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Home My WebLink About0046 MEADOWLARK LANE - Health 46 Meadowlark Lane Osterville 1 A = 117 172 `7 TOWN OF BARNSTABLE LOCATION T Co' M 424LLA Ca44_ 4t o SEWAGE# 'VILLAGE 09 krV i Rl . ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) / / d'►'p 1yl (size) NO.OF BEDROOMS 3 11 OR OWNER 1 CC:h 1 PERMUDATE: 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 d;k X� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 Meadow Lark Lane Property Address P+�1 Osprey Asset Management, LLC Owner Owners Name V information is + required for every Osterville ✓ MA 02655 5/8/2018?� 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. General Information filling out forms OS on the computer, - 13 use only the tab 1. Inspector: key to move your cursor-do not James Ford use the return key. Name of Inspector Ford Septic Services, LLC 'tab Company Name P.O. Box 49 Company Address Osterville MA 02655 City/Town State Zip Code 508-862-9400 S12482 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 v luation by the Local Approving Authority 5/14/2018 In spec s Signature Date The s em inspect shall submit a copy of this inspection report to the Approving Authority(Board of Hea h 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �x,a 46 Meadow Lark Lane Property Address Osprey Asset Management, LLC Owner Owners Name information is required for every Osterville MA 02655 5/8/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e 46 Meadow Lark Lane Property Address Osprey Asset Management, LLC Owner Owners Name information is required for every Osterville MA 02655 5/8/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4.times a year due to 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 l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 Meadow Lark Lane Property Address Osprey Asset Management, LLC Owner Owners Name information is required for every Osterville MA 02655 5/8/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: s 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 Y2 day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments CAM ASvey`'r 46 Meadow Lark Lane Property Address Osprey Asset Management, LLC Owner Owners Name information is required for every Osterville MA 02655 5/8/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply: ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5_ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ 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•3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 46 Meadow Lark Lane Property Address Osprey Asset Management, LLC Owner Owners Name information is required for every Osterville MA 02655 5/8/2018 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): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments °M 46 Meadow Lark Lane Property Address Osprey Asset Management LLC Owner Owners Name information is required for every Osterville MA 02655 5/8/2018 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection 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: unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑. Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 f Commonwealth of Massachusetts d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 Meadow Lark Lane Property Address Osprey Asset Management, LLC Owner Owners Name information is required for every Osterville MA 02655 5/8/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: pumped after inspection Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: mantenance 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 Meadow Lark Lane Property Address Osprey Asset Management, LLC Owner Owners Name information is required for every Osteryille MA 02655 5/8/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: installed on unknown date Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 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.): 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: 1000 Sludge depth: 4 l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ., 46 Meadow Lark Lane Property Address Osprey Asset Management, LLC Owner Owners Name information is required for every Osterville MA 02655 5/8/2018 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 17 Scum thickness 6 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 12 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.): Tees were present. There was no of leakage. The tank was pumped after the inspection. An Outlet riser was installed the cover is 3" below Grease Trap (locate on site plan): Depth below grade: n/a 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 46 Meadow Lark Lane Property Address Osprey Asset Management, LLC Owner Owners Name isrequired for every Osterville MA 02655 5/8/2018 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: n/a Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No l5ins-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 46 Meadow Lark Lane Property Address Osprey Asset Management, LLC Owner Owners Name information is required for every Osterville MA 02655 5/8/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): 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•3l13 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 46 Meadow Lark Lane Property Address Osprey Asset Management, LLC Owner Owners Name required for is every Osteryille required for eve NIA 02655 5/8/2018 page. City/Town State Zip Code Date.of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leachingfields 20'x 12' per as- number, dimensions: built ❑ 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, I dug down in the stone and there was no sign of failure The bottom to grade was 4' .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 l5ins•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 e 46 Meadow Lark Lane Property Address Osprey Asset Management, LLC Owner Owners Name information is required for every Osteryille MA 02655 5/8/2018 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.): N/a t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts qiiv Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . �,•'•- 46 Meadow Lark Lane Property Address Osprey Asset Management, LLC Owner Owners Name information is required for every OSterVllle MA 02655 5/8/2018 page. Cityrrown 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 2 0 Cto q - 13 0 A B a0X 1a a d 18 t5ins-3l13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 • Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments A,•'' 46 Meadow Lark Lane Property Address Osprey Asset Management, LLC Owner Owners Name information is , required for every Osterville MA 02655 5/8/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 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: 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. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °°, a,•''t 46 Meadow Lark Lane Property Address Osprey Asset Management, LLC Owner Owners Name information is required for every Osterville MA 02655 5/8/2018 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i t t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 { t t -� P d I S�yQTw ' ce �-- Refr,� t J� 0 0 t (� CK s i. ti �i I I �. OP r I � U q1 cl� S� AsBuilt Page 1 of 1 j[ ' TOWN-OF BA/RNSTABLE LOCATION T 6 M ,-J INW k 6'1. SEWAGE M VILLAGE l Q• ASSESSOR'S MAP&LOT Uf 17 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY Imo ' LEACHING FACILrrY: (type) `� X/a d ►''2 r CQ (size) NO.OF BEDROOMS 11 S &OR OWNER. *'H PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Will and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by + 1 / i116 http://issgl2/intraneVpropdata/prebuilt.aspx?mappar=117172&seq=1 5/2/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 MEADOWLARK LANE Property Address MARY CAVICCHI Owner Owner's Name information is required for every OSTERVILLE MA 02655 12-6-12 page. City/Town State Zip Code Date of Inspection E , 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. General Information on the computer, s, use only the tab 1. Inspector: D y key move your our 1 cursor-do not KEN ARPIN use the return Name of Inspector key. ARPIN INSPECTION SERVICE Company Name 4 SMITH CIRCLE Company Address LAKEVILLE MA 02347 City/Town State Zip Code 508-947-5185 S13939 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 12-6-12 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Boaed ` 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. ru ( � �v t5ins•11/10 ;, Title 5 Official Inspecti V:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M s 46 MEADOWLARK LANE Property Address MARY CAVICCHI Owner Owner's Name - information is required for every OSTERVI LLE MA 02655 12-6-12 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: HOME HAS 4 BEDROOMS IS ON MUNICIPAL WATER AND WAS UNOCCUPIED ON DAY OF INSPECTION . SYSTEM CONSIST OF A 1000 GALLON TANK A DISTRIBUTOIN BOX AND A 18'X14' FIELD UNKNOWN SYSTEM DESIGN CRITERIA NOTHING ON FILE AT BOH. PROPERTY BEING LISTED BY BOARD OF ASSESSORS AS 3 BEDROOMS . DUG TO BOTTOM OF FIELD IN 2 AREAS CLEAN STONE AND NO LIQUID ENCOUNTERED . HOME HAS WAS OCCUPIED UNTIL 8-12 AND HAS BEEN USED ON MOST WEEKENDS SINCE PER OWNER 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. I .❑ Y ❑ N ❑ ND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M s 46 MEADOWLARK LANE Property Address MARY CAVICCHI Owner Owner's Name information is required for every OSTERVILLE MA 02655 12-6-12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y .❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to 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-11110 Title 5 Official Inspection.Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 MEADOWLARK LANE Property Address MARY CAVICCHI Owner Owner's Name information is 12-6-12 required for every OSTERVILLE MA 02655 " page. Cityrrown 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. - ® T clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•11/10 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 ,M s 46 MEADOWLARK LANE Property Address MARY CAVICCHI Owner Owner's Name information is required for every OSTERVILLE MA 02655 12-6-12 page. CityTrown 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. ❑, ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure', w 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts . . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 46 MEADOWLARK LANE Property Address MARY CAVICCHI Owner Owner's Name information is required for every OSTERVILLE MA 02655 12-6-12 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? El ® 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): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#'of bedrooms): t5ins•11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ��M s••''r 46 MEADOWLARK LANE Property Address MARY CAVICCHI Owner Owner's Name. information is required for every OSTERVILLE MA 02655 12-6-12 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: HOME HAS 4 BEDROOMS BOARD OF ASSESSORS LISTING 3 BEDROOMS NO SYSTEM DESIGN ON FILE AT BOH Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 25 GPD 9 ( Y 9 (gP ))� Detail: 2010 =8000 GAL 2011=10000 =19000=25 GPD . WAS OCCUPIED UNTIL8-12 AND USED ON MOST WEEKENDS SINCE PER OWNER Sump pump? ❑ Yes ® No Last date of occupancy: 8-12 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease'trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M s 46 MEADOWLARK LANE Property Address MARY CAVICCHI Owner Owner's Name information is required for every OSTERVILLE MA 02655 12-6-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: UNKNOWN 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 EJ 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 46 MEADOWLARK LANE Property Address MARY CAVICCHI Owner Owner's Name information is required for every OSTERVILLE MA 02655 12-6-12 _. page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1970 BOARD OF ASSESSORS LISTED CONSTRUCTION AGE Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 12"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.): NO SIGNS OF LEAKAGE Septic Tank(locate on site plan): Depth below grade: 12"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: 8'X4'X4' 1000 GALLONS i Sludge depth: 2" t5ins°11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts a . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 MEADOWLARK LANE Property Address MARY,CAVICCHI Owner Owner's Name information is required for every OSTERVILLE MA 02655 12-6-12 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 .31" Scum thickness 0 • Distance from top of scum to top of outlet tee or baffle 6„ • Distance from bottom of scum to bottom of outlet tee or baffle 14„ 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.): BOTH TEES INSTALLED UNDER LIP OF TANK CANNOT BE ACCESSED THROUGH COVERS BOTH TEES IN PLACE AND LOOK TO BE IN GOOD CONDITION LIQUID LEVEL AT BOTTOM OF OUTLET INVERT NO SIGNS OF LEAKAGE Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I usetts Commonwealth of Massach Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 46 MEADOWLARK LANE Property Address MARY CAVICCHI Owner Owner's Name information is OSTERVILLE MA 02655 12-6-12 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No r Date of last pumping: Date Comments(condition of alarm and float switches, etc.):, I *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 46 MEADOWLARK LANE Property Address MARY CAVICCHI Owner Owner's Name requinform r on is OSTERVILLE MA 02655 12-6-12 requiredd for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan)- Depth of liquid level above outlet invert AT BOTTOM OF OUTLETS 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.): BOX IS LEVEL AND DISTRIBUTING EQUALLY TO BOTH OUTLETS NO SIGNS OF LEAKAGE SOME SLIGHT DETERIORATING OF BOX BUT STILL WATER TIGHT LIGHT CARRYOVER 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 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 46 MEADOWLARK LANE Property Address MARY CAVICCHI Owner Owner's Name information is required for every OSTERVILLE MA 02655 12-6-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length; ® leaching fields number, dimensions: 1 18'X12' ❑ 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.): SOIL IN AREA DRY NO SIGNS OF BREAKOUT OR HYDRAULIC FAILURE EXCAVATED TO BOTTOM OF STONE IN 2 AREAS CLEAN STONE NO LIQUID ENCOUNTERED BOTTOM OF FIELD 1' BELOW PIPE FIELD 3' BELOW GRADE 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 i Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 MEADOWLARK LANE Property Address MARY CAVICCHI Owner Owner's Name requinform r on is OSTERVILLE MA 02655 12-6-12 requiredd for every • page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form is �a 19 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 MEADOWLARK LANE Property Address { MARY CAVICCHI Owner Owner's Name l information is OSTLLE i MA 02655 12-6-12 ERVI required for every TTER ( State Zip Code Date of inspection page. own D. system Information (cont.) Sketch Of Sewage Disposal System: Prof�ds a view of the sewage disosl system,or benchmarks. Locate all wets within 100 feet.including Locate ties c at least two permanent reference landma where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately l l � - l n 3 6CA fi 1 j R � '2 a $ � x.3 i Tlb 3 '3 i .. fl-T 1 a ��A C c� -t-�- j-�r✓�i ( �c?n �r.�r o_s e s o n i Title 5 Official lnspedr on Form:subsurface sewage Disposal system•page 15 of 17 t5ins•11Ho I r Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 46 MEADOWLARK LANE Property Address MARY CAVICCHI Owner Owner's Name information is required for every OSTERVILLE MA 02655 12-6-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) r Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to 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: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: CHECKED GROUND WATER MAPS AT BOH PROPERTY GRADE IS AT 19.5' GROUND WATER AT 5' SEPERATION FROM BOTTOM OF FIELD 10'+- ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: YARD SLOPES 4'TO BACK YARD 30'AWAY. BOTTOM OF FIELD ABOUT 4, BELOW GRADE GROUNDWATER MAPS HAVE GRADE OF PROPERTY AT 19 LEAVING 10+-OF SEPERATION Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 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 46 MEADOWLARK LANE Property Address MARY CAVICCHI Owner Owner's Name information is OSTERVILLE MA 02655 12-6-12 required for every page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems)completed E System Information— Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Bk 27237 Ps283 Cs3=26-2rt]t13 tit 43 2 46P Return to: Michael).Gill,Esq. 776 Main Street Hyannis;MA 02601 DEED RESTRICTION WHEREAS,Osprey Asset Management,LLC,a Massachusetts limited liability company, having a principal place of business at 776 Main Street,Hyannis,Massachusetts,is the owner of the land and the building(s)thereon located at 46 Meadowlark Lane, Osterville, Massachusetts,and being shown as Lot 14 on a plan entitled"The Meadows,Subdivision Plan,Osterville,Barnstable County,Mass."dated May 24, 1966,and duly recorded with the Barnstable County.ftegistry.of Deeds in Plan Book 205,Page 59; WHEREAS,Osprey Asset Management,LLC as the owner of said Lot 14 has agreed with the Town of Barnstable Board of Health to a restriction as to the number of bedrooms which can be included in any home built on said Lot 14 as a pre-condition to obtaining a disposal works construction permit in compliance with 310 CMR 15.000 I state Environmental Code, �I Title V,Minimum Requirements for the Subsurface Disposal of Sanitary Sewage; - i I WHEREAS,the Town of Barnstable Board of Health,as a pre-condition to granting a disposal works construction permit for a septic system in compliance with 310 CMR 15.200,State Environmental Code,Title V,Minimum Requirements for the Subsurface Disposal of Sanitary Sewage,and authorizing the issuance of a building permit for the construction of a single family home on this property,is requiring that the agreement for. the restriction on the number of bedrooms in any house constructed on Lot 14 be put on record with the Barnstable County Registry of Reeds by recording this document, NOW,THEREFORE,Osprey Asset Management,LLC does hereby place the following restriction on its above-referenced land in accordance with its agreement with the Town of Barnstable Board of Health,which restriction shall run with the land and be binding upon all successors in title: Bk 27237 Fg 284 k8049 1. 46 Meadowlark Lane,Osterville,Massachusetts may have constructed upon the Iota house containing no more three (3)bedrooms. Osprey Asset Management,LLC. agrees that this shall be permanent deed restriction affecting Lot 14 located at 46 Meadowlark Lane,Osterville,Massachusetts,and being shown on the plan recorded with the Barnstable County Registry of Deeds in Plan Book 205,Page 59. For Grantor's title,see deed recorded with Barnstable County Registry of Deeds at Book 26974, Page 182. Property Address: 46 Meadowlark Lane,Osterville,Massachusetts 02655 Executed as a sealed instrument on this 26th day of March,2013 t Osprey Asset Management,LLC By: Michael J.Gill,Manager COMMONWEALTH OF MASSACHUSETTS Barnstable,ss March 26,2013 On this 26th day of March, 2013,before me,the undersigned notary public, personally appeared Michael J.Gill who proved to me through satisfactory evidence of identification (a Massachusetts driver's license) to be the person whose name is signed on the above document and acknowledge to me that he signed it as his free act and deed, before me. ALEXAM)MT.SENATORI NOWr pok . cawroo�at "y Notary Public My commission expires: 4 BARNSTABLE REGISTRY OF DEEDS TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION ,e 1 - a. Parcel l r Permit# 1 Z / Map - 'f t,d r ^ 2 U 3 Health Division ��'d a.g ate Issued - ��°"�`� �� • / D �, � Rpplication�jee Conservation Division s —41 Tax Collector �oaa Permit Fee` 13 �t I li i— --S�PTBC SYSTEM MUST EE Treasurer k C�1, — c �/�3 )INSTALLED `�� . IN COMPLIA Planning Dept. TITLE 5 Date Definitive Plan Approved by Planning Board ��5�i �f � Ed9TAL G®�E A 't Ti.i ,� tlYG La.i ti'r .EEi�f ,3 jHistoric-OKH Preservation/Hyannis j Gc � Imo- - i Project Street Address ----.--o Village AA • Address Owner Uk2 i W 0 • �V p j Telephone `• �' ALL11 Permit Request I � Square feet: 1 st floor: existingproposed 2nd floor:existing proposed Total new P P Zoning District Flood Plain Groundwater Overlay Project Valuation ` Construction Type Lot Size -'Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family 8' Two Family ❑ Multi-Family(#units) Age of Existing Structure Li V t 1�7 Historic House:_ ❑Yes` ❑No On Old King's Highway: ❑Yes ❑No Basement Type: bTull ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) oo Basement Unfinished Area(sq.ft) Ii Number of Baths: Full:.existing new Half:existing new Number of Bedrooms: ex' ing_ _ new Total Room Count(not including-bat s : existing new First Floor Room Count I Heat Type and Fuel: leas ❑Oil El Electric ❑Other Central Air: ®Yes ❑No Fireplaces: Existing —�— New Existing wood/coal stove: ❑Yes ❑No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:t�existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization Cl Appeal# Recorded 0 Commercial ❑Yes ❑ No If yes, site plan review# Current Use ^JJ O, Proposed Use �0,yn�� BUILDER INFORMATION —� Name s 2 �� Telephone Number <0 L l_r -- Address Tq y- r License# C) Home Improvement Contractor# 0 1 a4 r s Compensation Worker's ensation#p ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO .I ' floe w le 0-5 1 - Y d O i F� 1 r r 3 b VV L� sr 0on r STATEMENT ` JOSEPH P. MACOMBER & SON," INC. -4 508-778-4554 Tanks - Cesspools - Leachfields Pumped & Installed Town Sewer Connections DATE 4/1 /0 3 P.O. Box 66 Centerville, MA 02632-0066 775-3338 775-6412 Mary .Cavicch"i Box 1 4 9 - _._..........._....__........_0steryi_11e.i_Mass,_0.26.5.5..............-- ......_._....... _ Cash Upon Completion. 1 % interest TERMS: every 30 days. PLEASE DETACH AND RETURN WITH YOUR REMITTANCE $ AATE,. � C ULYIB §/DES $JO•,.. ARSE s• E[�hFS: A BALANCE FORWARD 4/ ...L.03.............._Sept i c...._S' stem...._evalua.tio............._.._..._..._...:........... ..... . y _ This is a title five _ .........................s...e.pt i c-...s_ys t. m.......(7....$_.._O.Qd .)....................._.._...._ .__.._ s_..........._.......__....__..... The system consists of _.............__..... _�..-l_.0_.Q O_._ga 11 on....... .e.F . . ...--.............. ._._....._ - _.._.L._,leachin ._...f... .�d...-......................... ..:.. ............... -. -...................._..............._: 20 'X12 ' _..._.._................._The...._sept c s.vs_tem.....is...._in..._.._..._._... ........_.. ._.__ proper working order at- ..................._ ..............__....W......... ..........:_�_7.._5.:.. _................... ........... - _...._............. ._...._......_......_................_....._.................................._.. r T„ t For_......... 4 6 Meado_w ,L-ark ..Lane............._ _ .-. . _ -- ..._.. ........_..... _...._.. w._......._._..... . ..._....._....._..._......:_...._...---......_..... . . _......_........__---._ ........... n .PAY LAST AMOUNT JOSEPH P. MACOMBER & SON, INC. 7N THIS COLUMN v fi 1 taco /2✓lC lOAZ Ile ter i . Ci- ell f • �ICCGtae � k-7 � �� _ RIDGE VENT g - - RIDGE BOARD 2x14 - Y (P) FOUNDATION. (P) FOUNDATION FOOTING WALL(107 (16'W It 12' D) SIMPSON LRU210 RAFTER HANGER OSPREY ASSET k ROOF R MANAGEMENT, LLC 12 PNE}2lJTHER" 776 MAIN STREET ar HYANNIS, MA 02601 . 5/9'COX PLYWOOD ROOF SHEATHING INSTALL - //— BAFFLE U c aBAFf'LES FOR � � ARCHITECTURAL I<•�,'' p tt (P) DRILL AND'DOWEL EXISTING /R FLOW 2x12's (16'O.C.) - \ ASPHALT SHINGLES, _ FOUNDATION WITH J4 REBAR 3 - - / W/ R-38 INSULATION \ W 30� FELT PAPER. SITE PLACES 12'APART. EMBED / \ REBAR 4' INTO EXISTING - �._O• / - \ FOUNDATION AND EXTEND INTO / SIMPSON NEW FOUNDATION WALL 12'. GILL EPDXY GROUT(5,000 PSI) CONTINUOUS / DRIP EDGE � I8'-2'f xa FACIA ,/2•GYP—BD FAMILY Roots RESIDENCE CONTINUOUS) / - TIE VENTED SOFFIT ' STUD TO TIMPSON OP PLATE - ' - HOUSE WRAP e'-11 1/2' FIRE RATED FLOOR SHEATHING SIMPSON TSP A&E FIRM :.: SHEATHING 3/4'PLYWOOD STILL TO STUD III TURNING MILL' 2'-0• CONNECTOR CONSULTANTS,INC. VENT LOCATION 2x6 FRAMING WRFI BOISE CASCADE BRICK VENT 2-7/8'x8' DI-V L 'ERS,ENGINEERS AND 26'-0' TYPICAL - R-21 INSULATION - AJS 2518 2 REO'D,LOCATE AS SIMPSON JOIST HANGER (16.O.C.) INDICATED ON (P)-CRAWL SPACE VENT CONSTRUCTION. .ITG MANAGERS #1 CEDAR MIT3518 OR APPROVED w/ R-30 INSULATION FOUNDATION PLAN PO BO 11t 9 sA"..' H"MAo2563 3'X 8• MIN. SHINGES,. EQUIV. ' FOUNDATION PLAN 2 PLACES'� 1ND1�`�D 4•TO WEATHER �e• TEL(—tturnngmillc nsultantso n8-4246 it - 2X12 P.T._PLATE (� � � � FIN. GR. CUT TO MEET SITE.ADDRESS: - 42. - - ENTIRE WIDTH OF VAPOR RETARDING BARRIER FOUNDATION WALL - �12_ MIL THK OVERLAP SEAMS BY 46 MEADOWLARK �6,TAPE SEAMS WITH 4'TAPE. ANCHOR BOLTS iEXTEND 6' UP INTERIOR OF / Z 10• 4'-0• LANE FOUNDATION WALL AND ADHERE /\/\/\/\/\\/\/�\/\\/\\/�\ -G' OSTERVILLE, MA 02655 3 ADDITION CROSS SECTION SUBMITTALS 5 REMOVE EXISTING 6' SLIDING - DOOR. OPEN WALL OPENING T° - A-102 SCALE: 1/2 = 1'-0" 9'-6•t AND INSTALL 2-2x8 n HEADER REScheck Software Version 4.4.4 1 I Compliance Certificate FAMILY ROOM ADDITION 'z Project Title:.Gill Residence. B 03/01/13 ISSUE FOR PERMIT Enow Cade: 20091EGC ' L000—. Barnstable,Massachusetts A U2/13/13 ISSUED FOR REVIEW Cam.-Ty".ype. nadir Family P PROFESSI 1� 1 EXISTING WALL AND conditioned Flm.Area: 0112 `.eeJ OF Heatag Degree Data: 6137 HONE UTILITIES. � kWALL OPENING TO - come.Zone; S .AND INSTALL 4-1-3/4• Perin Dole ode 17%B•VERSA—LAM 2.0 FULL SHEET WOOD Construction site: wn OedAgene Designer/Contractor. `1AMES 00 SP BEAM HEADER. STRUCTURAL PANEL 4a Maadav Lana Mats Glo Taming mitt consuitents,Inc D FINISH P V3 AN 0`- - FEACH ENDASTEN PER ITC osmreule.MA ozsss npWin inn SLt Management lxe s�dpwd�,IM 02Ss3 (1'1 . - Q R602.10 _ Hy al.,Mn 02'W1. STROKE y 111200oR' Campion—1B.1%BahrTnen Cade Maximum UAW Yaur UA BB FLOOR PLAN �1 GABLE,END BRACING ems°>~~ m •.��'•• ..,a•'° °am ON AI B A-102 SCALE: NONE ALI A— ., _ 102 SCALE: 1/4' = 1'-0' Envelope Assemblies ' fiGross GI-itig 1 Cavlty Cont orinneter DRAWN BY: SRS V Coiling l:CemeEml Cooing 6T2 38.0 O.o 1S y Wa01:Waad Fmme1S`a.c 181 21.0 0.0 6 CHECKED BY: MFJ Window 1:Vinyl Fmme:Dauma Pena wile I -E 10 0.300 3' SHGC:0.00 '�. Window 2 Vinyl Fmme Double Para in L—E 10 0.3a0 3 SHEET TITLE: ,�•,,, SHGC:0.00 WINDOW SCHEDULE Daar,.Sotl pn 63,E FOUNDATION Weo2:Wood Fmme.16-ox. 152 2t.0 0.0 6 ROUGH OPENING MFR./MODEL REMARKS Wlndaw3:VhylF—DouolePanewMLow-E is 0.300 6 FLOOR PLAN ERSON 200 SERIES 30'x46' LOW E GLASS 3'-0'-x 4'-6"' 244DH3046 — - sHGc:o.00 wen 3:Wood Fmma 16•oc. 1e1 z1.o o.o T EItSf)N 200 SERIES 28'x46' LOW E GLASS 2'-8' x 4'-6" 244DH2646. - AND DETAILS ,�- Window 4:Vm ylFmme:DauOm Pane wWithLovnE 10 0.300 J W SHGC:0.00 ' E:.THE CONTRACTOR IS REQUIRED TO SUPPLY/CONSTRUCT WOOD STRUCTURAL VAndow6:Vinyl Fmme.DaumeP-ho Win 1--E 10 0.300 3 110NAL RESIDENTIAL CODE 2009 SECTION R301.2.1.2 PROTECTION OF OPENINGS. - SHGC:0.00 - d;. Door2:Glaee 41 0720 9 SHGC:0.00 DOOR SCHEDULE .a" co mm,apganaaSmam,noompaeadWildingdmlgrdeeo wln leedhemIs—istentweWildmgplans,apeo®numlm 000,raroalculauo ROUGH OPENING MFR./MODEL ns REMARKS SHEEP NUMBER: 1*6 — suEm tied with the permit epplieation.The p opomal building has Daen dooiBned remenm m meet M 20091ECC maui In REScoaoJ Vemian 4AA end to 6 mmpy wile 0m mendemry regwremenm Ilsmtl In Ne REScheck InapeGon ChecYLSL �. '=JEN BERGLAS PER MFR. — - �PA71,0—ANDERSEN RSEN STORMWATCH 5'-11-1/4' X 6'-8' FWG051168' IMPACT RESISTANT -1-02 _ Hama-Tina Slgtmrom Dam A TMC 13.04 v