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HomeMy WebLinkAbout0015 MILNE ROAD - Health 15 Milne Road OsterviH6 A= 118-016 ,i i TOWN OF BARNSTABLE LOCATION i 5 Y(�'1,q�, rA , SEWAGE# VILLAGE ®skxyl� �, ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) h�,� (size) 10®Q NO.OF BEDROOMS _ OWNER. 5 �� PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within.200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 100 feet of leaching facility) Feet FURNISHED BY 1 � � ^ � \'� � � � O. _ \ � \ate c� � �'�' - \ .� - _ _ O SEWAGE INSPECTIONS L.OcknoN 15 r ne, rd DATE ASSESSOR'S MAP & LOT INSPECTOR MN K CAPACITYip C-F LEACHING FACILITY: (type) t-7 (size) c© NO.OF BEDROOMS cTJTMDER OR OWNER `OW E_''N MAILING ADDRESS � 1 �.. ® ��l��� :�- ,.;,. ��I � ..�tL�, � � s � \ \\\ ���\ r��\ �. Q� �J w � SS�2iao'V' �_� Q.ry_S-a311�11S(V1 �, "O N 1IV4233d 3`7 V M3SL)s f�1011'C1701 - �. a c bP e d f'T K 1 r Commonwealth of Massachusetts W T°"itl:e,� 5-:®fficial Inspection Form m Subsurface SdWage Disposal System Form --Not for Voluntary-Assessments- -- -- ------. �M 15 Milne,rd.,, Propett Address;;- Rona Garfield Owner Owner's Name.; information is 4,, required for every Osteryllle Ma 02655 4/12/16 ,..• page. CityR own; , r State Zip Code. _ . Date of.lnspection 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 sl# /I55 filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector t f Y . .. DiBuono Sewer and Drain � Company Name 8 Johns path Company Address Bra S Yarmouth Ma f'`' '" 02664 - _ State ---_--•------- ----- ____Zip_Code___.._... ;,5Q8-36;,4-9587 S103522 License-Number—.._._—_-_____ . ' a 1,' ;2c..�c.,CT �`'ti✓ifi`4f3a'- L"u�?a fra^ a- •ri'' ice••t 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 b he Deal Approving Authority 4/12/16 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under, the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 i �� . .; Commonwealth of Massachusetts Title 5 Official Insp o • F ect'®n �Forrrn a Subsurfa6e'Sewage Dirsposal System Form - Not?for"Voftantary'Ass'd§sments 15 Milne rd c° F Property Address, Rona Garfield Owner' — -Owner's Name information is required for every Osterville _ Ma 02655 -- 4/12/16 page City/Town State . .. _ Zip Code - Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/a/ways;complete:all of Section.,D A) System Passes: ® I.fave 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. �l ,Comments: ; The system contains a 6x8 block cesspool as well as a 1,000 gallon leach pit. Leach pit was dry at time of inspection and shows a stain line within 26" of invert pipe _ •o � _1 i,, - � `� •.1, _ r,o :>,� i�.n �' ' -- —- -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 belo`w) ? 794'ir r�j,� ?:.1= �i?•.. .6N i�?il;.G 'e•, � a, Rr c "�i Q�'.3l6 t''�� I C�''�. ' P\O e'rfil A �}( P :1.P. r... t�W —• ii L .. ut.r��'} J�• , ..: i.. • , 3314.. ..7'. S •-•,/51 .N i..iS� Ir erne tJ„ 4 t•.. t5ins•3%13' r Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 'I Commonwealth-of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments_, M 15 Milne rd ,., ,.•, ,. Property Address Rona Garfield Owner •-., •: • t. ..,:: Owner's Name information is required for every Osterville Ma 02655 4/12/16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if`(with approval of Board of Health): ❑ broken 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): ion . - 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 t.x.aR- Commonwealth of Massachusetts Title 5 Official Inspectio`r Form Subsurface,Sewa'ge'Disposal System Form - No't=for° ordntary'Assessmenfs t 15 Milne rd.__ __--Property Address------------ Fy,,,i�7t3*+ i::nu , _ Rona Garfield - ---.-----_ Owner Owner's Name information is �. required-for every-Osteryill'e''` Ma_ . .. _ ._02655------- - -4/12/16 _ page. 'GityTTown State. _Zip Code .. .__.Date.of Inspection B. Certification (cont.) 4 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: L 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 perforrr'ed at a DEP.certified laboratory, for fecal - coliform bacteria,indicates absent and the presencor-of,ammonia-nitrogen and nitrate nitrogen is equal to Yor less,than 5 p:p ,,,.provided that no other failure criteria are triggered. A copy of the analysis must be'attached to this form. 3. Other: - rY.r_-•.. •.. . .__. __ -_. .�- x .asy.,:::.,:: •.. # _ a. _ w._�s3. .:.QG .2L ... -+s'&',^' _' D) System Failure Criteria Applicable to All Systems: .-:You"must indicate"Yes" or"No" to each of the following for all inspections: ,' ,.�.`i��.`� ,•, i,,-li;l-ii:`•Ye§=r' -. Nocf {7�ilx ; �:�,:: :�rft (_.-,i iJ ^vitiasigacku of sewage into faciht"or 5 stem component due o overloadedr _ p g y,, y p, t o clogged SAS or cesspool i _ ;t.;❑ _ ., LIE ,y 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 r:, ® or clogged SAS or cesspool,. ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins•3l13' " 'E' " '" " '' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 official Inspectionfor _ Subsurface Sewage Disposal,System Form -Not for Voluntary Assessments •, . ,.' 15 Milne rd iA Property Address Rona Garfield Owner Owner's Name information is Osterville Ma 02655 4/12/16 required for every , page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No El Required pumping more than 4 times'intthe last ye'ar'NOTdue to clogged or [A Required 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. ❑ ® ' r. 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 .. labo'ratory;for fecal coliform bacteria�indicates-absent and the presence .. `-of.ammonia nitrogen and nitrate'nitrogen`Wequal'6o-dr less than 5 ppm, provided.that no other failure criferia are triggered."A'copy of the analysis and chain of custody must be atta-'chetl-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 j. ❑ ❑ . ,f the system is within 400 feet of a surface,drinking-water supply ❑ ❑ the system is within 200 feet of a tributary toys-rsurface drinking water supply thesystem,is located in,a nitrogen sensitive area (Interim Wellhead Protection ❑ ❑:. :�` Area= IV11PA) 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 iWSection D above the large system ha's failed.�The owner or operator of any large system considered a'siohificant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should'contactthe appropriate regional office of the,Department. x t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 ti w Commonwealth of Massachusetts Title 5 Official Inspecti®n Fora, a SubsurM'd&1Sewade disposal System Form = Not for-Volunta'ry Assessments J ..•1:li.,1 , Property Address -----=—Rona.Garfield Owner Owner's Name information is ,;� required for-every- OStefVllle ''` ` �11Z'- Ma- --- 02655-- 4/12/16 - page. City/Town'" State.. -Zip Code . Date of Inspection C. Checklist Check if.the-following have been done. You..must indicate.','yes"sor"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) `i' _ . I ® ❑ Was the facility or dwelling inspectedi'forls g`ris'of sewag'euti'back up? C -! e,)y l ® ❑ W as the site inspected for signs of break out? ® ❑ jj-Were all system components, excludin'g'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,ln.f_ormation Residential Flow Conditions: Number of bedrooms (design): 3 Number bedrooms (acfual):of ' I i 330 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): _.._ . .r, ::, . ,.%.Lis✓,1,�.:. l�.i.._1�, e-u:.5 t5ins•3113 i ""`'``` i" 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 15 Milne rd Property Address Rona Garfield Owner Owner's Name -- information is required for every Osterville Ma 02655 4/12/16 page. Cityrrown State Zip Code Date of Inspection' D. System Information Description: The system contains a block cesspool as well as a 1,000 gallon leach pit. Leach pit was dry at time of inspection and shows a stain line within 26" of invert pipe. Number of current residents: , . - 2 Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? (Include laundry.system inspection El Yes ® No information in this report.) Laundry system inspected? i ® Yes El No r . Seasonal use? _ ® Yes ❑ No Water meter readings, if available last 2 years usage d 218 Gpd Detail: Sump pump? ❑ Yes ❑ No :4,i Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day,(gpd)' L Basis of design flow(seats/persons/sq.ft., etc.): Grease trap.present? ❑ Yes ❑ No Industrial waste holding tank present? El Yes ❑ No Non-sanitarywaste discharged to the Title 5 system? ' F. , 9 Y El Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts ' Title 5 Offs;vial Inspecti®''; ®rr Subsurface•>Sewz(ge"®-isposal Systeiivi Form'-Not fo"r•Volunta y-'As`sessments'� 1.5_I1-/,l it ne rdProperty Address Rona Garfield _. Owner Owner's Name information is required for-every - Ostervillc' Ma - _ 02655 page. a Clty/Town` i, n� _ _ _ � State. __ _Zip Code Date of Inspection D. System Information (cont.) 2016 weekend use Last'date of occupancy/use: Date -- Other(describe below): General Information''' Pumping Records:i.r, Source of information: ANone provided.-,,.; ; Was system{pumped`as=part of the inspection? '"r} "} `'' '` ''' ` ` ' Yes ® No -- - If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ; ❑ Septic tank, distribution box, soil absorption system ® Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ _— Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system.owner).and,a copy of latest :!fir. Inspection of the I/A system by system operator under contraict " ❑' ' )x`'Tight'tank. Attach a copy of the DEP'approval' ` C'lY ___ _.-__ --._._._ - ❑- ------ - Other(describe): •F>„r; . ::trrli�.: Single cesspool with a 1,000 gallon leach pit. t<') l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form a � Subsurface Sewage,Disposal System Form- Not for;VoluntaryAssessments; w, ,••'' 15 Milne rd :r Property Address Rona Garfield Owner Owner's Name information is „r required for every Osterville. Ma 02655 4/12/16 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: cesspool seems to be original 1968. Leach pit was added later on Were sewage odors detected when arriving at the site? El Yes ® No Building,Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ❑ 40 PVC ❑ other(explain): Distance from private_'water_supply well or suction line: E tc i c f l:.ee - t± Comments (on condition of joints, venting, evidence ofleakage,,,eac; Orangeburge pipe Septic Tank(locate on site plan):. ± Depth below grade: feet • b Material of construction: ❑ concrete El metal El fiberglass, ❑.polyethylene ❑ other(explain) S If tank is metal, list age 3'.. . I Ji.i:.. i .. 4itJ .. _ .,tiy q(.• �,v, ;a .. ,. , t` years . Is age confirmed by_a Certificate,of Compliance? (attach a,copy,of certificate) ❑ Yes ❑ No Dimensions: , -Sludge depth: - t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 _, r Commonwealth of Massachusetts W Title 5 Official Inspecti®n,+®`rrn a Subsurface=Sewage Disposal System Form - Nof fog VoluntaM'ry`Asse'ssments',' -__ 1.5.Miln.e..cd. _. Property Address . Rona Garfield Owner Owner's Name information is t required for every ery ,. Ostille — Ma 02655-- -- 4/12/'6 f (� page. "Cltyrfown' "' 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-- -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 How were dimensions determined? _Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 0 " i Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑polyethylene ❑ other(explain): Dimensions: - - Scum thickness _ ---•------- ----Distance-from top of scum to top of outlet tee or baffle Distance from bottom'of scum to bottom of outlet tee'or baffle Date of last pumping: Date t5ins•3/13 t Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official. Inspection Form a Subsurface Sewage,Disposal,System Form - Not for Voluntary;Assessments,; 15 Milne rd Property Address - - - -- ----._ Rona Garfield Owner Owner's Name - - information is required for every Osterville Ma 02655 v 4/12/16 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. ite 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 Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy,attached?.`' ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title Off`idalInspection'"�Forrri - Subsurfa'ce'�Seviiage-Dsposal System Form ='Not for Voluntary'Asse'ssments 15 Milne.rd__ Property Address y Rona...Garfield . Owner Owner's Name information is required for every fOsterville 3' Ma -- - - _02655 - - -- 4/12/16- page. Clty/Town` _ State-..- Zip Code_ Date oflnspection D. System Information (cont.) _ .; ;`r Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert na --- Comments (note if;tiox is level and distribution to,outlets-,eq!uai;-:any evidence of solids carryover, any evidence of leakage into or out of box, etc.): I- :ij t.. 1 - lib.(1" rr,ir.,. a, t.•yy -l. ;l !`_-,,r! is{'1 {'; 'io Pump Chamber(locate on site plan): Pumps in working order: El Yes El 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 conditiorial pass. Soil Absorption System (SAS) (locate on site plan, excavation not regt]ired): ' If SAS not located;explain why: .._.. ..._..__.__---'-----__...... ...ice .:, ?ir(��<'r��?I•'!i�l.! t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 ®fficiat.lnspecti®n Form,,: k a ,. m Subsurface Sewage Disposal System Form,- Not for Voluntary�Assessments�a - wM 15 Milne rd Property.Address Rona Garfield Owner Owner's Name - - - - information is required Osteryille, Ma 02655 4/12/16: page. Cityrrown State Zip Code - Date of.Inspection ' D. System Information (cont.) Type: ® leaching pits number:,..,',,,, 1 : ;�lv El. *leaching°chambers ❑ leaching galleries number:.. ❑ leaching trenches _ number, length: ❑ leaching fields number, dimensions: _ ❑ overflow cesspool number: ❑ innovative/alternative system Type/name_of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 Depth—top of liquid to inlet invert - ` 3611 Depth of solids layer..; _ 2 11 Depth of scum layer 12 , Dimensions of cesspool 6x8 Materials of construction Block Indication of groundwater inflow ❑ Yes ® No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title OfficialInspectiohu Fdrrn _ f E ^ Subsurface`�Sewa'ge�Disposal'System Form -NbeforrYoluntary A'ssessmentsMf' M 15 Milne r-d— - - Property Address _....Rona Gartield_.____.._.__.., _ ` Owner Owner's Name information is ;v,, requiredforevery lste,rville - _ Ma - - --02655 -4/12/16 page. Ctty/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, .In. . etc:):';' - 1,- :I''sJr_i .a;!l ."It 0 I f,. . , No ponding no`break'oat '[` itc.:YY>.. ri^ ;•31 f-•nr�11r'r;'" IXS Privy (locate on site plan): Materials of construction: Dimensions I Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t I I ; l5ins-3/13 r" Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts ro Title 5 Official Inspection Far Subsurface.SewagenDisposal,System Form - Not for Voluntary,, ssessments� 15 Milne rd ::.n�:i•,i Pik _.. Property Address Rona Garfield Owner O wner's Name information is required for every Osterville Ma 02655 4/12/.16, page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage;disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate'all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes.below: ❑ hand-sketch in the area below drawing attached separately - F. h t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ; . . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Milne rd Property Address Rona Garfield Owner Owner's-Name information is ... r;1."` required for every Osterville---- —, - Ma .,02655 ' 4/12/16 page. City/Town -•--•-- • --- '=' State ' Zip Code Date of inspection D. mati®n cont Site Exam:__..-__v.. Check Slope t '' -Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10+ ftfeet Please indicate all methods used to determine the high ground water elevation:. ❑ Obtained from system design plans on record ' If checked, date of design plan reviewed: Date ® Observed site (abutting'property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers- (attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Property sits high above nearest water venue 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 f t >,i. �•.,ate' ,. Assessing As-Built Cards w 'L `' ,•t�� .. . � ,.", �::{ ;.+1�`J ,,. .°- -. ,,,; , ., -p ,; � ,,,��, , . Page Ijof2 ,TONIM OF BARNSTABLE LOCATION A 6 K};I nP • f_;t3. SEWAGE 11 e - - V[T.LAGE• ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE ND, _ SEPTIC TANK CAPACITY GXoq, LEACHING FACILITY:(type) (size)• . . NO.OF BEDROOMS _ • OWNER j PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted.Oroimdwater Table to the Bollom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200.feet of leaching facility) -.., ,.• . 4 e EQga of Wetland and Leaching Facility(if any wetlands exist within 3d0 feet of leaching facility) Feet FURN1smm BY s- i CJ j hitp://www.townofbanistable.us/Assessing/HMdisplay.asp?mappar=MQjt6&seq;=1; 3 a:,~ • • 8/24/2015 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Milne rd Property Address Rona Garfield Owner Owner's Name information is required for every Osterville Ma 02655 4/12/16 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 4, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ,M 15 Milne Rd. Property Address Brad Moore ' t' Owner Owner's Name ' information is required for Osteryllle Ma. 02655 4/28/2011 �°- every 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: A. General Information When filling out I forms on the computer, use 1. Inspector: only the tab key to move your Robert Paolini cursor do not Name of Inspector use the return k... key. Capewide Enterprises,LLC. ' Company Name f- P.O.Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code (408)477-8877 ' S14454 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 15.340of Title 5 (310 CMR 15.000).The system: t ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4/28/2011 Inspectors Si ature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. II t5ins•11/10 Title 5 Official Inspection Form:Subsurface SewageqDspostem•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 15 Milne Rd. 'M Property Address Brad Moore Owner Owner's Name information is required for Osterville Ma. 02655 4/28/2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 r F � Commonwealth of Massachusetts .m W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments A. 15 Milne Rd. Property Address Brad Moore = _ Owner Owner's Name information is required for Osterville Ma. 02655 4/28/2011 ' every page. CitylTown 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 bozdue 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): X ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): X ❑ 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments °M 15 Milne Rd. Property Address Brad Moore Owner Owner's Name information is required for Osterville Ma. 02655 4/28/2011 _. every 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: 1 a �t 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 o 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 15 Milne Rd. Property Address r Brad Moore Owner Owner's Name information is required for Osterville Ma. 02655 4/28/2011 every 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 CM 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. 15ins•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 ;M 15 Milne Rd. Property Address Brad Moore Owner Owner's Name information is required for Osterville Ma. 02655 4/28/2011 every 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? t f El Z. 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) I ® ❑ 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)] I D. System Information Residential Flow Conditions: A Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•131.6 of 17 a Commonwealth of Massachusetts W Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �M 15 Milne Rd. Property Address Brad Moore Owner Owner's Name information is required for Osterville Ma. 02655 4/28/2011 every page. City/Town' State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 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 2009:129,000 g ( y g (gp ))' 2010:184,000 Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 4/28/2011 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CM 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 W Title 5 Official Inspection Formf Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 15 Milne Rd. Property Address Brad Moore Owner . Owner's Name information is required for Osterville Ma. 02655 4/28/2011 every 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: Capewide Enterprises,LLC. 'a ``. Was system pumped as part of the inspection? ® Yes ❑ Iv'o If yes, volume pumped: 1000 ' gallons How was quantity pumped determined? Measured Reason for pumping: Maintenance r 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) t ❑ 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 15 Milne Rd. Property Address Brad Moore Owner Owner's Name information is required for Osterville Ma. 02655 4/28/2011 every 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: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 18"feet Material of construction: ❑ cast iron ® 40 PVC ® other(explain): Orangeburg Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank(locate on site plan): Depth below grade: 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: Sludge depth: t5ins•11/10 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 M 15 Milne Rd. .Y_ Property Address Brad Moore Owner Owner's Name information is required for Osterville Ma. 02655 4/28/2011 ` every 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 # 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 How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): f: t t 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 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 15 Milne Rd. Property Address Brad Moore Owner Owner's Name information is required for Osterville Ma. 02655 4/28/2011 every page. Cityfrown 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 Date of last pumping: Date Comments (condition of alarm and float switches, etc.): k Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑lNo t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 S • • � K Commonwealth of Massachusetts Title 5 Official Inspection FormA Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Milne Rd. Property Address Brad Moore Owner Owner's Name information is required for Osterville Ma. 02655 4/28/2011 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 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °�M ,e''• 15 Milne Rd. Property Address Brad Moore Owner Owner's Name information is required for Osterville Ma. 02655 4/28/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy dry soil.No signs of hydraulic failure.Water level was 32" below invert at time of inspection.Stain line observed 2' below invert. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): 1 main with overfolw leach Number and configuration pit. 4 Depth—top of liquid to inlet invert 1 5" Depth of solids layer 311 Depth of scum layer Dimensions of cesspool 6'x6' p r Materials of construction Concrete Block Indication of groundwater inflow ❑ Yes ® No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ;M 15 Milne Rd. Property Address Brad Moore Owner Owner's Name information is required for Osterville Ma. 02655 4/28/2011 every page. Citylfown 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.): No signs of hydraulic failure.Water level was up to outlet invert to leaching pit. 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 Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 15 Milne Rd. Property Address Brad Moore Owner Owner's Name information is required for Osterville Ma. 02655 4/28/2011 every 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 b B O O t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 15 Milne Rd. Property Address Brad Moore Owner Owner's Name information is required for Osterville Ma. 02655 4/28/2011 every page. City1rown 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: Bottom of LP 13' 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: As-Built ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate #2 annual ranges of groundwater elevations. 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 O Massachusetts . Title 5 Official Inspection Form \ \ Subsurface Sewage Disposal System Form Not for Voluntary Assessments . �. @ � w® 15 Milne Rd. Property Addrs . Brad Moore \ � eee Owner's Name information is ` required for eeemlle Ma 02655 +2 20 1 \ . @e#ge. City/Town @a Zip Code Date¥Inspection E. RepoC Completeness Checklist : M InspcloSummary: K,BC % orEchecked Inspection Summary D (System Failure Criteria Applicable to All Systems) c completed \ System Informaon—Estimated depth to high groundwater Sketch of Sewage Disposal Sy stem either drawn on page 15 or attached inseparate fle »3. . �\ . :, \} < 4 � } � f Aerm Title a Official Inspection m«ssurfacesageoosalsm.Page9rr YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which You must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1"FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) w Syr F a DATE: Fill in please: r$�� * 'L APPLICANT'S YOUR NAME/S: p zGj r° p BUSINESS YOUR HOME ADDRE CS " � TELEPHONE # Home Telephone Number P, c u. a f w v NAME O N: NAME OF NEW BUSINESS TYPE OF BUSINESS IS'THIS A HOME OCCUPATION? YES NO p ADDRESS OF BUSINESS l cy ,�.� �� MAP/PARCEL NUMBER ' g (Assessing) When starting a new business.there are several things you must do in order to be in compliance wit h th the rules and regulations of the Town of Barnstable. This . form is intended to assist you in obtaining the e information 9 you may:need. y You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make'sure you have the appropriate"permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements'that pertain to this type of business. Authorized Signature* COMMENTS: 2. BOARD OF HEALTH . This individual nforme t �itreqments that pertain to this type of business. F` /(( MUVCOMPLYM ALL Authorized Signature** HAZARDOUS MATERIALS REGULATIOK1,1 COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: ��'}.+^-'v r,. _ �-�<..� �., �....,-. �:4�--a'✓' �^w.F�:..�. may..x: :""4w�Y s •tea. ��`i - _ Date: Gct TOWN OF BARNSTARLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: Cae "-N C' C—, 1 a,J BUSINESS LOCATION: 97 e-C ©sTep—V 1 INVENTORY MAILING ADDRESS: IOTA MOUNT: TELEPHONE NUMBER: CONTACT PERSON: EMERGENCY CONTACT TELEPHONE UMBER: MSDS ON SITE? N TYPE OF BUSINESS: ��s i .�-r�-� G��-t �ocr-Icr4 INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: �� Last shipment of hazardous.waste: Name of Hauler: o Desti .nation: 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 n NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) 7 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, r Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink i . b 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 �2m 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 r hydrochloric acid, other acids) l� Floor &furniture strippers Other products not listed which you feel Metal polishes may be toxic o 'hazardous (please list): Laundry soil & stain removers (including bleach) _ Spot removers & cleaning fluids i (dry cleaners) G 0 5 '' ' -yj a0 Other cleaning solvents Bug and tar removers r Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS No. (0- O Fee 3 3 Z60 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Zipprication for �Dig;ponf �&pgtem Con.5tructton Permit Application for a Permit to Construct( ) Repair X. Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. Q. Owner's Name, dr0ess,�nd4gl.No. Assessor's Map/Parcel _DAD C of r �����[©-J l v ti f Installer's Name,Address,and T_el.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alt rations(Answer when applicable) (,Q_�Leg, Zau r®Jon L ,G �Q ' 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 Bo rd of ealth. /01, Si ed Date "8 Application Approved by Date .:'Application;Disapproved by.:, Date �>zs for>the Tollowing reasons, Permit No. Gc5o t_o 31'3 Date Issued �� No. c^.0 0(D 3?3 _77y) Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWNfOF BARNSTABLE, MASSACHUSETTS Y ZfppYication for Migponi l �&pgtent Congtruction 30ermit * Application for a Permit to Consttruct Repair(� Upgrade Abandonr' O ❑ Complete System ❑Individual Components Location Address or Lot No. �. °rs t. 0 ner's Name,AAdress,and I.No. Assessor's Map/Parcel ,'Cd_.01 C_ 'u— 6co��)7 t)-!W330% Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil ? 1— L$ � ,p t Nature of Repairs or Alt rations(Answer when applicable) k,, �Qtl ('OJY3) t)A 6_) DOZAV 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 Health Si ed C% Date �a Application Approved by Date ; I :30 �+ Application Disapproved by: e Date for the following reasons Permit No. 3e 3 Date Issued R 30 lc THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewag Disposal System Constructed ( ) Repaired (-A) Upgraded ( ) t Abandoned( )by ^ 1 t r �Q f 0 r) at tj Qd ical ��4 .pl' 1 f o MAt. I has been constructed in accordance J with the provisions of Title 6 and the for Disposal System Construction Permit No. c^4COG -' �S14�� dated Installer �C���S�'� �p �Wl t Designer #bedrooms Approved desi n flow gpd The issuance of this permit shaii o/f be construed as a guarantee that the syste wiII funs Date 13 Inspector No. ;�Co Fee ,�Qd THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS 0igpogar *pgtem Construction Permit Permission is hereby granted to Construct ( ) epair ( +tt Upgrade ( ) Abandon ( ) System located at l dl (��t'.2�[1it and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction must be •gmpleted within three years of the date-of th si permit. Date Approved* w _ _ f Doc_ 1 P 042 s 814 08-29-2006 12 a 31 . BARNSTABLE LAND COURT REGISTRY r DEED RESTRICTION WHEREAS,ADAM J. HOSTETTER, of 1293 Santuit-Newtown Road, Osterville, Massachusetts, is the owner of the real estate located at 15 Milne Road, Osterville,Massachusetts (hereinafter referred to as "Premises"), and being shown on subdivision plan 9755-D dated March 1947, drawn by Whitney and Bassett, Engineers, and filed in the Land Registration Office at Boston, a copy of which is filed in Barnstable County Registry of Deeds in Land Registration Book 56, Page 106, with Certificate of Title No. 8886, and said land is shown thereon as Lot E-2. WHEREAS,ADAM J. HOSTETTER, as the owner of said lot has agreed with 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 as a pre-condition to obtaining a disposal works construction permit in compliance with 310 C.M.R. 15.00 State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage; 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 C.M.R. 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 on4he number of bedrooms in any house constructed on the lot be put on record with the Barnstable County Registry of Deeds by recording this document; NOW, THEREFORE, ADAM J. HOSTETTER, does hereby place the following restriction on his above referenced land in accordance with his agreement with the Town of Barnstable Board of Health, which restriction shall run with the land and be binding upon all successors in title: 1. The premises may have constructed upon the lot a house containing no more than two (2)bedrooms and the former garage which has been converted into a "games room" shall not be utilized for sleeping purposes. This deed restriction shall continue in full force and effect until such time that construction of a residence with greater than two bedrooms is allowed as of right. For title, see Certificate of Title No. 175692. Executed as a sealed instrument this day of August 2006. Adam J. Hostetter COMMONWEALTH OF MASSACHUSETTS Barnstable, ss. On this �`� day of August, 2006, before me, the undersigned notary public, personally appeared Adam J. Hostetter, proved to me through satisfactory evidence of identification, which was fir_ 5 � Vm ��Vn to be the person whose name is signed on the preceding or attached document, and acknowledged to me that he signed it voluntarily for its stated purpose. otary ublic Cheryl K.Grumatein M commission expires: Notary Public y p My Commission Expires 0212M MAP �.. � PARCEL LOT s DATE_7130104___ 15 11 i.ene Rd. PROPERTY ADDRESS:______________�___ 0ete2v.c.e.ee, (�a. r r 02655 On the above date, the septic system at the above address was Inspected.. This system consists of the following;I. 1-6'X6 ' &-eoek ee.6,3/2ooe. 2. 1-1000 ya.eeon eeach.ing iz.it. Based on inspection, I certify the following conditions:' 3. 7h.ii .iz not a t.it.ee /.ive zept.ie zyztem. c ` 4. The zept;ie .6y,3tem .iz .in jmopea woak.iny o2dea at .F the pae,ent time. 5. Na.in ee,3�312oo e wa. '12" watea to .invent. 6. 1000 ya.e.eon eeach.in y pit waz d2 SIGNATURE: _ Name:_ Sauce Naca.i i stew______-- . C Company:Address:_Box_¢.6- Cente�zv.�L e, 17 .__02632 �NDEPT. Phone:_(508) 775_3338 ------ --- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY a FJOSEPHrP. MACOMBER & SON, INC. ��. Tanks-Cesspools-Leachfields Pumped .& Installed Town Sewer Connections . ; P.O. Box 66 Centerville, MA 02632-0066 y 775-3338 775-6412 /: COMMONWEALTH OF MA,SSACHUSETTS E+XECUTIVE OFFICE•OF F, "IROrNMENTAL AFFAIRS DEPARTMENT OF +'NVIRQNEN�`AL pROTCTION �H TITLE 5 OFFICIAL INSPECTION FORM--Np.T E SYSTEM FORM SUBSURFACE SEWAGE DISPOSAL PART•A CERTIFICATION Property Address:'. 15 Milne. Road pyEeryi 1 1 ' U 0 5 Owner's Name: Ra rha ra Ra t SOn Owner's Address: Same Date of Inspection: Name of Inspector: (Pleaseprint) .: Company Name; , ems. & .S,on Inc. Mailing Address: Cen /zv,z e, aba. 02632 Telephone Number. 5 0 8—77 .4333 CERTIFICATION STATEMENT I certify that I have personally inspected the.sewage.disposal system.at this address and that the.information reported below is true.,accurate and complete as of the time of the inspection.The inspeetionmas performed based on my training and experience in-the proper function and 1maintenance40 tle 5(31.6 CMR 15••000)of on-�ite sewage a1The system:systems.I a DEP . approved system inspector pursuant to gection.15c340.o T, f Passes -Conditionally Passes Needs Further Evaluation.by the Local Approving.Authority Fails . . .Inspector's Si acre: Dater 0 �0 Insp . The system inspector shall submit a copy of this inspection report to the.Approving Authority.(Board of Health or Ow Of 10,000 DEP)within 30 days of completing this powner shaection.If ll submit he report to e systep'Is.a..Ahateid the appernropriate reg ognaloffiee of the gpd or greater,the inspector and the system DEP.The original should be sent to•:tho system owner and copies sent to the buyer,if applicable,and the approving. authority. Notes and Comments i �, U'l�•� �. 5hau� �� �e�ptPe 4 nrt¢�,in' &. JP 't'®��I ****T'his•reP ort.only describes conditions at the time of inspection'and under the* Condindert ons of same e,different ^ time.This inspection does not address_how the system will perform in the future conditions of use. page I ' Page 2 of 11 OFFICIAL INSPECTION:FORM—NOT:FOR VOLUNTARY ASSESSMENTS SITBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART A CERTIFICATION (continued) Property Address: 15 Milne Road Osterville Owner: Barbara Batson Date of Inspection: 7/3 0/0 4 Inspection Summary: Check 4A;B;C,D or,I,/ALW.4AYS£completerall of Section.'D A. System Passes: M 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: e 5(j5k-m B. System Conditionally Passes: 110 One or more system components..as described in the"Conditional Pass":section need to be replaced.or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not.determined(Y,N,ND)in the for the following'statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic-tank(whether metal.or not)is-structurally unsound,exhibits substantial:infiltration or exfiltration.or tank failure is,imminent. System will pass inspection:if the existing tank is replaced with'a complying,septic tank.as Approved by the:Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less.than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled-or uneven.distribution box.System will pass inspection.if(with approval of Board of Health): broken pipe(s)are replaced. obstruction is removed distribiftion box is leveled or.replaced ND explain: 00 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 pipes)are replaced obstruction is removed ND explain: ' n Page 3 of 11 OFFfiCIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIOON.<lF'ORM PART.A CERTLFICATION(eontinued) : Property Address: 15 Milne Road Osterv,ille Owner:. Ra rha ra Ra t ann Date of Inspection: r C. Further Evaluation-is Required by the Board of Health: nO Conditions,exist which require further.evaluation.by.theBoard ofHealth:in order,toAdlemiine if the system is failing to protect publiahealth,;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: (�O Cesspool or privy is,within 50 feet of.a.surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2. System will fail unless the Board of Health(and Public Water Supplier;if any)determines-that the system is functioning in a manner that proteets 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 watersupply. rw The system has a septic tank and.SAS:andthe SAS is withint50 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.:rriore from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from-pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5.ppm,provided that no other failure.cfiteria are triggered.'A copy of the analysis must ber.attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR YOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART A CERTIFICATION(continued:) Property Address: 15 Milne Road OstPrvi_1 1 P Owner: Ra rha ra R-a arin r Date of Inspection: 7 ISO Q 4 D: System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to.each.of the:followingfor,all:inspections: Yes Np Backup of sewage-into facility.or.system component duelo overloaded or clogged SAS or.cesspool _ Discharge:or ponding of effluent to the surface;of the:gound 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 _ V/ hiquid depth in-cesspool is less than 6"below invert or available volume is less than'h•day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS;cesspool or privy is below high ground water elevation. Any.portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface / water supply. _ V Any portion of a cesspool or privy:is within a;Zone l 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 colifo'rm bacteria and volatile organic compounds indicates that the well is free from polluton;_from:that.facility and.the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5.ppm,provided that no other failure criteria are triggered..A'copy of the analysis must be attaehed.to this foriq.] 1�p (Yes/No)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;00.0 gpd to 15;000. gpd• You must indicate either"yes"or"no"to,each of the following: (The following criteria apply to large systems in addition to the criteria above) yes na — _ 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 sha.11 upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS �LtBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1 5 let; 1 na Read 0C;t-(-ryj Ill e Owner:. Rarhara Bz farm Date of Inspection:11 0 QA Check if the following have been done You must indicate"yes"or"no"as to each,of the following: Yen No —/ — Pumping information was provided by the owner,occupant,or Board of Health _ V 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? t/ Have large volumes of water been introduced to the system recently or as part of this*inspection? _ v Were as built plans of-he system,obtained and examined?(If they were not available#tote as N/A) N Was the facility or dwelling inspected for signs of sewage back up? J _ Was the site inspected for signs of break out? v _ Were all system components,excluding the SAS, located on site? 7 _ Were the septic tank manholes uncovered,,npened,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? t/ _ Was the facility owner(and occupants if different from owner)provided with information on tha proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS).on the site.has been determined based on: Yes no Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance - is unacceptable) [310 CMR 15.302(3)(b)] 5 Page 6 of l 1 OFFICIAL.MSM-QTI:O. ,F-0RM-NOT FOR VOLUNTARY ASSESSMENTS .g IBSITRFACE S VAOE I)ISI QSAI.. STUM,�INSPECTION FARM PART.0 SYSTEM INFORMATION Property Address: 1 C; Ed In Road (lcfcrvi 1 ]-e Owner' Rarhn-a Rat;sQn Date of Inspection: . 7./ 4)4 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):,._:- 'Number of.bedrooms(actual): 0 DESIGN'.flow based on'31-0 CNN 15.203'(for example:'l 10 gpd of z#- bedrooms): l� 0 " Number of current residents: .: Does-residence have a garbage grinder(yes or no):(I/0- Is laundry on a separate sewage.system-(yes or•no):.10 [if yes separate inspeption required] Laundry system inspected(yes or no): ` R4 L PD . Seasonal use:(yes or no): �i Water meter readings, if available(last 2 years usage(gpd)): a)OS 1 )PO=S$ 0D Sump pum (yes or no): j Last date of occupancy: lP!f1 COMMERCIA.IbUSTRIAL Type of estab) i. nt: IU Design flow•. Oa on310 CMR 15.203)% Lq gpd Basis.of diri'flow(seats/persons/sgft,etc.):;I IAi Grease trap ppresent(yes or no): Industrial waste holding tank present.(yes or no):} Non-sanitary waste discharged to the Title 5 system-(yes or no): Water.meter readings,if available: Y llh Last'date of occupancy/use: OTHER(describe):. GENERAL INFQRM.ATION . Pumping Records n Source of information: , ram cc Was system pumped as part of the inspection(yes or no):(145 If yes,volume pumped: 00 allon§--Ho), was quantity pumped determined? _ Reason for.p..umping: �2 TYPE OF SYSTEM , —Septic tank,distribution box,soil absorption system ,/'Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) —Tight tank. _Attach a.copy of the DEP.approval Other(describe): QW14MV 1©e10 ( Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no). 6 _ Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM A PART C SYSTEM INFORMATION(continued) Property Address: 15 Milne Road Qstervi 1 1 P Owner: Barbara Rats; n Date of Inspection:7I'l BUILDING SEWER(locate on site plan) Depth below grade: . Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: I o Coo a is(on condition of joints,ventin evidence of leakage,etc.): ' ` .. SEPTIC TANK:(ti0 (locate on site plan) Depth below grade: ft Material of construction:f Lconcrete metalh fiberglass'_OApolyethylene _other(explain) If tank is-metal list•age:Ujj_ Is age confirmed by a Certificate of Compliance(yes or no):certificate) _(attach.a copy of Dimensions: �A Sludge depth: f1k Distance from top of sludge to bottom of outlet tee or baffle:flk- Scum thickness: f tQ\ Distance from top of scum to top of outlet tee or baffle:�. . Distance from bottom of scum to bolt m of outlet tee or baffle: How were dimensions determined-. Comments(on pumping recomirieridf eak,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related too tlet my rt, a idence of eakage,etc:): GREASE TRAP: (locate on site plan) Depth below gradrt:4l9 Material of construction:&concre4Lmetal 6&fiberglas _polyethylene 9&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 orrbaffle: Date of last pumping: a m Continents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evide ac of leakage;et .): T1t1P S TTO/�Prtinn Tlnrm Arl sionnri 7 Page 8 of OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS 111 5URFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 15 Milne Road 0--f-Pruri 1.1 a. Owner*-,. Barbara Batson Date of Ibspection: 7/3 n/n a TIGHT or FIOLDING TANK: (tank must be.pumped at time of inspect ion)(locate on site plan) Depth below.grade: Material of construction: concrete metal fiberglas's&-polyethylene V( other(explain): Dimensions: Capacity: gallons Design Flow: _ gallons/day Alarm present(x e�s� or no) Alarm level: V Uk Alarm in working order(yes or no):J Date of last pumping: r1'%_ Comments(condition of a1arm and float.switches, etc•): —rtkvL+ ri lC i'lst-� DISTRIBUTION BOX: F4 (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of bo��cc, etc.): PUMP CHAMBER: (61 (locate on sife.plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(no.te condition of pump cha ber condition of pumps and appurtenances, etc.); 11 "P • 8 . I Page 9 of 11 OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INNSPECTION FORM PART:C SYSTEM INFORMATION(continued). Property Address: 15 Mi 1 nP gnarl OGtervi_1.1e Owner:. Rarha ra Rat_nn Date of Inspection: 7 /-4 n /n a SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: 10 Type ' L4fL leaching pits,number: hLQ leaching chambers,number: (W leaching galleries,number: d� leaching trenches,number,length: leaching fields,number,dime stons: (Lk overflow cesspool,number: (AO innovative/alternative system Type/name of technology: a- T-.y- Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): �� tI C '( a,ttt,., � � 3 r �ri. v(St 1�n i C CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) r f • Number and configuration: 0 X w r Depth—top of liquid to inlet invert: � ." !• Depth of solids layer: Q Depth of scum layer: O Dimensions of cesspool: �) (4` ' Materials of construction: eAfLP Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): l (h PRIVY: (locate on site plan) Materials of construction: VIA Dimensions: Depth of solids: .VLON Comments(note cond' ion of soil,si s of hydraulic failure,level of ponding,condition of vegetation,etc.): i Ul �r 9 Page 10 of I 1 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 15 Milne Roar Ostervillt- Owner: Barbara Batson Date of Inspection: 7 3 0/0 SKETCH OF SEWAGE DISPOSAL SYSTEM -'Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. `w 0� i 06 10 I Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS �. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 15 Milne Road Osterville Owner: Barbara Batson Date of Inspection: 7/3 0/0 4 SITE EXAM Slope Surface water Check cellar Shallow wells r Estimated depth to ground water 1�0 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) .Accessed USGS database-explain: You must describe how you established the high ground yvater elevation: Ly-eA_ i t -00 -J cDn.6 . 7 -,rs+-e-r..r'-esT.a-c.rnn-, ._ .. . - •. T,.-,-e-+.•--rs--•--?.:--•--...�. I, Ma•rrnnrrrsrrs—:ZTrxr:ar.:nrrrrar.*r:srrrsrr.:-.�•m*':• •• TOWN OF Aa-rnstahlp BOARD OF HEALTH SUI)SKIFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION ( iSfff/iTRtTTSiTTTTT.f►RR•.�tl•TT•T•^t••—••� •...-^:•r•:-::r.r.+r..^.--nr.-r+•rs:rrt—iirr.+nr-rorrrrz•t•n:rrr.-a.rermr'+►'FT�+��"OAR�Qf�^� -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 15 Milne Road, Ostpryillp MA 02655 ASSESSORS MAP , BLQ„CK AND .PARCEL OWNER' s NAME - PART D - CERTIFICATION NAME OF INSPECTOR Bruce Macallister - COMPANY NAME Joseph P. Macomber & ''Son Inc . COMPANY ADDRESS Box 66 Centerville MA 0261? Street Town or City State ZIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX 508 .) 790 1 578 _ R CERTIFICATION STATEMENT ` I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate, and omplete as of the time of �inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one: 6 System PASSED The inspection which I have conducted has .not found any information which indicates tfiat. the system fails to adequately protect public health or the environment as defined in 310 CMR. 16 . 303 . Any failitre criteria. not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED \__* The inspection which I have con ircted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 310 CMR 15 , 303 , and as specifically noted on PART�C -_ -AILURE CRITERIA of this inspection form . 1 &/So-6 If Inspector 'Signature f Date, One copy of this certification must be provided to the OWNER, the BUYERhere applicable ) and the' BOARD OF HEALTH. * If the inspection FAILED, the owner or operator shall upgrade ' the system. within o'ne year of the date of the inspection., unless allowed or required otherwise as provided in 3;10 cri.R 15 . 3.05 partd.doc Fs s... .................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ......... _. .................OF..................................... --------------------------------------------- �+( Appliratinn -for Di-npgfittl Works Towitrurtion Pumit Application is hereby made for a Permit to Construct ( i4-m Repair ( ) an Individual Sewage Disposal System_at: -A Z.a-,_ —/)--------d5`'' ' � -- ------------------------ `-s .�... at' dd ess or Lot No .............. ner -Addr ss ------------------- ...--- ---------JW..-Q-----------•----....--- Installer Address 4- — ............ feet U Dwelling—No. of Bedrooms----A._____------------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ---0&0leW-------- No. of persons_-_---;l-- --------------- Showers (/ ) — Cafeteria ( ) p' Other fixtures ------------------------------------------------------ w Design Flow_____________________tf0_..............gallons per person per day. Total daily flow-__--_-WA---------------------------gallons. WSeptic 'Dank—Liquid capacity._--_.-___.-gallons Length................ Width.-_--..-_----.. Diameter-----........... Depth---------------- x Disposal Trench—No_____________________ Width.................... Total Length---_-__-____....___ Total leaching area......-..-----------sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet-------------------- Total leaching area-.__-..____---___sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by--------- ---------------------------------------------------------------- Date.......................... ------------- Test Pit No. 1------------_---minutes per inch Depth of Test Pit_................. Depth to ground water_---------------------- t14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.-.-._-____-----__------ a O Description of Soil-----/ q KC___.__f ''�'� x U -•••-••--.._...-•---------------------------------------•--...-•------------•-------•----------•-•-----•......------------------------------------------ W ---------------- - ----------------------------------------------------------------------------------- ------------------------------------- --------: ------- ------------------ U Nature of- epairs or Alterations—Answer when applicable._.-____I�. T'�WJ___---O-Vila_ --dam_..__ 20, .�i --/ ... ••-- - :- ---------------------------------------------------------------------------------- ------------------ ----------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. ��a Date Application Approved By------ -- •-- - --.................................. 7 ;KS- ?'S--------- Date Application Disapproved for the following reasons--------------- --------•••------•---•••---------------•---------•----._.............-----• ------------------- ------------------------------------•----------------------------•_......•--••-----••----------.---- Date Permit No......................................................... Issued... -•--- .......7.. Date A No7-••--•---....•..5.. F��..��.�................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _._......... _ . ........ .OF....................................... -- ... - ........-_.......... Applirtttinn -for Di,spusttl Workii C owarurtion Vrrutil Application is hereby made for a Permit to Construct ( 4+} r Repair ( ) an Individual Sewage Disposal System_at: d5 ,�wt1/ �.S --------------------------------------------------------------------------------------------••---- --••--•••---------•••••----••---••••-•----•-•--•...--•---...•----••--•-•---••-••-••-......-•-•--. ` �h��atig - Address or•Lot No. ........... ai, /-- O Address C .. --•-•• -----••....--•-•••-•----••--•----•--•--•--•-•••••--•--•-•--•-----•-•---•---•••• -•--._1 .------------------------. Installer Address d Type of Building Size Lot_45' -_____________Sq. feet U Dwelling—No. of Bedrooms..--k-----------------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building -.-/Q4c')---C(4__--____ No. of persons....... :-_______________ Showers (I ) — Cafeteria ( ) Q' Other fixtures d - ------------------------------------------------------------------------------------------------------ W Design Flow.....................+�o...............gallons per person per day. Total daily flow.._.._..Z!!!---___.--__-_____._.--.--.-gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width---------------- Diameter-----....-.----- Depth------.--------- x Disposal Trench—No- --------------------- Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft. 3 Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area--------_.........sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-:�%------------ ---------------------•--------------------------------- Date--------------------------------------.. a Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water--. --.--_------------- 44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water--.-..---_--__-.---_---. 9 p ----------------- -------------------------•--•-------•-•----•--••--------••••......•-•--•••--•......................................................... D Description of Soil-_---At �4._... .'_� _.._.. i9' x •---•••---•-•-••-----•--•.......................••--•---•--•--------------........------------------•---••---------- V ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------•---nJ - r9/--------OV f.._.` ----- -----------------/--- U Nature of epatrs or Alterations—Answer when applicable-------- ...................��0"`�__._ �OGG- .•3L-_�cf. --'--------- ------------------------------------------------------------------------------------------------------------------------------------------------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Jays p� ,�'��I<_cf,�.._�rz___ S.,gned.... •--••-•----•------. Pj DateApplication Approved BY .. == l... .----------------------------------- t PPf following ------•--------------•----------------•------•-•-•-•---•-------•-•.........Date-----•-----•-- ------- Application Disa roved or the ollowZn reasons________________ --------------------------•-•-------•---------------------------------------------------------------•----•---•••-•-•-•----•......-•-•--•-••----•-•--•......----•---------•---........--•-----•-•••••-••- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH (h , l..rr .......YZ.........OF........... . .... ..r,.......................................... Tntifirtttr of Tomplittnrr THIS IS TO DER UI Y, That the In ividual Sewage Disposal System constructed ( ) or Repaired ( ) IPS4114 ------------- has been installed in accordance with the provisions o rticle XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit ..- dated.... _.._.. .r..... ................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH �22 '....'.... �:...........OF........i --- No......................... FEE,2-------------.... Permission is hereby gr, to ------- Permission to Constru�t ( ) or Repair—, ) an Individual gewa D_isptisal System J atNo. / a � /................ 1 ----------------------------------- Street as shown on the application for Disposal Works Constructio fP�rmit No........:......... Dated... _.' S_._'7. / d ---•- ` Board of Health DATE...�_._—..-------------/.� FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS SKI ASSESSORS REF.: o Ma 118, Parcel 16 p ``� �r Area Coverage )qg Lot Area — 17,162±SF Original Coverage: 3,350tSF — 19.5% y" Jas Ernest✓ N/p Proposed Coverage: 3,626tSF - 21.1% OVERLAY DISTRICT: C! c207155 ✓OXt"per AP — Aquifer Protection District v 1 CFndH O O O_O� 2.7' s 0� O q U - OHO OHO '(17 00 �V gg (10' 81'7 � 20 �/ �IF :� j ) 6 O5, is O U 1 t 4 _ Location Map: 1 S tY w 63.6' CB/DH Scale: 1" = 2000t Shell Shed Guest Hse Fnd 3.3' s.7i . CV �1. 1 Roof Paved 1 O L Overhang Drive j FLOOD ZONE. LotE2 N ! Parcel Area A Zone X pprox p Septic System . 1 ohw FEMA Ma o 1 7,162E SF By BOH Card 3 #25001 CO544J LEGEND: O N Exist. ! ohw Effective July 16, 2014 rri Deck hw 1 OO Water Gate (round) i I Catch Basin i ,.......�.. .... ..... 3 , 3 ZONE: Hydrant ::::95::.:.. j c, •c El CB/DH i i m i Area Cmin. 87,120 SF RPOD Proposed Deck ry #15 ® (min.) ( ) a Frontage (min) 20' Utility Pole I Sty w/f i i I Width (min) 100' ohw— Overhead Wires i & Additions DwellingI 0 Drainage Manhole ! 1� W Setbacks: �N a Front 20' Light Post \ la Side 10' p �0 Rear 10' c �-._- Exist. j° O _ Deck CB/DH Find Prop..',.. 1 Z �N OF b� I d `.::i - Side __ :`.iDeck.:.o ...•::. ::...:.:`:••:i:.:::: 8 j 3 �" lwrd (10) ``i`.10'.,{{.: ............. NOTES: 1D 3. _ ; RICHARD R. % 157,39' _ _is.2'- i L'HEUREUX M 1.) The structures shown were located on the ground by S81'11' NO'. 34.312 conventional survey methods on 07/MAR117. 20 E ChOin n ci '� '^�e► C io 2.} The property line information shown hereon was k Fence , CB/DH d' TEAS P ' Find lANOgJ compiled from available record information. I Y 3.) The elevations shown are based on NAVD '88, a fixed meas sea level datum. 0 5 10 15 20 30 40 FEET Sheet # Title: Prepared For: Notes/Revisions: Plan Showing Proposed Deck & Additions CapeS u rv ' Scale: 1„=20' 1 at 15 Milne Road 23 West Bay Rd, Suite G Date: Rona E Garfield See.Above �f � Osterville MA 02655 28 �UL 17 BARNSTABLE (OStervllle) MASS 1 (508)420-3994 (508)420-3995 fax Dwg: copesurv@copecod.net C614_6g1