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HomeMy WebLinkAbout0024 OLD MILL ROAD - Health 24 Old Mill Road.. � Osterville F/R A _.; 141 058 X)v 30 2016 14:32 Jim The Inspector Man 5085349919 j page 1 ■ ■e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Old Mill Road Property Address Michael Minahan Owner Owner's Name information is required for every Osterville MA 02655 11-29-16 page. City/Tewn State Zip Code Date of Ingpection 4 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information' filling out forms ���NWillllUr ii on a computer, lab'.. CJ/ /��`/� ``\� \``\\ 'o"OF use key to move your _ 1. Inspector: cursor. do not Jsmes D.Sears. =�: JAMES use the return Name of Inspector r - - key. z vS.EARS Capewide Enterprises, LLC *�`., Company Name _ i'-�1 n RTl4\V- z3, 153 Commercial Street ���iq�s IN30- \ Company Address Iran� Mashpee MA 02649 CitylTown State Zip Code 508-477-8877 81623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system'at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: t ® Passes j • ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approvjing Authority - f 11-30-16 spector'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 in Y p section- If the system has a design flow o 9 p Y 9 f 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 insp ection and under der 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 doc rev.5116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 1 of,17 Y _ I I , Nov 30 2016 14:32 Jim The Inspector Man 5085349919 page .2 Commonwealth of Massachusetts Title 5 Official Inspecti®n For Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 24 Old Mill Road Property Address Michael Minahan Owner Owner's Name information is required for every Osterville MA 02655 11-29-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15,304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1500 Gat. Tank D Box and one chamber.= B) System Conditionally Passes:- El 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): r ' r r t5ins.cloca rev.6/16 - Title 5 Official Irspection Form:Subsurface Sewage Disposal System Page 2 of 17 Nov 30 2016 14:32 Jim The . Inspector Man 5085349919, page 3 Commonwealth of Massachusetts j . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Old MITI Road Property Address Michael Minahan t } Owner Owner's Nam® information is required for every Osterville MA 02655 11'-29-16. 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): 4 ❑ 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): y ❑ 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): 0 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 CMRr 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: 1 , ❑ 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 . 15ins.00c rev.6/16 Title 5 Official Inspecon Form:Subsurface_Sewage Disposal System•Page 3 of 17 Ncv 30 2016 14:32 Jim The Inspector Man .5085349919 page 4 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form Not for Voluntary Assessments 24 Old Mill Road Property Address Michael Mihahan Owner Owner's Name tion isrequired for every very Osterville MA 02655 11-29=16 page. Cityfrown 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: f 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. a 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due,to overloaded or clogged SAS or cesspool E ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® Liquid depth in is less than 6" below invert or available volume is less than '/day flow I FAC',y!in�G' t5ins.doc+rev.6116 Title 5 Official Irspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Nov 30 •2016 14:32 Jim The Inspector Man 5085349919' page 5 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Old Mill Road Property Address Michael Minahan Owner Owner's Name Information is required for every Osterville MA 02655 11-29-16 page, Cityrrown State . Zip Code Date of Inspection B. Certification (coot.) Yes No El ® 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. ❑ z Any portion•of a cesspool or privy is within a Zone 1.of a'public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.) ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of,the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. j 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 El ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department, t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 w x Nov 30 2016 14:32 Jim The Inspector Man 5085349919 page 6 Commonwealth of Massachusetts Title 5 Official Inspection Form T Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Old MITI Road Property Address Michael Minahan Owner Owner's Name information is Osterville required for every MA 02655 11-29-16 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of waterjbeen introduced to the system recently or as part of 1 this inspection? i ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as NIA) • - ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located'on site? ® ❑ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees, material"of construction, . dimensions, depth of liquid, depth of sludge and depth of scum? ® Was the facility owner(and occupants if different from owner) provided with - information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® -Determined in the field (if any of the failure•criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: I - Number of bedrooms(design): 2 Number of bedrooms (actual): 1 DESIGN flow based on 310 C M R 15.203 (for.example: 110 gpd x#of bedrooms): 220 15ins.doc•rev.6116 Title 5 Offiolal Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Nov 30 '2016 14:33 Jim The Inspector Man 5085349919 page 7 Commonwealth of Massachusetts - Title 5 Official Inspection Form 6 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Old Mill Road Property Address Michael Minahan Owner Owner's Name information is required for every Osterville MA 02655 11-29-16 page. City/Town State Zip Code Oate of Inspection D. System Information Description: The system is a 1500 Gal. Tank D Box and one chamber. i • Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage NA ( Y 9 (gPd))� Detail: ` Sumppump?, Sum ❑ Yes ® No I Present Last date of occupancy: j Date Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based one 310 CMR 15.203): Gallons per day(9pd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No • i Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-doc•rev.6116 Title S Official Inspection Form:Subsurfa:e Sewage Disposal System•Page 7 of 17 - I Nov 30 2016 14:33 Jim The Inspector Man 5085349919 page 8 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments, " 24 Old Mill Road Property Address Michael Minahan Owner Owner's Name formation is squired for every Ostervllle MA 02655 11-29-16 page. Cityfrown State Zip Code Date of Inspection } � D p D. System Information (cont.) Last date of occupancy/use: u - Date ; - Other(describe below): . General Information Pumping Records: " Source of information: : 4/10/12 Was system pumped as part of the inspection? ❑ Yes '® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: „ 1 _ Type of System: i ® Septic tank, distrib6tion box. soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy E ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): F t5ins-doc•rev.6/16` - - Title 5 Officlai Inspection Form:Subsurface Sewage Disposal System-Page B of 17 ii ENov 30 '2016 14:34 Jim The Inspector Man 5085349919 page 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M®�' 24 Old Mill Road • Property Address Michael Minahan Owner Owner's Name information is required for every Osterville MA 02655 11-29-16 page. Cityrrown Stale Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 2003 Permit # 2003 -435 Were sewage odors detected when arriving at the site? ❑ 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: feet • Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH -40 Septic Tank (locate on site plan): i I Depth below grade: 14" feet Material of construction: - y _ ® 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 1500 Gal. Precast Dimensions: Sludge•depth: 2„ t5imdod•rev.6/18 - - - _ - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I Nov 30 2016 14:34 Jim The Inspector Man 5085349919 page 10 . Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Old Mill Road Property Address Michael Minahan Owner Owner's Name information is required for every Cistetville MA 02655 11-29-16 page. Cityrrown 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 28 Scum thickness 1 Distance from top-of scum to top.of outlet tee or baffle t3 . 1711 Distance from bottom of scum to bottom of outlet tee or baffle i Asbuilt-P Ian-Tape How were dimensions determined? Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I Tank at working level. Tank and cover's at 14" below grade. In and outlet tee's. No sign of leakage or over loading. b , • 1 Grease Trap (locate on site plan): Depth below grade: feet i 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 15ins.doc.:;rev.6I16 Tine 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Nov 30 "2016 14:35 Jim The Inspector Man 5085349919 page 11 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ;N 24 Old Mill Road Property Address Michael Minahan Owner Owner's Name information is required for every Osterville MA 02655 11-29-16 page. Citylrown 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.): l - 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: t I 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.doc•rev.6116 TIlle 5 Official Inspection Form;Su0surtace Sewage Disposal Systerr.•Page 11 of 17 r Noy 30 2016 14:35 Jim The Inspector Man 5085349919 page 12 _ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Old Mill Road Property Address Michael Minahan Owner Owner's Name information is required for every Osterville MA 02655 11-29-16 page. Citylrown 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 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 20"x20"-13" below grade. Box is clean and solid w/one line out. No sign.of over loading or solid carry over. - t , I Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑' Yes 0 No*- ' Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): i " If pumps or alarms are not in working order, system is a conditional pass: Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6116 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Nov 30 2016 14:35 Jim The Inspector Man 5085349919 page 13 Commonwealth of Massachusetts Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Old Mill Road Property Address Michael Minahan Owner Owner's Name information is OStervllle required for every MA 02655 11-29-16 page. citylrown State Zip Code Date of Inspection D. System Information (cost.) Type, ❑T leaching pits number: Y ® leaching chambers number: 1 ❑ 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.): Leaching is one 500 Gal. dry well chamber w14' stone. Chamber at 19" below grade. Wet bottom, ` clean like new wall's No sign of over loading or solid carry over. i Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): • i Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction -- Indication of groundwater inflow ❑ Yes ❑ No 15ina.doc•rev.6116 4 - - - Tille 5 Official Inspection Form:subsurface Sewage Disposal Systerr•Page 13 of 17 Nov 30 2016 14:35 Jim The Inspector Man 5085349919 page 14 4 Commonwealth of Massachusetts Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form-Not for Voluntary Assessments { 24 Old Mill Road Property Address Michael Minahan Owner Owner's Name information is required for every Osteiyille MA 02655 11-29-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privyl on site �ocate plan).- Materials of construction: , Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): • i j 15iris.doc-rev,8116 Title 5 Official Inspection Form:Subsurface Sewaga Disposal System-Page 14 of 17 Nov 30 2016 14:36 Jim The Inspector Man 5085349919 page 15 commonwealth of Massachusetts F = Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments 24 Old Mill Road Property Address Michael Minahan Owner Owner's Name information is required for every Osterville MA 02655 11-29-16 page. City/Town Slate 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 .A-3 3 3" !3- FRaY7 r t5ins.doc-rev.6/16 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Nov 30 2616 14:36 Jim The Inspector Man 5085349919 page 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - 24 Old Mill Road i Property Address 1 Michael Minahan Owner Owner's Name information is required for every Osterville MA 02655 11-29-16 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells i Estimated depth t high ground water: 10'+ feet , Please indicate all methods used to determine the high groundwater elevation: ® •Obtained from system design plans on record C 8-14-03'. , 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: T.H. on Design plan 8-14-03. 104 no G.W. at 10'+ Bottom of chamber.'s at 6' above T.H. Depth. f Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 ORlclal Inspection Form!Subsurface.Sewage Disposal System•Page 16 of 17 f Nov 30 2016 14:36 Jim The Inspector 'Man 5085349919 page 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments "^ 24 Old MITI Road - Properly Address Michael Minahan Owner Owner's Name information is OSterville MA 02655 11-29-16 required for every page. Cityrrown State Zip Code Date of inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked k ® inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater i ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i • s t5ins.d0c-rev,606 Tine 5 orfcial i spacwn Form:Subsurface Sewage Disposal System•Page 17 0117 FORM30 CIW HOBBSBWARREN'm THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE H CITY/TOWN W 0 DEPARTMF*IJT ADDRESS G,,M Svey`oe ^ n TELEPHONE Address T�/wo l`/ Occupant . I'2 I'� Floor Apartment No. No.of Occupants_ ___ No. of Habitable Rooms_No.Sleeping Rooms �____. No.dwelling or rooming units_ No.Stories Name and address of owner _ D emarks Reg. Vio. - YARD Out Bld s.: Fences: j Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains.- Walls: Foundation.- Chimney: BASEMENT Gen. Sanitation: Dampness: Stairs: Li htin : \ STRUCTURE INT. Hall,Stairway: 0 ) Obst'n.: / Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑-P. Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusin ,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom —Pantry Den —Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR .410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) THIS INSPECTION R FIT IS GNED AND CERTIFIED UNDER THE PAINS AND PENALTIE��PER J INSPECTOR ITLE `S ECTOR T A.M. DATE 0 TIME P.M. A.M. THE NEXT SCHEDULED REINSPECTION P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises.This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter II, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to Iobligation f h r n wh m the order i issued to comply with such order. include affect the legal o the person to o s p y (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents br to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating,gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner i to remedy said condition within the time so ordered by the Board of Health. �,gran,(]•f�•�.;,e,..i„�r, v.�r�-.:.,r,.;�'sua�*rld7e3a�at��#f�1ta%f... .:.7`11+�[M'i3 'f;.;yes..•. rn THE COMMONWEALTH OF MASSACHUSETTS 16RM30 CAW HOBBS&WARREN BOARD OF HEALTH CITY/TOWN ZU W DEPARTMENT ADDRESS` I TELEPHONE Address — Occupan Floor Apartment No. No.of Occupants_- No. of Habitable Rooms No.Sleeping Rooms No. dwelling or rooming units_ No.Stories Name and address of owner t�-�) 'I ,I t} Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: ,r Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs.- Lighting: \ STRUCTURE INT. Hall,Stairway: Obst'n.: 1 Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: / Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den —Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom=4 :s.... Hot Water Facil. Su :Ten:,Gas-Oil=Elect,.:___. T Stacks;Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR. (See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES S OF,PERJ.I�RY l�' INSPECTOR TITLE r A.M. DATE r TIMEwool P.M. . t A.M. THE NEXT SCHEDULED REINSPECTION P.M. v""•a 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises,shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and we of the occupants or the public. Because Chapter II, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold,to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash,which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. r f 09--04--2003 a DEED RESTRICTION WHEREAS, Harvey G. Williams, late of 24 Old Mill Road, Osterville,Massachusetts, was _P the owner of the premises at 24 Old Mill Road, Barnstable (Osterville), Barnstable County, m Massachusetts, (hereinafter referred to as 24 Old Mill Road, Osterville) and being shown on U] a plan entitled "Plan of Land, Osterville, Barnstable, Mass., Scale l Inch--20 Feet b June 1946, Whitney&Bassett, Architects and Engineers, Hyannis, Mass."duly recorded in a� Barnstable County Registry of Deeds in Plan Book 75, Page 29; a� m O WHEREAS, Joan E. Perry, as Executrix of the Estate of Harvey G. Williams, the owner of v asaid lot has agreed with the Town of Barnstable Board of Health to a restriction as to the number of bedrooms which can be included in any home built on said lot as a pre-condition � to obtaining a disposal works construction permit in compliance with 310 CMR 15.000, -14 rA State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of ,.4 Sanitary Sewage; o WHEREAS, the Town of Barnstable Board of Health, as a pre-condition to granting a N disposal works construction permit for a septic system in compliance with 310 CMR 15.200, State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage, and authorizing the issuance of a building permit for the renovation of a Q) single family home on this property, is requiring that the agreement for the restriction on the r' number of bedrooms in any house constructed on the lot be put on record with the rd Barnstable County Registry of Deeds by recording this document, NOW, THEREFORE, Joan E. Perry, as Executrix of the Estate of Harvey G. Williams, does ov hereby place the following restriction on his above-referenced land in accordance with this agreement with the Town of Barnstable Board of Health, which restriction shall run with the a land and be binding upon all successors in title: 1. 24 Old Mill Road, Osterville may have constructed upon the lot a house containing no more than two (2)bedrooms, and Joan E. Perry as Executrix of the Estate of Harvey G. Williams, agrees that this shall be a permanent deed restriction affecting the premises located at 24 Old Mill Road, Barnstable (Osterville), Massachusetts, and being shown on the plan recorded in Plan Book 75, Page 29. For title of Harvey G. Williams see the following deed: Book 838, Page 332. Executed as a sealed instrument this 1 day of 144o" —'' 2003. CFCs T�" wner's Signature Joan E. Perry, Executrix of the Estate of Harvey G. Williams COMMONWEALTH OF MASSACHUSETTS Barnstable, ss <� l��' 2003 Then personally appeared the above-named JOAN E. PERRY, Executrix of the Estate of Harvey G. Williams, known to me to byq person who executed the foregoing instrument and acknowledged the same to be h e c and deed, before me, Davi B. Cole Notary Public My commission expires: March 22, 2007 2 t r. M COM ONW EALTH OE:MASSACHiJSETTS z EXECUTIVE OFFICE OF.ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVI' d RONMENTAL-PROTECTION. . TITLE 5 OFFICIAL INSPECTION FORM-NOT,FOR VOLUNTARY ASSESSMENTS SUBSURFA-CE-SE-WAGE DISPOSAL--SY-S-T-EM-FOR�� PART A CERTIFICATION Property Address: 24 Old Mill Road,,Osterville,MA CJ� Owner's Name: Steve Gemborys Owner's Address: 5 Boghill Road,Harwich,MA 02645 _ C = i CD Date of Inspection: 06/02/2010 Name of Inspector:.Michael T.Bis►enere Company Name:. A&K Septic Systems Plus. Mailing Address:565 Carriage Shop Road,East Falmouth,MA 02536 c Telephone Numher:508-540-670 .. r P 6 CERTIFICATION STATEMENT I certify that I have personally inspected the ewage disposal system at this'address and that the information reported . below is true,accurate and coinplete.as of the time.of the inspection.The inspection was performed based on my- training and experience in:the proper function and:inaintenance of on site sewage disposalsystems.I am a DEP- approved system inspector pursuant to Section.15.340 of Title'5(310.CMR.15.000)::Theaystem: X :.Passes n Conditionally Passes - Needs.Further Evaluation by'r the.Local Approving'Authority Fails Inspector's Signature: ' Date;; 06/02/2010: The system inspector shall submit a copy of this inspection report:to Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a desk flow of 10 OTQO gpd oI greater,,t d the_syste � meL sham _ subrrnt the`report to the-appropnate regional office of the DEP -The original should-- wont to the system owner and copies sent to the buyer, if applicable, and the approving authority: Notes and Comments: System consists of 15.00 gal. Septic Tank, D=Box and one 500 Gallon Chamber.''The discharge cover on the septic tank,is wrthin.6 inches to_:grade as well as the'D-Box and the lnspecfion'Port.: _ z - — This-report only describes condittons_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. - - Title 5 Inspection Form 6/l5/2000 g L� a e 1 rn P , i I i Page 2 of i i" OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS " SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ; CERTIFICATION(continued) Property Address: 24 Old Mill Road,Osterville,MA i Owner: Steve Gemborys -ae of Tnspection: 06/02/2010 Inspection Summary: Check,A,B,C,D or E/ALWAYS complete all of"Section D A. System Passes: r X I have not found any information which indicates that any of the fail-- 'criteria descnbed in 310 CMR 15 303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are.indicated below:. Comments: B. System:Conditionally Passes: One or more system components as described in the Conditional Pass"section need to be replaced or repaired.The system;upon completion of the replacement or repair,'as approved by the Board of Health;will pass. Answer yes,no or not determined.(Y,N,ND);m the':. for the following statements If"not determined"•please y 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 septictank 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. -. - AND explain- Observation of sewage backup or-break out or high static waterlevel 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 e s are replaced"PPO obstruction_is_Lemoved__w`. � ~- = -disfibufion box-is leveled or n aced ND:ex lam P The system required pumping more than 4 times a year,due to broken or obstruc ted : pipe(s).The.system.will pass uispechon if.(with approval of the Board_.of Health).-T�- _ --- . 777 broken pipe(s)are replaced 1 =_ -=obstruction is removed- - - - _ - ND explain ` Trtle 5 In Form 6/15/2000 2 , rage s or it OFFICIAL INSPECTION.FORM NOT FOR VOLUNTARY ASSESSMENTS, SUBSURFACE-SEWAGE DISPOSAL;SYSTEM,INSPECTION FORM' PART A CERTIFICATION',(continued) ` Property Address: 24 Old Mill Road,Osterville,MA Owner-.=Steve-Gembor_ys Date of Inspection: 06/02/2010 '' C. Further Evaluation is Required by the Board of Health. Conditions exist which require further evalu&ion`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 mannerwhich 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 2. System will,fail unless the Board of Health(and Pubhc`Water Supplier,d 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 iswithm;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 withiW. n a Zone 1,.of a public water supply The system has.a septic tank and SAS.and the:SAS is:'withm'S0 feet:of a private water supply well The system has a septic tank and SAS and theSAS is less than-.100 feet but 50._feet or_tnore fiom a T _= pnvate water upply—weIl** Method used to detennine.;dI tance **This system passes,ifthe well water analysis,performed.at a DEP certified laborato for.coliform y bacteria and volatile organic compounds,indicates that the well is,free from pollution from that facility and the presence of ammonia nitrogen and.nitrate nitrogen is equal to or less:than 5 ppm;provided that no other failure criteria are triggered A"copy of the analysis must be attached to'this forma 3. Other: ti. Title 5 lnspection Form 6/15/2000 3 d. Page 4 of i i - OFFICIAL INSPECTION V IM—NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPEC'I'ION:FORIVI PART•A. CERTIFICATION(continued) Property Address: 24 Old Mill Road,Osterville,MA,:.: . Owner- Steve Gemborys: W. Date.of inspection:.06/02/2010 . D. System Failure Criteria applicable to all'syste ms You must indicate"yes"or"no".to eacli of the following for all inspections Yes No X Backup of sewage into facility or system•component^due to overloaded or clogged SAS.or cesspool X Discharge or ponding-of effluent to the surface of.the ground or sur6ce waters due to.an"overloaded'or CIO gged SAS or cesspool .'• X Static liquid level m the distribution box above outlet'invert due to an overloaded or clogged:SAS or cesspool ' X Liquid depth in cesspool is less than 6.',below invert or available volume is less than 'h day flow X : .Required pumping more than,4'tunes in last year NOT due to.clogged of.obstructed i e s Numberbf tune- s pumped .. : . X Any portion of the SAS,cesspool or privy is below high ground water elevation X An y portion of cesspool or privy is within 1.00 feet of a surface water su '1 'or triliu water supply PP Y tary to a surface' X Any portion of a cesspool or priry is within a:Zone 1'of a public well: X Any portion of a cesspool or.priry is within 50.feet of a private water supply:well _ X Any portion of a cesspool or privy is less than,l00 feet but.greater than 50 feet from a private water supply well with no acc9.table water.quahty analysis. [TWs system passesjf.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 uitrate nitrogen is equal to or less than`5 ppm,provided that no other failure criteria are triggered.A copyaf the analysis must be attached to this form.] No (Yes/N6)The system fails.I have determined that one or more of the above failure:criteria exist as described in 310 CM1Z,15.303,therefore the system fails The system owner-owner the Board:of Health to determine what will be necessary to correct the failure t E. Large Systems. :. To be considered a large system the system must serve a facihty_with a�design flow of:10,000 000 _- - gpd to-15, You must indicate-either"yes"or"no' to each of the following (The following criteria apply_to large systems m addition to the criteria above) r. yes no f the system his within 400 feet of a surface drinking water*. -y 'thinb4y tem � tfrta _ f dgucrng water_su 1 the system is located in a nitrogen"sensitive area(Interim Wellhead Protection Area ,IVUPA)ora,mapped Zone'II of public water supply well. If you have answered'.'yes"to any.jquestiori 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 lie system - — - - considered a significant threat under Section E d-failed_under Section_D-shalLupgrade_the system m- - -� — - a`ccordance with 310 CMR'15 304.The.system owner should contact the appropriatex.e.. l office ofthe _. . Department. - - - - - t ,. s -Title 5 Inspection Form 6/15/2000 " 4 - a i i • 5' rage.5 or i i x OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST f Property Addressc.24 Old Mill"Road,Qsterville,MA Owner: Steve Gemborys Date of Inspection:,06/02/2010 Check if the following have beeddone.':You must"indicate"yes"or"no"as to each.of the-following Yes` No X _ Pumping information was provided by the owner,occupant,or Board of Health - X .,Were any of the system components pumped out ui the previous two;weeks.? X' Has the system received normal-flows m the previous two week period ' X Have large volumes of water been introduced to the system recently or as part of this inspection? X' Were as built plans of the system obtained and examined (If.they were not available note as N/A) X Was the facility or dwelling inspected for signs of sewage back X' Was the site inspected'for signs of break out X Were all system components,excluding the SAS;located on Site X Were the septic tank manholes uncovered,opened,and the infenor of the tank inspected for,the condition of the baffles or tees,material'of construction,dimensions,depth.of liquid,depth of sludge;and depth of scum. . X _' Was the facility.owner(and occupants'if different from owner)provided with mforniation on the proper maintenance of subsurface sewa a.dis osal systems _ -,.---The size an.d_location of the Soil Absorption System°(SAS)on the site-has-been'detei�n Yes no Existing information For,example,a plan at the Board of Health. , i X Determined in.the field,(if any of the failure criteria related to Part C..is at issue approxiniation of distance is unacceptable)[310 CMR 15.302(3)(b)] v a Title 5<Inspection Form 6/15/2000 5 rage b or I I OFFICIAL INSPECTION FORM-:NOT FOR VOLUNTARY ASSESSME NTS SUBSURFACE SEWAGE:DISPOSAL SYSTEM INSPECTION;FORM' PART C r SYSTEM INFORMATION F Property Address: 24 Old Mill Road,Osterville,MA'_ }' Owner:Steve Gemborys Date of Inspection: 06/02/2010. t: FLOW CONDITIONS RESIDENTIAL *:umber of-bedrooms-(de'sign}•=Number-of-bedrooms(a*aj). 5 DESIGN flow based on 310 CMR 15.201(for example:,I to gpd x*ofbedrooms): Number of current residents: Does residence have:a garbage grinder(yes or no) NO Is laundry on a separate sewage system.(yes or no):N6.'{if yes separate inspection required] ,.". Laundrys ins ected system p (yes or no) _ Seasonal use:(yes or,no): No " - Water meter readings,if available,(last 2 years usage(gpd)) Sump pump,.(yes or no).: ,No Last date of occupancy: 2008 COMMERCIAL/INDUSTRIAL''' Type of establishment Design flow.(based on 310 CMR 15.203): gpd 3; Basis of design tlow;(seats/person's/sgft,etc.) 4 Grease trap present,Cyes of no): Industrial waste holding tank present(yes or no) r Non-sanitary waste discharged to the Title 5`system(yes or no) Water meter readings,if available: Last date of occupancy/use OTHER(describe):: GENERAL INFORMATION Pumping Records Source of information A&K Septic.Systems Plus Was system.pumped.as part of the inspection(yes°or no): No ' If yes;volume.pumped:;How was quantity pumped'deteimined? Reason for pumpin g.. TYPE OF SYSTEM X Septic.tank,distribution-box,soil absorption system ; Single.cesspool. Overflow cesspool Privy " _ - Shared_-system(yes cr naj(afye;atta[d_ r( , " mspect�onrec6ras,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.66 py of the DEP approval _.. Other(describe)`. i -Approximate age of_all coonents date m` kn _st_alled(if ower and source of tnformation.2003 Owner.__a_ _ Were:sewage odors.detected:when-arriving at the site:(yes or no):No t Tide'S Inspection Form 6/15/2000 : 6 : S Page i or i i OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY - _ ASSESSMENTSSUBSUREACE.$FWAGEDISPOSAL"SYSTEMINSP CTION FORM _ PART C SYSTEM'INFORMATION(continued) Property Address: 24 Old Mill`Road,'Osterville,MA Owner: Steve Gemborys' Date of Inspection: 06/02/2010 ^ BUILDING SEWER(locate onsite plan) Depth below grade:6" Materials of construction X cast iron, 40 PVC K other(explain) Distance from private water supply well or suction line ' Comments(on condition%of joints,venting,evidence of leakage;etc..)., SEPTIC TANK (locate onysrte plan) s" Depth below;grade:3" Iylaferial'of construction X concrete metal fiberglass Uolyethylene Q other (explain):. ' If tank is'metal list:age Is age confirmed by a;Certificate of Compliance(yes or no) (attach a copy.of ;ry certificate) Dimensions: standard 1500 gallon Sludge depth: 1" F Distance from top:of sludge to bottom of outlet tee or baffle:39"Scum,thickness 1" Distance from to of scum to`top of outlet tee or baffle"8" Distance from bottom of scum to.bottom of outlet tee or baffle How were-dimensions determined:'field instruments Comments(on pumping recoininendations,inlet and outlet tee or baffle condition,-structural mtegnty,liquid levels ' as related to outlet invert;evidence of leakage,etc):Recommend pumping every two years s GREASE TRAP.NA(locate on site plan) Depth below.grade. Material of construction: concrete, metal. _ fi ber 1 a— ass of - eth le • — - _—P- Y. . ne 4. :other _ (explain) — - — -- — - — _ Dimensions: - .. T k Scum thickness Distance from top of.scum t'top of outlet'tee or baffle. Distance from bottom of.scum to bottom of outlet tee or baffle: Date of last pumping:' Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels 4as related to outlet:invert e�idende-f�l . etc. — - - a. �. 4 r - ; -- - -- - - - �-�.-a -- Title 5'Inspection Form 6/15Z2000 .- rage is of T i` - .. s - .. OFFICIAL INSPECTION FORM` NOT FOR VOLUNTARY ASSESSMENTS. . SUBSURFACE'SEWAGt ) SPOSA SY TE INSPECTION FORM' PART C SYSTEM INFORMATION(coritmuedj . .. I ... 1 Property Address: 24 Old Mill Road,Osterville:MA Owner. Ste . ve Gemborys Date of Inspection::06/02/2010 . . :- -, .. TIGHT or.HI OLDING TANK NA (tank must be pumped at time of inspection)(locate;"on site,plan) Y Depth below.grade. Material of construction concrete . metal •' fiberglass e Polyethylene other(explain)'.'' . =,. . . Dimensions: ' Capacity gallons ,, Design,Flow: Qallons/day1. Alarm,present(yes or no): Alarm level:. Alarm m working order(yes'or no): : Date of Jat pumping: Comment s:(condition of alarm and.float switches .etc) - a` . r a. DISTRIBUTION BOX if present must lie opened)(locate on site plan);' Depth of.liquid level above'outlet invert 0 f Comments note if box is level and distnbution to outlets equal,any evidence of solids carryover;any evidence of �. leakage into or out of box;etc+) Liquid level is normal inb box . - .; . . .:, PUMP CHAMBERc NA,(iocate on site plan) II­ Pumps in working order.(yes'or no) ' A1.larms in'worlang order(yes or no);` ti Comments(note condition of pump chamber,condition of pumps and appurtenances,etc):y i .4 A .�.. .. ': 1' 1 -,: y ` i...`. . ' . :''y .. .- . . t .: . :.5 - ^,: I 7 - " .t .. - T .�b-'- _r...... ---t _ _ __ _ . - ..1 _ .... .. i T" :. : .. '. r;.'."..l Y Title 5'lnspection Form 6/15%2000 g , ;,. ::; . . -_... 5 _ � , ::, 1. .. rage 9 of i t: 5 : . OFFICIAL INSPECTION FORM..-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTLON:FORM . PART C _ SYSTEM INFORMATION(contmued)rt - Property Address;_24 Old:Mill Road,Osterville MAI. 1. Owner::.Steve GemI.borys , Date of Inspection: 06/02/2010 1. SOIL ABSORP-TION-SYSTEM .-,SA. SAS ( ) (locate-on s.11 ite plan,excava ion not required) If SAS not located explain why . - <.. . . _ rt . . ,. -7: l . , . . Type,. .x . leaching pitsnumber.`. . X leaching chambers,number 1 500 Gallon _�':-r,�_.�.�'.I­I�a--.,I..-._-1,r.'�,I`.rr�0��r-,-.��M_,,�,."-�;�.�.A.._".-; leachinggalleries,number. , leaching trenches,'number,length leaching fields;number;:.dimensions r overflow:cesspool;.number innovative%altemativesystem Type/name of technology . Comments(note coridition of soil,signs of hydraulic failure,level of ponding,.dam soil condition of . etc: .::. vegetation,: ) . . . P CESSPOOLS NA (cesspool must be pumped as part of uispectiori)(locate on site,plan) ': Number and configuration Depth_ .top of liquid to inlet invert . Depth'ofsolidslayer: $" - "Depth of wum layer:-. ,, , Dimensions of cesspool . . ., Materials of construction Indication of groundwater inflow es or no Comments(note condition. 5-0 ,signs of hydrauhc'&ilure,level of bonding,condition of vegetation,etc:) PRIVY NA (locate on site.plan) t �f-ei� �,{{ _ram_ ` Dmlensions:I.rp Depth of solids Comments(note condition of soil,signs of hydrauhc,failure,"level of pondnig,condition of vegetation,etc:) r. ..r: 4, - - Title 5 rr I'tivection Form 6/15/2000 9 . . . ` . .!-.-.--.1 1�,��..�.".'p,.I.�.;'-�,"I.:.'-.-...,-,.,..��,,,,I,:..,:.',I..I.,-.':''.'---.�.'':�..%1.�...-.1�..-:1-,-.I�'':P-7'"i...I,�I.-II,1.,.,-:-;1..,-:'-::1.,..�,�,:...--..',.,..';.,..,-1-:-:�'��':,..'.-'1.,,-.':....i,I:.,,-'.7I..--.--.-�.I1..�.-..-I I.,;A:-..1-2,�,-�1 I,...�-....-:1..-I"--.1�..,t��.'.,:�'.*-.f-:*'..�',...:,.�,1�,':.�-.�"�.--:-�o...--,.,:.�.1-.-1'f.--'..:..:--I1,�-.�.�I'1.�"-.,,�,"1-,-*..�..�,.I1��I.I.1...-...;..I-�':.:�,',.'I,..'-�-,,I':��,;.'�.-�..'..I-�-..-.,.�.....''.-I....-I.-,.'I-.�I,-'.:..:�.�-�.��'-,3-..�;�....:..;I.,�..�.-.-:.-.��.�,::..,�,..,�'.:�,,-�-..—.:'.:1-,."���.."-.'--."-.III...-.'I—!!�'.4-.".I,I..-.!��....:...*�..�:I�-�,-�I:.,�:1'�-:-�....,.-;-.-;�-,.1:.,--.I'.:�*7':--:-1".,:.-,i-:.-1I:...:...:.I'..-.�.,—.'',"�1..�i I-...-.:,�:-:.'1;.:.'�.�..1p:.�..�..I,..'�,.-�-.:,-....1�:..�:�.,.:�'.,.��..�"..I:�,�-.-.'�o.�1,.-":,i�--1...-'.1.,��,...I-�,.,�-.1--�-'%-�':..',---.'I;:,'-':-.,:I-[:..!',.,.;,,.,-.,--..:.,.'I:.�II..-...'-.-�.,'-�:--�,I-,,...��.'..',.-��m,'�.--....:,.��-,�-�-1-",...%"I'll,-,i-.,,.I.�.,:�.:*'�-.,.�.--i,...:�.'�.�,.�.----�..-..''.I�.:,..�"-.'��-,��l--—I-�'�.��':T-',o-.1..-�."..'��.P,,�-I,�.-:.-..,�-.'i.-:'',.�'''1.I-,:*1i�"'',r W I-.�;.--1 I'_1."���..1*-..4��.,..I I3,'-.'1.�I,�,:.-.,j'�"�.-.'i.��':.��.-...''*i..­.-,:-.'-.".�1I":I-.�I�,­...:.-.,;:---�,—,..�1..-�1-1 I e.:.-',��"..-�..-.,.:.4'..!r:..���.-II���---�,,�-�.%�--�I-�....-�-..,.1��'3�.�.:-..�"-...-.�.�.,:.-..--.�-..,..-,,."''m:.,�...'..�',---�.'-.:,_'.'..�.-...,o��.,:I:.,.,.-,1-­..-:.%.V-...;---.-�.,d1,�-,'.1,.,1,.-,,��z.,,�.-,�:-."�.�..�-.4''.'—',-:��i;;.�,:^,-.-...:;:.*..1I"I�..,I_�:4-.:T''��1!'.'--4�7.�.II_-..---�..�".'I.�.­.--,�,..,�-','��':''"II.."i:r,--:�-*".�j:.-..--,�1�;-;-�."..:;.�:.,-:.�Y�"�--�-�`'.,-."-�',.--.�--:.�,,s-'..,I0-.7—.I,..".i.�"�:.''I-,�'.�,''-,-./,�:'�-�,�,.,/1......:,I,-.,�;�:.I��.7_-�-..',:..k-.�.%�'�.-,;.�.1;"�"'...-..,,-,.a�.;.'�--.''-I�I-.'1��.",'.�I,".-..,i.7-�,-'I.-1r-.-..:.-�.--'�,'.',--.:�:i:'-..'".-.1.:'-"';-.:..'--%.�--1:--'.'�.,.v�..�.:�:-�.:.-:,...,.i..''-�,,.".1�'..-�-,"!-�II�.�.��1m''1.�.'.—�1,-'--'..�,-.f.'-:,'-'.1�-�:.�-,�..I.,..�.-11:"'.:.1::''.::,,�I*�,,�—....,II'`..'.�.I-.�.-:.��.*I.-----*"-II�.d-'11_,:�-,,-�p,-.'.I..77-.'�:-',I".��I1--""�--..�'.-:�,.,�­-.-.�.II..-.:.i�.-:-'-"-1'-�."�.":.'-�2'-.4.-::.1.,!-.-I..�..,I..I-:".��-.:...";-.=7...-.-.—:''1.r'��"�'''�.;".�--.:..*'.,..1.1�:*.1,-::��.�.t�—.-----,�--,'.�--,�..-�...�.�.,-.::::.i,'���1,.:'!'.'-',.�,'�1.,:.!.-I-�.:�.-'.�.......'D.4 I�.�-...'..,�,,','II.i..�..*]-��.�..,-."�.'..:,.-I-Z.',I I.�:-.---�,,-:..-I-�--'.,41',-:.,i.'��-,-.-f.,,i.�'.-��I....:I'----',::"';.-1�':-:-..-.-:,�II;,,..�.-'I�-.,1'.�-..-'.�.".��','..'-.,.i--.'-,-...-­'1'....-.�-".;...,.'-*.*.-...".�I.--.fI%�'-.:�..,I��...:-:�...'---..��.,:1"�.'.�,:�"-I:'',1,:i,'�-�.-��.I�1';'..:�.I-�:-.--�:I:.. _:�. .. — <. Y rage_au or i:. , ;: -..:F - OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS - SUBSURFACE SEWAGE-DISPOSAL SI'STEM-INSPECTION FORM':; PART C SYSTEM INFORMATION(continued) ' . Property.,Address: 24 Old:Mill Toad,Osterville;MA a Owner Steve Gemborys , —`— fi e.of nsI p- tion .:06/02/2010 . - . SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two'permanent reference,landmarks or benchmarks Locate all wells within 100 feet.Locate where.public water supply enters the building _. . . _ . . % - r `-r= `; - a . ... ,. - . � r. 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I�1"1-...�,"�.i-...',,-,.,�I"-:"f.,.-....-,-�-.�-,,%:��,,'-i�..,-'..-,,'--.I"..-:�.f��...�'..,..:-"�"--..�.�. a $ ": S. �y �8 $� _ , - a aZ - -- -- -- " - - - -- - — - - , *' i f. ':a.. _ - .'.,. , , .. - <.' - LL `, Title 5 Inspection F6rm 6/l5/2000 10 :— . . :. �. ,0. .•. . I 1 i or'"i f . - . 1, . . 'I- . .1 I . . I I . . . . , � . ,. .. ,�9 �',1 I - .-: OFFICIAL INSPECTION FORM NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' I. PART C _ - SYSTEM INFORMATION(continued) Property Address: 24 Old Mdl Road,Ostervdle,MA . Owner.: Steve Gemborys Date of Inspection: 06/02/2010 :'" 1. ' - `SITE EXAM Slope:. Surface water ; Check cellar - . - - Shallow-wells Estunated depth to ground water 7.PLUS'feet Please indicate(check)all'methods used to deten,n a the high ground water elevation ,: 14. Olifained from system design plans on record-If checked,date of design plan reviewed Observed site(abutting.property/obseryahorihole within 150_fee' of.SAS), - ,Checked withaocal,Board of Heafth-explain:`: `•Checked withaocal excavators installers (attach documentation) . Accessed USGS database-explain You musf descnbe how you established the high ground water elevation Augured;Hole.@ 7 feet-,no H2O .� v` �'�e ` �„ �.0 ��,� ��.�'0 1: � w . .............9 . N. r� U Q a - , . . I�YIM b e. - E• w _1. i _-� _ __ _ _ __ .. _. _ to .: .. - .. z_ % ...: _ -:. i ��,, i '' ((// F i ... ' 4 y �r _ -: ...--.. F-. .s. . y .-:,._.ram -�-._ - „�+- -.- _ _.- -T-- ` r :: .. .'.. .. lrtle 5:;lnspection Form 6/1'5/2000 I TOW OF BARN STABLE p� LGCa`TION a IC! t c Ql\1 VILLAGE OSTervt I L F.SSOR MAP & LOT 41 s-rr INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 92 sS o) LEACHING FACILITY: (type) Gtskpt (size) NO.OF BEDROOMS C I BUILDER OR OWNER �S t- I-1A ,�t (,v�_f�r�4m r PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: - Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leacj ing facility) Feet .Furnished byTn Sig an r � �ya9 a39 ly TOWN OF BARNSTABLE LOCATION d l0 t1'//1V SEWAGE # c200-3' VILLAGE O s c ery J It ASSESSOR'S MAP & LOT big INSTALLER'S NAME&PHONE NO. 35'�, Z-/aC0//: /6- yd8^��OZp SEPTIC'TANK CAPACITY �/ LEACHING FACILITY: (type) SOU�9'�loa � (size) NO. OF BEDROOMS °Z BUILDER OR 9LA R Z2 4 Q PERMIT DATE: l`5--03 COMPLLANCE DATE: !s( ?'0'3 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ti r b .. W O P, 1 - 17, �3 - 33' 93 ' an ; No. qx�3 J� THtE C;OMMOI WEALTH OF MASSACHUSETTS FEE _BOARD nO�F,,'cHEALTH APPLICATION FOR DISPOS L SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct Repair Upgrade Abandon ( ) - Complete System ElIndividual Components L ca on Owner's Name MAP 1+1 P a -,8 19 d l b-lc t o CI IL+ Map/Parcel# Address Lot# Telephone# lastaller's Name Design me fAddress Telephone# Sod_ 8<Ssa Telephone# Type of Building: I/J Lot Size G 9 08 Sq.feet Dwelling—No.of Bedrooms 21 Garbage Grinder (V9 Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.re uired) gpd Calculated design flow gpd Design flow provided gpd Plan: Date - 1 _'03 Number of sheets Revision Date Title 5Jrq;5 46E ED oL ,7mA) p e Description of Soil(s) d"—5 �-��Ih Z(c� Lc S4A�b ~�/ r m�� 54W.D Soil Evaluator Form No. IV VAI/ C, Name of Soil Evaluator .YAh%A) J),0Y 6— Date of Evaluation 0 DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees not to place a system in operation until a Certificate of Compliance has been issued by the Board of Health. Sign e Date v Z!a 3 Inspections FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 NO. 3 THEWS.QMIVIOI4WEA9999LTy.Ii OF MASSACHUSETTS_ _� FEE BOARD 0�4F HEALTHx _ - p t ram:, A t '"d Wilt! BL O F D/4 .STi�I. k' r APPLICATION FOUR DISPOS L SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct Repair Upgrade Abandon ( ) - Complete System ❑Individual Components 2-+ O" M)toL lb• Y/,L L i r- JDA N PE-J212y L ca on ' Owner's Name LMap/Parcel# z ! - i Address Lot# Telephone# ..�• Cr Q� i� s Name taller' N Designe' Name ,' ace AKt a/�s• 7e� PO go X Sg 5- Address Address Telephone# `!j "S 5";� Telephone#"> ry Type of Building: _&tt,5 ,I 1J G Lot Size Cj 08PSq.feet Dwelling—No.of Bedrooms 21 Garbage Grinder (A/6) Other—Type of Building "' No.of persons Showers ( ), Cafeteria ( ) 1 Other fixtures yf: Design Flow(min. re ,wired) gpd Calculated design flow gpd Design flow provided gpd _ Plan: Date - -D Number of sheets _� Revision Date t Title S'I i 6-15E 4(- r0/L .yDA) PE,t',L`� _ Description of Soil(s) �.I..9 u Ld/4 G�N.. ���( fM� �/�1J./� tv 2 dot /�) $A1V.f} Soil.Evaluator Form No. MVN!C, Name of Soil Evaluator N:1614Al .DdyGE Date of Evaluation 9 + -03` DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE S and further agrees not to place a system in operation until a Certificate of Compliance has been issued by the Board of Health. t I Sign e Date gal. 07 U 3 ' Inspection > 9%s A ' FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 THE COMMONWEALTH OFMASSACHUSETTS!' FEE' �U BOARD. OF HEALTH CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) ❑Complete System i The undersigned hereby certify that the Sewage Disposal System;Constructed{ '),Repaired(kf,Upgraded( ),Abandoned( ) ff � by: �lotelt;'ic Con) l , j at has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No.2faD3 A 3<dated 9- 5- 03 Approved Design Flow (gpd) Installer �m �1%f Designer:.? �Gt/e . »�c„�% Inspector _ Date 9 CJ 10 The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 No. C —� THE COMMONWEALTH OF MASSACHUSETTS FEE A,. BOARD OF HEALTH t DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to ConstrL ( ) Repair (I,,+•) Upgrade ( ) Abandon ( ) an individual sewage disposal system at / 0J -, ,i/c e as described in the application for Disposal System Construction Permit CQ 3 "�3 7 )J�O . pp p y e rt No. dated / 3 Provided: Construction shall be completed within three years of the date Ol ii1's p r• 'tom cal conditions must be met. ` Date )�k Board of Health1s--•�. FORM 2 - DSCP DEP APPROVED FORM 5/96 '•:' FORM 1255 (REV 5/96) H&W HOBBS&WARRENT" PUBLISHERS- BOSTON ' TOWN OF BARNSTABLE LOCATION 2 Y 0l0 I761�/' '• SEWAGE # 0P-00.3- '1-?S VILLAGE ©31 eP•l L c ASSESSOR'S MAP & LOT - 05d INSTALLER'S NAME&PHONE N0. t e /2�Ca//,:s% y99-675-071Q SEPTIC'TANK.CAPACITY LEACHING FACILITY: (type) .�-00G9 %4 22&e"O (size) NO:OF BEDROOMS BUILDER ORqyg,[ER p D"oa� l�cmr PERMITDATE:. 7- 7 0,3 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by l '3? '*0 i _ Lw v awl a WV - o S r D� eF /�ouSe, h CEFITERYILLE-OSTERYILE-MARSTOFIS MILLS FIRE DISTRICT 1875 ROUTE 28 • CERTERVILLE, MA 02632 (508) 790-2380/FAXG(508) 790-2385 OIL/HAZARDOUS MATERIAL RELEASE FORM F.A.# F /� LOCATION: ADDRESS OF RELEASE: DATE OF RELEASE' PRODUCT PELEASED.� 0// � o�f�.,. / /�C" ESTF IATED WA€1TITY CORRECTIVE ACTION TAKEN BY RESPONSIBLE PARTY: NOTIFICATIONS: FIRE DEPARTMENT: YES(�() NO( ) DATE• ��/��%S IME � t' /� NATIONAL RESPONSE CENTER YES(z}- NO( ) DATE TIME: s' Y/ / 4 DEPT.OFEi'+NVIRONfvEITALPROTECTION YES( NO( ) DATE: �TIME: '-i"•. OIL SPILL COORDINATOR: YES( ) NO( ) D ATE: T UKE: TOWN BOARD OF HEALTH: YES(e,)'NO( ) DATE• k/iZLZ_TIME ,=.•.i . /T'r/s,/• lrv��i.�s/rr TOWN HARBORMASTER: YES( j NO(, DATE: _ / TIME OTHER AGENCIES: / COMMENTS: A A j�. REPORTED BY:�� ,: �f��`,�/, DATE WHITE COPY-FIRE DEPARTMENT YELLOW COPY-D.E.P. PINK COPY-BOARD OF HEALTH C-O-MM FORM *59 a 'li4Ajcc-& rd/(� \�ul•L._ COMMONWEALTH OF MASSACHUfED INSPECTION EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED JUL 1 0 2003 TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUN A1Q �r� � IT SUBSURFACE SEWAGE DISPOSAL SYSTEM PART A CERTIFICATION Property Address: 24 Old Mill Road Osterville, MA 02655 Owner's Name: Estate of Harvey G. Williams Owner's Address: c%Joan PenT, Executrix 18 Hinckley Circle, Osterville Date of Inspection: June 24, 2003 f Name of Inspector: (Please Print) James M Ford Company Name: James M. Ford Map: 141 Mailing Address: P.O. Box 49 Parcel. 058 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 l CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes NeeR Further Evaluation by the Local Approving Authority ✓ Fail Inspector's Signature: Date: June 26, 2003 The system inspector shall subm a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 f x Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 24 Old Mill Road Osterville, MA Owner: Estate of Harvey G. Williams Date of Inspection: June 24, 2003 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health,will pass. 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 1 obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 f Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ' ` CERTIFICATION (continued) Property Address: 24 Old Mill Road Osterville, MA Owner: Estate ofHar-ey G. Williams Date of Inspection: June 24, 2003 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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen`is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 24 Old Mill Road Osterville, MA Owner: Estate of Harvey G. Williams Date of Inspection: June 24, 2003 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] I Yes (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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 24 Old Mill Road Osterville, AM Owner: Estate of Harvey G. Williams Date of Inspection: June 24, 2003 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection ? n/a Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of breakout? ✓ 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: 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 I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 24 Old Mill Road Osterville, M4 Owner: Estate of Harvey G. Williams Date of Inspection: June 24, 2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a Number of current residents: 0 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIALJINDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped in 2002 Was system pumped as part of the inspection (yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM 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): Approximate age of all components,date installed(if known)and source of information: Unknown Were sewage odors detected when arriving at the site(yes or no): No 6 f Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 24 Old Mill Road Osterville, MA Owner: Estate of Harvey G. Williams Date of Inspection: June 24, 2003 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: Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) (Cesspool acting as septic tank) Depth below grade: To,grade Material of construction: concrete _metal _fiberglass _polyethylene ✓ other(explain) Bricks If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 5' Wx 6'Tx 8'bottom to grade Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: -- Scum thickness: L'' Distance from top of scum to top of outlet tee or baffle: -- Distance from bottom of scum to bottom of outlet tee or baffle:` -- i How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): The cesspool had 3'of water on the bottom. The cover was to grade: GREASE TRAP: None (locate on site plan) Depth below grade: 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 24 Old Mill Road Osterville, AM Owner: Estate of Harvey G. Williams Date of Inspection: June 24, 2003 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None (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: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 f Page 9 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 24 Old Mill Road Osterville, AM Owner: Estate of Harvey G. Williams Date of Inspection: June 24, 2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers, number: j leaching galleries,number: leaching trenches,number, length: leaching fields, number, dimensions: ✓ overflow cesspool,number: I 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.): The overflow cesspool was 5'W x 3'T x 7'bottom to grade and had 6"of water on the bottom The scum line was up to the inlet pipe. The cover was to grade. There were signs of failure. 4 CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 9 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: 24 Old Mill Road Osterville, MA Owner: Estate of Harvey G. Williams Date of Inspection: June 24, 2003 Map: 141 Parcel: 058 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. 1 a 6 a9 10 s Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 24 Old Mill Road Osterville, MA Owner: Estate of Harvey G. Williams Date of Inspection: June 24, 2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 14' +/- 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: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using the Barnstable topographic map and the Cape Cod Commission water contours map the maps were showing approximately 14'+/-to ground water at this site. This report has been prepared and the system inspected and failed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. 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