTS $125.00 Town of Barnstable Q Board of Health This.is to Certify that Point Oil Company 935 Main Street, Osterville, MA Is Hereby Granted a License For: Storing or Handling 111 - 499 gallons of Hazardous Materials. This license is granted in conformity with the Statutes and ordinances relating there to, and and expires 06/30/2017 unless sooner suspended or revoked. ---------------------------------------- WAYNE MILLER,M.D.,CHAIRMAN. PAUL J.CANNIFF,D.M.D. 07/01/2016 JUNICHI SAWAYANAGI THOMAS A.MCKEAN,R.S.,CHO Director of Public Health tam -'_ _ OL ee- Q , 935 Main Street Osterville, MA 02655 - I 508-771-2329 Nancy Mann n Town of Barnstable • Regulatory Services r ` Richard V. Scali,Director "' VA ' Public Health Division BAMSTAB Thomas McKean,Director 109'2014 200 Main Street,Hyannis,MA 02601 575 , Office: 508-862-464-4 Fax: 508-790-61V fV APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE HAZARDOUS MATERIALS IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE, CHAPTER 108, HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL,PERMIT(RUNS 7ULY l st-:1"iJNE 3 0th). APPLICATION FEES CATEGORY 1 PERMIT 26— 110 Gallons: $ 50.00 ❑ CATEGORY 2 PERMIT 111 —499 Gallons: $125.00 X-C-1-- CATEGORY 3 PERMIT 500 or more Gallons: $150.00 ❑ • A late charge of$10.00 will be assessed if payment is not received by July 1st. ASSESSORS MAP AND PARCEL NO. DATE O� FULL NAME OF APPLICANT: `� �1 C NAME OF ESTABLISHMENT: I (+ ADDRESS OF ESTABLISHMENT: MAILING ADDRESS(IF DIFFERENT): r TELEPHONE NUMBER OF ESTABLISHMENT:�-� �'1 1 a EMAIL ADDRESS: (' Q , SOLE OWNER:' YES NO IF NO,NAME OF PARTNER: FULL NAME,HOME ADDRESS,AND TELEPHONE# OF: CORPORATION NAME 1A G PRESIDENT U. TREASURER G CLERK IF PREPARED BY OUTSIDE PARTY: • ST� =APLICANT Name: Company Address Telephone#: Email: Q:\Application FonnsUiAZZAPP Rev I6.docx Page 1 of 2 i _ _ • . , . ,. . ; - • j ` + • �,.rf iA`«ti .� ma's <•�;� . � o��, ;:�:u r �: ,.,� I r TOWN OF BARNSTABLE BAR -W02 Ordinance or Regulation WARNING NOTICE . Name of Offender/Manager tMt(ny1- Address of Offender MV/MB Reg. # Village/State/Zip �} Business Name io+ � �f 0 i m/pm; on -TI7-< 20/8 Business Address Signatur!a f Enforcing Officer Village/State/Zip '� �`�t -, M YA j Location of Offense Enforcing Dept/Division OffenseX�' Facts � aJe- 102�-(O. Pet t0 i e,eWt— 1A)ITw'K IVLeSS S . f This will serve only as a warning. At this time no legal action has been taken. It is the goal of Town agencies to achieve. voluntary compliance of Town.Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. WHITE-OFFENDER CANARY-ORD./REG_-PROG. PINK- ENFORCING OFFER GOLD-ENFORCING DEPT. TOWN OF BARNSTABLE . 2 Ordinance or Regulation BAR -W G022 WARNING NOTICE �t t Name of Offender/Manager lu t#f�"V ov Address.of Offender MV/MB Reg. # Village/State/Zip Busi.ness.Name ^ `�t ' :na /m/pm, on�-7z,<; 20 !r3 Business Address Signature'.of Enforcing Officer : Village/State/Zip YA o Location of Offense ''`%A- p e+ 1 ,.- } } ( Enforcing Dept/Division ' Offense ` ' "'- Facts This will serve only as a warning. At this time no legal action.has been taken.. It is the goal of Town agencies to achieve . voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are:attempts to gain voluntary.compliance: Subsequent violations will result in appropriate legal action by the Town. WHITE-OFFENDER CANARY-ORD./REG.-PROG. 'PINK-ENFORCING OFFER GOLD- ENFORCING DEPT. .r CE13TERVILLE-OSTERVILLE-MARSTOWS MILLS FIRE DISTRICT 1875 RATE 28 TERVILLE, MA 02532 (508) 790-2380/FAXC(508) 790-2385 OILMAZARDOUS MATERIAL RELEASE FORM F.A.# /'� '� --7 LOCATION: ADDRESS OF RELEASE •fin MlgIAj DATE OF RELEASE: PRODUr-T RELEASED: s,-,,-_�t ESTIMATED WANTITY: --� -- - r CORRECTIVE ACTION TAKEN BY RESPONSIBLE PARTY: UNU IJOviil+ !tv TI ia - NOTIFICATIONS: FIRE DEPARTMENT: YES( NO( ) D ATE: TIME ►/t-/-Z NATIONAL RESPONSE CENTER. YES( ) NO( ) ",DATE-:• •-- TIME: DEPT.OF ENVIRONMENTAL PROTECTION YES( NO( ) DATE�_c.� IME: t,v ^rY OIL SPILL COORDINATOR: YES( ) NO( ) DATE: /`Ol' / TIME.V 5 TOWN BOARD OF HEALTH: YES(,/Y NO( ) DATE•.��TIME- TOWN HARBORMASTER: YES( ) NO( j DATE_ . f v TIME: - OTHER AGENCIES Ivi yr 4- r Q#& r"_%-v - R I . COMMENTS �A .VlSrni rl-47 r cJP6 /'1 ne vo(L.►"t0 Uri JY1C.l. c � v,.�� ri v r• pti► PIKKi dW i j•-o✓mod //Kl//a,< 7•- /O aTS v► INS/nx: v�� i�ct..l,<d' on1 ! hG yy�.�y. (►�K /.�M. .�IVC� Ic of A„�• n-► r �rx!►<� Ii 7KuCl� 1-+rU� W{t75'f•�'t 'j.TL✓tK/N^ 1,✓L�t�crt v� _ Le S �c✓nr�,v rz. p(4 P'fIN WGQ nrf�N<rJ �h1- jsrr !`ft C f.S aF c.sry C-ONC Ve 4T c 01 O f h. ll. H(SSO,Z bd�i �✓f}G/S _ Q�� s s t�v0�r a WPKc /N b�/r9fC ,t� �`l�.r7fnu /hG o/C C'rh x/ r rrn.�r r/'9 d CD t�17t IT 7 tx- r 1� •�j•YN o/G ?a �f M`l o lowr� v/�l /JG�/N ?llph/� 11-049YO of /4&oi CT-/, /UD?rf/�� Orly G '!J� � /cQ REPORTED BY: fZ e .bl DATE ,o l..l R Z. / 1 / a WHITE COPY-FIRE DEPARTMENT YELLOW COPY-D.E.P. PINK COPY-BOARD OF HEALTH C-O-t'IM FORM #SB d � r. I I �I r ,� � � ,. � .. - - .. � - .� . . .. . . _ _ 1 I • � � � _ � � S M E A D vr.rr,Nr vnii OFMAKII'r^ —M9DF.IN I_I$A (WrY ORGANI7_FD AT SM17An r,� A �35 TOWN OF BAMSTABLE �v Y L;;rt'-.TION 427,44,d /'y 5%r /B _ SEWAGE # VILLAGE ® S f—em l/ille ASSESSOR'S MAP& LOT / - INSTALLER'S NAME&PHONE NO. OAI/f el f SOZ SEPTIC TANK CAPACITY LEACHING FACILITY: (type)r1yo (size) f00 &A-1- e NO.OF BEDROOMS ` BUILDER OR OWNER PERMIT DATE: Iq- 9.7 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by � �` �� .. � i i � �y � �I.:_.4i .� h � � �s � , , �� i ��/Lf"'_" � r ®� � „, r _ , 2 GALLERY PLACE, OSTERVILLE A = I v TOWN OF BAR tLSTABLE LOCATION l ! GE # VILLAGE � !`1 V� ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY cJ S LEACHING FACILITY: (type) S�(�t�(size) l` NO.OF BEDROOMS BUILDER OR OWNER PERMPTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) �� Feet Furnished by ee iN ASSESSOR'S MAP NO. PARCEL LOC9TION. SEWAGE PERMIT NO. m —mi S5 7 VILLACE ©57�(zui} e� INSTALLER'S NAME A ADDRESS L PaP( )c P�(� �SSby "jSR UILDER OR OWN DATE PERMIT ISSUED _ DAT E COMPLIAN'CE ISSUED rr Y 17 As ib Gas ba l— �tl�we-- 7V sroig F 'j-�f/•h77 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS - John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 z P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A A ( t CERTIFICATION Property Address: 2 GALLERY PLACE OSTERVILLE Name of Owner ROGER STANFORD Address of Owner: 47 MORELAND TERRACE NEW BEDFORD MA.02740 Date of Inspection: 3/16/9991. ,� Name of Inspector:(Please Print)JOHN GRACI � `99y - I am a DEP approved system inspector pursuant to Secdon 15.340 of Tide 5(310 CMR 15.000) Company Name: John Graci Title V Septic Inspection Mailing Address: P.O.Box 2119 TeaTicket,Ma.02536 Telephone Number: (608)564-6813 • r i CERTIFICATION STATEMENT I certify that I have personally Inspected the sewage disposal system at this address and that the Information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The Inpection Is based on criteria defined in Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system is Needs Further EvaluatioryBy the Local Approving Authority performing at the time of the Inspection.My inspection does Fails not imply any warranty or guarantee of the longgevity of the c septic system and any of its components useful life. Inspector's Signature: Date:3/19199 The System Inspector shall i a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM EVERY YEAR TO PROLONG THE SYSTEM'S USEFULL LIFE.: revised 9/2/98 Page 1 of 11 { SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 2 GALLERY PLACE OSTERVILLE Owner: ROGER STANFORD Date of Inspection:3/16/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: _ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: na One or more system components as described in the"Conditional Pass"section need to be replaced or iepaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. na The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. na Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _ broken pipe(s)are replaced _ obstruction Is removed _ distribution box is levelled or replaced na The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _ broken pipe(s)are replaced _ obstruction is removed . v r revised 912198 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A -CERTIFICATION(continued) Property Address: 2 GALLERY PLACE OSTERVILLE _ g Owner: ROGER STANFORD Date of Inspection:3/16/99 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 the public health,safety and 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 ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.' 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nla-(approximation not valid). 3) OTHER Wa revised.9/2/98. Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART A CERTIFICATION(continued) Property Address: 2 GALLERY PLACE OSTERVILLE Owner: ROGER STANFORD Date of Inspection:3/16199 D. SYSTEM FAILS: - You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage Into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped n&. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface-water'§upply. X Any portion of a cesspool or privy is within a Zone I'of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2198.> Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 2 GALLERY PLACE OSTERVILLE Owner: ROGER STANFORD Date of Inspection:3/16/99 ' s Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal Flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) 11 5.302(3)(b)) X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 e. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 2 GALLERY PLACE OSTERVILLE Owner: ROGER STANFORD Date of Inspection:3116/99 FLOW CONDITIONS RESIDENTIAL Design flow:-=g.p.d./bedroom Number of bedrooms(design): 2 Number of bedrooms(actual):2 Total DESIGN flow: 2212 Number of current residents:11 Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NO If yes,separate inspection required . Laundry system inspected(yes or no):JM Seasonal use(yes or no): YES 7 Water meter readings,if available(last two year's usage(gpd): n(a Sump Pump(yes or no): NQ Last date of occupancy: COMM RCIA /INDUSTRIA Type of establishment: nla Design flow: n/a gpd(Based on 15.203) Basis of design flow: nla Grease trap present:(yes or no):M Industrial Waste Holding Tank present:(yes or no): NQ Non-sanitary waste discharged to the Title 5 system:(yes or no):MQ Water meter readings.if available:nla Last date of occupancy: nLa OTHER: (Describe) n/a Last date of occupancy: n!a - GENERAL INFORMATION PUMPING RECORDS and source of information: SYSTEM WAS PUMPED LAST SUMMER System pumped as part of inspection:(yes or no):NQ If yes,volume pumped n(a gallons A Reason for pumping: n(a TYPE OF SYSTEM X 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval , Other: n/a APPROXIMATE AGE of all components,date installed(if known)and source of information: 1950 WITH A NEW PIT APPROXIMATELY 10 YEARS w Sewage odors detected when arriving at the site:(yes or no) fllQ revised 9/2198 Page 6 of 11 _ a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2 GALLERY PLACE OSTERVILLE Owner: ROGER STANFORD Date of Inspection:3116/99 BUILDING SEWER: (Locate on site plan) Depth below grade: 4QPVC-1'-V FOR ORANGEBURG Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: n1a Comments: (condition of joints,venting,evidence of leakage,etc.) n1a SEPTIC TANK: X (locate on site plan) Depth below grade: 2" Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) nLa - If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): N!Z n1a Dimensions: 6'X6'BLOCK Sludge depth: Z" Distance from top of sludge to bottom of outlet tee or baffle: 3?" Scum thickness: Distance from top of scum to top of outlet tee or baffle:SE Distance from bottom of scum to bottom of outlet tee or baffle: n&' How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) MAIN CESSPOOL AND ALL COMPONENT ARE STRUCTURALLY SOUND RECOMMEND PUMPING SYSTEM FOR MAINTENANCE EVERY YEAR, GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) Wa Dimensions: nla _ Scum thickness: nLa A ` Distance from top of scum to top of outlet tee or baffle:_nla Distance from bottom of scum to bottom of outlet tee or baffle n1a { Date of last pumping: nLa Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) s Wa t r revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C , SYSTEM INFORMATION(continued) Property Address: 2 GALLERY PLACE OSTERVILLE Owner: ROGER STANFORD Date of Inspection:3/16/99 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: nLa Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) nLa Dimensions: nta Capacity: Wa gallons Design flow: Wa gallons/day Alarm present: NO i Alarm level:.nLa_ Alarm in working order:Yes_No_ MQ Date of previous pumping: nLa Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: _ (locate on site plan) z' Depth of liquid level above outlet invert:nla Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) nLa PUMP CHAMBER: NO (locate on site plan) Pumps in working order:(Yes or No): NQ Alarms in working order(Yes or No): NQ t: Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) n!a { • •a revised'9/2/98 p Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2 GALLERY PLACE OSTERVILLE Owner: ROGER STANFORD Date of Inspection:3116199 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: E , nla Type: leaching pits,number: 614'LEACH PIT leaching chambers,number: jiLa leaching galleries,number: 111a leaching trenches,number,length: jVa leaching fields,number,dimensions: nLa overflow cesspool,number: n/a Alternative system: n& Name of Technology: jiLa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY-THE PIT HAS NOT HAD MORE THAN 2"OF WATER IN IT. CESSPOOLS: _ (locate on site plan) Number and configuration: nla Depth-top of liquid to inlet invert: nLa K Depth of solids layer: nLa Depth of scum layer. Wa Dimensions of cesspool: nla Materials of construction: nla Indication of groundwater: Wa inflow(cesspool must be pumped as part of inspection)Wa " Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n!a , PRIVY: _ (locate on site plan) Materials of construction:nta Dimensions:nfa Depth of solids: nIa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nla 4 � revised.9/2/98 Page 9 of 11 ♦ r F 1 S 1 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ` SYSTEM INFORMATION(continued) Property Address: 2 GALLERY PLACE OSTERVILLE c Owner: ROGER STANFORD Date of Inspection:3/16/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a e c ii ta.Y f y t � ' .��" � ..�« � '.r'• y '. cif revised 9/2/98 - Page 10 of 11 + , 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: 2 GALLERY PLACE OSTERVILLE " Owner: ROGER STANFORD Date of Inspection:3/16/99 NRCS Report name: n1a i a Soil Type: n1a Typical depth to groundwater: n1A < ; V+ USGS Date website visited: n1a Observation Wells checked: Mt2 Groundwater depth:Shallow _ Moderate _'Deep 41 ' y SITE EXAM _ Slope `' ' _ Surface water t Check Cellar _ Shallow wells Estimated Depth to Groundwater 10 Feet r + n Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record X Observed Site(Abutting property,observation hole,basement sump etc.) { _ Determined from local conditions , Checked with local Board of health r _ Checked FEMA Maps 4 .r _ Checked pumping records ` _ Checked local excavators,installers _ Jp X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed)4 .. USGS MAPS AND CHARTS AND VISUAL-10+FEET , a R.. •, J.. * revised 9/2198 I 3' S Page 11 of 11 � _