The URL can be used to link to this page

Home My WebLink About0182 OST.-W.BARN. RD - Health 182 OSTi ?-W `BARN 1 i� RAD OST. A=120=00'5 o 14 • No /' " � Fee /" THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION'- TOWN OF BARNSTABLE, MASSACHUSETTS 01ppfltatlon for M18posal Opstem Construction Permit Application for a Permit to Construct( Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components L cation Address or L No. i131 ®S�cL�'�-�r^Y� �- Owner's Name Address,and Tel.No.V�►%4r- Lp. ' V Assessor's Map/Parcel ® s' j Installer's Name Address,and Tel. o:TP V a a A e(-Aq Designer's Name,Address,and Tel.No. i\ �� Q t Type of Building: Dwelling No.of Bedrooms Lot Size I Al A or— sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.requ.red) �j�l gpd Design flow provided gpd Plan Date t�Z.I1 Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. �� j1>1 ,,,sa �.ww�► Description of Soil Nature oRepairs or Alterations(Answer when applicable) A s ICA ^ LGN -- Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in a accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued1 ix Ilan by this Board of HeIth. __ii gned �� Date 11 Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplication for Misposar *pstrm Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ stem Complete Sy stem y ❑Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date . Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )by at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer #bedrooms Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector I 1. A r I I i I I I �7 I i I � ti t ,� ' � t I I � I �. �� . I I I �� I z I I � i i I � � i r � � i s I I � I i I ' '�. I ' �' I ; �{ I i I � I � I I � '� � � �v I I I I I I — I I 6 � �': k s I� \)T] Y I I t. I I I I I y i I �. 1` i I I ! 1 • i .� F �._..'"t, - ,. ..,=:s• T i..'..ii'r.rn._ .r: �.. .',,,f ]q• �., dry s ' --, l - - - .-.__ - - s No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: y Yes PUBLIC.HEALTH DIVISION- TOWN OF BARNSTABLE, MASSACHUSETTS ftplication for -Mi 'Bal*stem Construction Vermit Application for a Permit to Construct( Repair( ) Upgrade,(. ) Abandon( ) ❑Complete System ❑Individual Components L�gcat/io�n+�Address or Lot No. 0)-a f ` av,- Owner's Name,Address,and Tel.N0. 444t1 ILA Y 6 c- il�� !,—;. Assessor's Map/Parcel `' *' } Installer's Name Address,and Tel.No.-VV,%., . Designer's Name Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size - sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) ,.Other Fixtures Design Flow(min.required) gpd Design flow provided i�Sgpd Plan Date � ) \7:t) t� Number of sheets Revision Date Title 11 , r ' j Size of Septic Tank � 1 e,„ t^ , Type of S.A.S. ► t@Sd �► ,+a, iax f Description;_of Soil Nature of Repairs or Alterations(Answer when applicable) " - Date last inspected: Agreement. The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. gneddf ' °�f � _ Date %3id1 • t4 Application Approved by .: R '`".. ,..ti +' Date % Application Disapproved by Date for the following reasons r Permit No. r Date Issued' " + THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ") Repaired( ) Upgraded( ) Abandoned( )by; o„* qc� [ L 4 i ;5 e,# 4 '" - at 1 ;'-�, r.ra-;�r „ _ - ,f � ,�'�,, - . ° has been constructed in accordance f j with the provisions of Title,5-and the for Disposal System Construction Permit No' )Q;- —45 dated Designer A\% " ko P �fox,l A,-, cd ye.. #bedrooms Approved design flow .._. _ gpd The issuance of this permit tshafllnot be construed as a guarantee that the system wllll fi io�nasasd`e g ed. , '"""""~ =•,,, Date f'.. , t' f 1 Inspector �.. - o N - -1- - - - -- - = - - Fe -- ------=-- . ) e THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair(. ) Upgrade( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. _ Date1 ,. /f Approved by,. •r"•4, .,. '"�' �,• TOWN OF BARNSTABLE LOCATION 2- �,A ke_ SEWAGE#202-0— e; VILLAGE } ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. 19 L, i 3 SEPTIC TANK CAPACITY LEACHING FACILITY:(type( " ® ® Qk-tob (size) 33�(!u k W(okf NOt OF BEDROOMS OWNER ��' L.a ' PERMIT DATE: �_ Z� Sao COMPLIANCE DATE: / Z/ . 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 � 3ull _ , got iP g TOWN OF B/ARNSTABLE i ;'.4TION 1 "W a ��i<�S tO f� /CJtl SEWAGE #�b 4195 VILLAGE ASSESSOR'S MAP& LOT 120 C 3� INSTALLER'S NAME&PHONE NO. J44WO A SEPTIC TANK CAPACITY /000 LEACHING FACILrFY: (type) L eq 4 (size) 10W 64.1 NO.OF BEDROOMS 3 BUILDER OR OWNER 6,(.54 \ `_ PERMTTDATE: COMPLIANCE DATE: I 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 99f leaching facility) Feet Furnished by .56�.�t tee^ /�`/;//b � I e t ,45 `-r >i A � lkt�C ® e eik a i /'//T60AN O�SATABLE I Y LO(flk ON :, Y -z-T— �w� _ SEWAGE # VILLAGE F- V 1 L F ASSESSOR'S MAP Sx LOT. S�12o - odir' INSTALLER'S NAME & PHONE NO. C��`_ ZA SEPTIC TANK CAPACITY LEACHING FACILITY:(type) L AC j�2) .T (size) 6 NO.,OF BEDROOMS PRIVATE WELT. OR'PUBLIC 'lVATERr BUILDER OR OWNER' BOSH DATE PERMIT ISSUED: La. — DATE C011PLIANCE ISSUED: �� VARIANCE GRANTED: Yes No �/ Y Of A C KTrl l�6ie r; , I Town of Barnstable Inspectional Services � r Public Health Division. i 1AEP16EABAm I�, ' , Thomas McKean,Director ' off°` 200.Main Street,Hyannis,MA,02601 Office: 508-862-4644 Fax.: 508-790-6304 c, t} Installer&Designer Certification Form Date: Sewage Sewage Permit# Z02D- 257Assessoe'.s MaPV.Parcel. , r .Q-- - Installer; C� L.cx.�n d s c �nc� Designer: ( 3o y �l Address:_ -p L -O� Address: On 2 Z 2 o. e LC�SCi was issued a permit to install a (da ) _ `{ .(inst ler) septic system at ( � u �"' "' `� �" ' f based on a design.drawn by (address) � £ f dated bf h It (designer) I certify"that the'septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank., Strip out.(if required) was inspected and the soils: were found satisfactory. I certify that the septic system:ref erenced above was installed with major changes (i.e. greater than 10'''lateral relocation of the SAS or any vertical.relocation of any component of the septic.system) but in`accordanee with State&Local Regulations. Plan revision or certified.as-built by designer to follow:`Strip out(if required);was:inspected and the soils Were found satisfactory. y constructed in c lance with the to rnms of I certi th t the system above was th ap roval Getters (if applicable) OF D. - ` F` AHERTY JR_ taller's signature) #No <t9 (Designe s Si tore) (Affix Desigrrtp Here) F PLEASE RETURN TO ARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. WoMdeptAHEALTMSEWER connecASEFTIC1Designer Certification Form Rev 8714-LIDOC' No. , � Ll / Fee ` �© THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zipphratton for �Dtgonl �&pgtem Cougtructtou Vermtt Application for a Permit to Construct( ) Repair(141Kpgrade( ) Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. UU W %rn 5+ fe �Oa e Oner��ant Ad dress,ddress,and Tel.No, of a�te�v , Ike vl �-G.y Assessor's Map/Parcel a /9a ON, aatn 5 e d/e I/ 0/e/o' Y le /� t r� SY Installer's Name,Address,and Tel.No.cSAAw vl � Designer's Name,Address and Tel.No. /L1.4 Type of Building: ? Dwelling No.of Bedrooms v l/ Lot Size sq.ft. Garbage Grinder ( ;44) Other Type of Building eS rC eh TA j No.of Persons 62 Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank 1 6;TO c( Type of S.A.S. L2,:f-,e4 4 Description of Soil Nature of Repairs or Alterations(Answer when applicable) �g0�c�ce o- fox Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been;igne—d ed by this Board of Health. Date 11-3-6 Application Approve by. Date 3 ApplicatiomDisapproved by: Date for the following reasons r— i Permit No. / Date Issued 3 - .y.-'»r*z• �.f -w r. , ' - „YR' .I 3'..... ....tip�a'"+•v' .-.,. r"o ., ` ... . v.. ._ ,k ^ (6 / i Fee ,Q© THE COMMONWEALTH-OF MASSACHUSETTS Entered in computer: f" PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zlppltration for 0t.5po.5a1 ,p.5tem Con.5trurtion Permit Application for a Permit to Construct O Repair(1,4upgrade O Abandon O ❑ Complete-System-❑Individual Components Location Address or Lot No. ' �` �+ (e t' d 1 ¢ l .�/ q r& _ /0� O.ner's�Na e,Addli s{s,end Tel.No. pZ p lJ �7 U C75�'Nr v I I e GCS fi y . (� / •1 Assessor's Map/Parcel ao - O 0 8� W t aG/n 5,�i�lP �({f� lelv`I`e 6�,q rt /Vf�� r�Y 3� fr Installer's Name,Address,and Tel.No. / Designer's Name,Address and Tel.No. r n/. �C.r'n1at. Type of Building: ? Dwelling No.of Bedrooms J JJ Lot Size e sq..ft, Garbage Grinder ( U Other Type of Building PS 261 T� No.of Person�s Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title t Size of Septic Tank wLIPO'Ev Ge Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) �QA14re D- 19oX �. Date`last inspected: ' Agreement: The undersigned agrees to ensure the constrdction and maintenance of the afore described on-site sewage disposal sysiem in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of ealth igned Date 11-3-D(O Application Approve byy Date d 3 Application Disapproved by: Date for the following reasons Permit No. C (D `7 Date Issued THE COMMONWEALTH OF MASSACHUSETTS ,,��✓�� BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( ) Abandoned( )by VA ro ` at �: ' `� \.J ��"`�a4� le C S 1`'v�lhas;�en constructed in accordance I with the provisions of Title 5 and the for Disposal System Construction Permit No. (0 ^')'75 dated 1� 13 Installer C. r `^� Designer #bedrooms Approved design flow gpd The issuance of this permit hall not be construed as a guarantee that the system�w�Iti�assigned. Date » 11 y Inspector ----C_'_ �� `��"-----------—-------•-------- Fee —---— I No. THE COMMONWEALTH OF MASSACHUSETTS ] . PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS ' J Bt.po.al �§p5tem Con!5trurtton Permit Permission is hereby granted to Construct ( ) Repair V') jU( grade ) Abandon1( ) 4: System located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction mus be completed completed within three years of the datrof this er nit. Date ' V Approv\ed,by TOWN OF BARNSTABLE i. ',a7TON -1 �nL�1 r SEWAGE # VILLAGE 075 Te'/'i}i f' ASSESSOR'S. MAP & LOT 'C L 4 INSTALLER'S NAME&PHONE NO. �j M uw� l�v 'SIN �155=cs`rc SEPTIC TANK CAPACITY LEACHING FACILITY: (type) L e'4 e (size) NO.OF BEDROOMS BUILDER OR OWNER kc, kt64 PERMIT DATE: 11 I<3.� COMPLIANCE DATE: I J Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any welts exist on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet f f leaching facility) Furnished by .S1,�t�i.• �l `%r//1,� Feet a r,�k 1a d�v 3i ._� d n V r l � Z �'S+ � �� o� 'r% cC1 Certified Mail Fee Ir $ «— Extra Services&Fees(check box,add fee as appmpdate) ❑Return Receipt(hardy) $ *�.r �..�° ❑Return Receipt(electroncopic) $ v� `� Postmark OO ❑Certified Mail Restricted Delivery $ Flefe O ❑Adult Signature Required $ t []Adult Signature Restricted Delivery$ O Postage —— m 109Z0 e-� Total Postage ant $ e�rro POWELL, GILBERT TR r 448 BOSS STREET _------ o Streafandnpt Nq JUPITER, FL 33408 ="Imwfjj�., """"""" ---- Certified Mail service provides the following benefits: •A receipt(this portion of the Certified Mail label). for an electronic return receipt,see a retail •A unique identifier for your mailpiece. associate for assistance.To receive a duplicate •Electronic verification of delivery or attempted return receipt for no additional fee,present this, delivery. USPS®-postmarked Certified Mail receipt to the ■A record of del'Jdry(including the recipients retail associate. signature)that is retained by the Postal Service- Restricted delivery service,which provides for a specified period. delivery to the addressee specified by name,or I to the addressee's authorized agent Important Reminders: Adult signature service,which requires the , •You may purchase Certified Mail service with signee to be at least 21 years of age(not First-Class Mail®,First-Class Package Service®, available at retail). or Priority Mail®service. Adult signature restricted delivery service,which •Certified Mail service is notavailable for requires the signee to be at least 21 years of age, International mail. and provides delivery to the addressee specified •Insurance coverage is notavailable for purchase by name,or to the addressee's authorized agent, with Certified Mail service.However,the purchase (not available at retail). {, of Certified Mail service does not change the ■To ensure that your Certified Mail receipt is insurance coverage automatically included with accepted as legal proof of mailing,it should bears 3 certain Priority Mail items. i USPS postmark.If you would like a postmark on f*, ■For an additional fee,and with a proper this Certified Mail receipt,please present your endorsement on the mailpiece,you may request Certified Mail item at a Post Office'for the following services: postmarking.If you don't need a postmark on this -Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion of delivery(including the recipients signature). of this label,affix it to the mailpiece,apply F,- You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece.C_ electronic version.For a hardcopy return receipt, complete PS Form 3811,Domestic Return Receipt attach PS Form 3811 to your mailpiece; IMPORTAffI:Save this receipt for your records. Ps r-orm 3800,Aprc 2ot5(Reversa)Psrr7sao•oe ooaeo47 C Town of Barnstable Barnstable lARlVSfA `caCft"RegulatoryServices Department BM 1 1 y MAS& 1639. ,0 Public Health Division m ��fON'A�A 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7015 1730 0001 4987 7046 April 2, 2018 POWELL, GILBERT TR 448 BOSS STREET JUPITER, FL 33408 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 182 Osterville West Barnstable Road, Osterville, MA was inspected on 02/01/2018 by Douglas A Brown, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Leaching facility with standing liquid level at or above the invert pipe (per Town Code 360-20 h). You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH �homascKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\182 Osterville West Barnstable Road Osterville.doc Commonwealth of Massachusetts lad - ass Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments E 182 Osterville West Barnstable Rd M Property Address Powell Gilbert T Tr/Seventy Seven Trusty Owner Owner's Name I information is CID required for Osterville ✓ MA 2-1-18 x` every page. Cityrrown State Zip Code Date of Inspection , Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information '�5' Q � forms on the computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector. use the return key. D.A.BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA. 02632 Cityrrown State Zip Code 508-420-4534 S14297 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes Fails ❑ Needs Further Evaluation by the Local Approving Authority 2-1-18 pe s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Lo"a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 182 Osterville West Barnstable Rd Property.Address Powell Gilbert T Tr/Seventy Seven Trust Owner Owner's Name information is required for Osterville MA 2-1-18 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System-Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old'or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N '❑ ND(Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M , 182 Osterville West Barnstable Rd Property Address Powell Gilbert T Tr/Seventy Seven Trust Owner Owner's Name information is Osterville MA 2-1-18 required for , every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or.uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ' ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form _Not for Voluntary Assessments M 182 Osterville West Barnstable Rd Property.Address Powell Gilbert T Tr/Seventy Seven Trust Owner Owner's Name information is required for Osterville MA 2-1-18 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) .System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or 40 clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•3113 - . Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 L f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 182 Osterville West Barnstable Rd Property,Address Powell Gilbert T Tr/Seventy Seven Trust Owner Owner's Name information is required for Osterville MA 2-1-18 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last.year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool orprivy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within-400 feet of a-surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 182 Osterville West Barnstable Rd Property.Address Powell Gilbert T Tr/Seventy Seven Trust Owner Owner's Name information is required for Osterville MA 2-1-18 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes- No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? . ® ❑ ' Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? ❑ ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and.location.of the.Soil.Absorption System (SAS).on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of-Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposat System Form - Not for Voluntary Assessments _ M 182 Osterville West Barnstable Rd Property Address Powell Gilbert T Tr/Seventy Seven Trust Owner Owner's Name information is required for Osterville MA 2-1-18 every page. City/Town State Zip Code Date of Inspection D. System Information Description: A 1000 gallon septic tank was located along with a d box and 600 gallon leach pit. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection El Yes [I No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: PROPERTY IS VACANT Sump pump? ❑ Yes ❑ No Last date of occupancy: 2017 SUMMER Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow.(seats/persons/sq.ft., etc.): i Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes. ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of'17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 182 Osterville West Barnstable Rd Property Address Powell Gilbert T Tr/Seventy Seven Trust Owner Owner's Name information is required for Osterville MA 2-1-18 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: 2017 SUMMER Date Other(describe below): . General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 L _ Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 182 Osterville West Barnstable Rd Property Address Powell Gilbert T Tr/Seventy Seven Trust Owner Owner's Name information is required for Osterville MA 2-1-18 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1991 PER AS-BUILT CARD Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑ 40 PVC El other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete El metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 GALLON PER AS-BUILT Sludge depth: MODERATE t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal-System Form-Not for Voluntary Assessments , 182 Osterville West Barnstable Rd Property Address Powell Gilbert T Tr/Seventy Seven Trust Owner Owner's Name information is required for Osterville MA 2-1-18 every 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 Scum thickness LIGHT Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? SCOUR POLE Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary ryAssessme nts rvill 182 O W r ste a West Barnstable Rd Property.Address Powell Gilbert T Tr/Seventy Seven Trust Owner Owner's Name information is required for Osterville MA 2-1-18 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑. Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 182 Osterville West Barnstable Rd Property.Address. Powell Gilbert T Tr/Seventy Seven Trust Owner Owners Name information is Osterville MA 2-1-18 required for , every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid.level.above.outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 li .. Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 182 Osterville West Barnstable Rd Property.Address Powell Gilbert T Tr/Seventy Seven Trust Owner Owner's Name information is required for Osterville MA 2-1-18 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: leaching pits number: 1 600 GALLON ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): PIT WAS OPENED AND HAD HEAVY STAINING INDICATING HYDRAULIC FAILURE AT SOME POINT IN THE PAST. PIT IS 27 YRS OLD. PROPERTY IS EMPTY NOW SO THE LIQUID LEVEL HAD GONE DOWN. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow F1 Yes No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 182 Osterville West Barnstable Rd Property Address Powell Gilbert T Tr/Seventy Seven Trust Owner Owner's Name information is required for Osterville MA 2-1-18 every page. Cityrrown 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.): r Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 182 Osterville West Barnstable Rd Property Address Powell Gilbert T Tr/Seventy Seven Trust Owner Owner's Name information is required for Osterville MA 2-1-18 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of.the boxes,below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of-Massachuseft Title 5 Official Inspection Form Subsurface Sewage Disposa[System Form-Not for Voluntary Assessments 182 Osterville West Barnstable Rd Property Address Powell Gilbert T Tr/Seventy Seven Trust Owner Owner's Name information is required for Osterville MA 2-1-18 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check.Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: El Checked with local excavators, installers-(attach documentation). ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. bins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Assessing As-Built Cards Page 2 of 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 182 Osterville West Barnstable Rd Property.Address Powell Gilbert T Tr/Seventy Seven Trust Owner Owner's Name information is required for Osterville MA 2-1-18 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file ® 9 P Y P9 P l5ins•3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 http://www.townofbamstable.us/Assessing/HMd splay.asp?mappar=120005&seq=1 2/19/2018 Town of Barnstable i AgNCT1A7 F_ R ' Regulatory Services Department Public Health Division 200 Main Street,Hyannis MA'02601 Office: 508-8624644 Richard ScA Director FAX 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 5111116 DEADLINES WREPAIR FAILED.SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) _ An`Y'marked in the ❑is'the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑Discharge or ponding of effluent to the surface of the ground ❑Pumping more than 4 times during the last year not due to clogged of obstructed pipe. :. o Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE(1)YEAR DEADLINE CRITERIA ❑Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑Any portion of the SAS, cesspool, or privy below high groundwater elevation o Any portion of the cesspool within a Zone 1 to a public well ❑Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). Two (2)YEAR DEADLINE CRITERIA q Single Cesspool o Any"conditionally passed systems" (broken cover,relocation of a pipe,relocation of a driveway due to H-10 components, etc) o Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code §360-9.1) eaching facility with standing liquid level at or above the invert pipe (per Town ode §360-20 h) OTHER Repair deadline: _ Q:ISEPTICIDEADLINES To REPAIR FAILED SYSTEMS•doc Commonwealth of Massachusetts 1'itie 5 ®fficial-- I ns ec i n F m 3 p t ® ®r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 182 W. Barnstable Rd. Property Address Joe Bush Owner Owner's Name information is required for Osterville MA 02655 10-10-06 every page. Cityrrown State Zip Code Date of Inspection Inspection Summary: Check A,B,C,D or E/ahaays complete all of Section D B. Certification (cunt:) 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 r 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 yearn old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfittration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to,broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5insp•08M6 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 182 W. Barnstable Rd Property Address Joe Bush Owner Owner's Name 02655 10-10-06 information Is osterville MA required for Cityrrown state Zip Code Date of inspection every page. B. Certification (cont:) B) System Conditionally Passes (cont.): 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: 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. J. 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. . Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 15 t5insp•08106 monwealth of Massachusetts - Corn - Ins ectiOn Folm 'tle 5 ®f$ICia0 o Not for voluntary Assessments Subsurface Sewage Disposal System Form - 182 W•Barnstable Rd property Address 02655 10-10-06 Joe Bush MA Date of inspection pmrnees Name state Zip Code lion is psterville d for Crty(rown .)age. B. Certification (con," ' Applicable to All SYsterns p) System Failure Criteria Yes No is within a Zone 1 of a public well. • Any portion of a cesspool or privy 1 well. ❑ ® r privy is within 50 feet of a private water supply onion of a cesspool o Anyp reater than 50 feet ® his of or privy is less than 100 feet but greater CT Any portion of a CeSsPo 1 well with no acceptable water qualityied ® a rivate water supp Y water analysis,performed at and the presence from P es ab' . system passes if the well w bacterfa indicates laboratory,for fecal coliform en is equal to or less than 5 analysis a ammonia nitrogen and nitrate nitrog eyed.A copy of the analysis provided that no other failure c�chea to s form l pro must be and chain of custody a facility with The system a design:flow of 2000gpd- rving stem is a cesspool se ' ❑ ® 10,000gpd: that one or more of the above em fails.The The system,fails. scribed in 3 0 CMR 15.303'therefore the sy eria exist as de he Board of Health to determine what will be ❑ cnt system owner should contact t necessary to correct the failure. with a ar` a system the system must serve a facility To be considered a i 9 E) Large Systems: to 15,000 gpd. design flow of 10;p00 gpd in addition to the . st indicate either"YeS9 or'no to each of the following, • For large systems,you.mu questions in Section D. Yes No water supply the system is within 400 feet of a surface drinking drinking water supply ❑ ❑ to a surface I system is within 200 feet of a tributary Interim Wellhead Protection ❑ ❑ en sensitive area( I well the system is located in a nitrogen 11 of a public water supply ❑ ❑ Area.—IWPA)or a mapped significant threat, he stem is considered aerator of any large If you have answered yes to any question in Sect m h failed.The owner or operator upgrade the es" in Section D above the large sY under Section D shall or answered Y 5 304 The system owner should contact the appropriate nsidered a significant threat Section E or fail system considered with 310 CMR system in accordance regional office of the Department. Title 5 pfficiw inspection Form:Subsurface Sewage Oisposal System•Page 5 of 15 Commonwealth of Massachusetts .f Title 5 Official Inspection. Form- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 182 W. Bamstable Rd Property Address Joe Bush Owner Owner's Name information is Osterville MA. 02655 10-10-06 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage.grinder? ❑ Yes ® No Is laundry on a separate.sewage system? (if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): ' Sump pump? ❑ Yes ® No Last date of occupancy: 10-10-06 Date Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 151.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged`to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts a Title 5 Official Inspection, Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - 182 W. Barnstable Rd Property Address Joe Bush Owner Owner's Name information is required for Osterville MA 02655- 10-10-06 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Building Sewer(locate on site plan): Depth below grade: 12"feet Material of construction: cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line:. feet Comments (on.condition of joints,venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 6" Depth below grade: feet Material of construction: ® concrete ❑ metal" ❑fiberglass ❑ polyethylene . ❑ other(explain) s If tank is metal, list age: . years Is-age confirmed by a Certificate of Compliance?(attach acopy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 30" i Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? tape t5insp•08/06 True 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 182 W. Barnstable Rd Property Address Joe Bush Owner Owner's Name information is required for Osterville MA 02655 10-10-06 every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Tight or Holding Tank(cunt.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No i 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 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.): new d-box Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp•08106 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts _ Title 5 Official -Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '< 182 W. Barnstable Rd Property Address Joe Bush Owner Owner's Name information is required for Osterville MA 02655 10-10-06 every page. CityFrown State Zip Code Date of Inspection D. System Information (cunt.) Cesspools(cesspool must be`pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy(locate on site plan): I Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 182 W. Barnstable Rd Property Address Joe Bush Owner Owner's Name information is required for Osterville MA 02655 10-10-06 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed,USGS database-explain: You must describe how you established.the high ground water elevation: Town maps show groundwater at 40'. t5insp•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 P " PAY!t *ad___2 Date: J5 2C 0 TOWN OF BARNSTABLE QO� 12 / TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: 4 S i BUSINESS LOCATION: 5f INVENTORY MAILING ADDRESS: to 1% " TOTAL AMOUNT- TELEPHONE NUMBER: D 2 — CONTACT PERSON: EMERGENCY CONTACT TELEP ONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: i� INFORMATION/REC MMENDA ONS: Ire strict: Waste Transportation: Last shipment of hazardous.waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum Antifreeze (for gasoline or coolant systems) Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor &furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers (including bleach) Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/E CANARY COPY BUSINESS OIL WASTE OIL OIL FILTERS ANTIFREEZE WASTE ANITFREEZE GASOLINE WASTE GAS DIESEL FUEL W/W FLUID ATF HYDRAULIC/ MISC. MISC. MISC. MISC. BRAKE FLUID COMMBUSTIBLE FLAMMABLE CORROSIVE PETROLEUM (GEAR OIL/GREASE/ LUBRICANTS) FREON ACETYLENE CAR WASH CAR.WASH PAINTS/ WAX DETERGENTS THINNERS SEALANT CLEANING BATTERIES/ POISION/TOXIC CAULK/GROUT SOLVENTS BATTERY ACID FERTALIZERS WASTE SOLVENT fir{�.'/� ��{G MSDS 5 LA of MANIFESTS &44 �.t Town of Barnstable-Health Department Page 1 HAZARDOUS MATERIALS INVENTORY SITE VISITS ..... ...... ........ ..... DBA: Bush Gardens Fax: ............_ . Corp Name: Mailing Address Location: 192 West Barnstable Road,Osterville Street: .......... __....... _......_.. ......... _. mappar: City: Contact: .Kathy Bush State: Ma Telephone: 508-428-8178 Zip: 00000 Emergency: Person Interviewed: Business Contact Letter Date: Category: :Landscapers Inventory.Site Visit Date: 5/15/2006 _._....._... ......... Type: Follow.Up/Inspection Date: ❑ public water ❑ indoor floor drains ❑ outdoor surface drains ❑ license required ❑ private water ❑ indoor holding tank mdc ❑ outdoor holding tank mdc ❑ currently licensed ❑ town sewage ❑ indoor catch basin/drywell ❑ outdoor catch basin/drywell expir -El on-site on-site sewage ❑ indoor on-site syste ❑ outdoor onsite system date: . _....._ ........................._......... 5/15/06 alp-Site visit concludes that no haz mat permit is required at compliance: this time. All chemicals are stored in flammable cabinets. Satisfactory f Page 2 Town of Barnstable-Health Department HAZARDOUS MATERIALS INVENTORY Chemicals: ❑ Zero Toxic Waste Materials ❑ gty's>25 Ibs dry or 50 gals liquid but less than 111 gals ❑ gty's 111 gals or more k description �qty __ ->unit o„f„measure ___ Misc.Flammable 3 gallons paint,varnishes stains dyes _ _ 2 gallons Nm pesticides I 10 gallons Insecticide 15 gallons Waste Transporter: Fire District: 'COMM Last HW Shipment Date: Waste Hauler Licensed: No .............. AWBMW PAt No.-- -- --''---'�- ---��`. Fee--Z----------------- BOARD OF HEALTH TOWN OF BARNSTABLE Applicat ion-for Vell Con0ruct ion Permit Application is herpby made for a permit to Construct (--rAlter ( ), or Repair ( )an individual Well at: -- ------dad----=---------__v_o=Ir------- ------------- n ocation — Address Assessors Map and Parcel � G� ---- ----------------------------- --------- -- --= --- - ------------- - - ------------------------ Own r Address Installer — Driller Address 7 _ I . Type of Building Dwelling Other - Type of Building ------- No. of Persons----------------____—__—_--____ Type of Well--- -, - ------- Capacity--- 1 �9 --------— Purpose of Well �� '--- ---- --- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until rtif .of C p is as been issued by the Board of Health. Signed-. - - --------- - -�`7— ---- date ;a� Application Approved B ---- --— °'� 2 date Application Disapproved for the following reasons:-------- ---------------_—__________—__—_—____—_ ----— — — -- - - --- —----------------——------ _ date v Issued Permit No. -- —t -- ___ date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS T _CERTIFY, Thai the Individual Well Constructed (Altered ( ), or Repaired ( ) bY------ 'L'P�C—f _ Gc.� D�,c� Installer w at has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit I�l"v LAVA 0 Dated Y THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE---- - Inspector------___—-------- �,�_-:.,,,.��-a..^ •wad.:.=<:'i-�:,�.�, - NY��iM„w�' .'ws"'SY+•`y"o"a�, ..-'.�'=;►-;.fir-^"��_ .. _ _.. _i w � - 00 No., Fee- - n -«�� Fee-'�----------------- BOARD 6F'HEALTH TOWN OF BARNSTABLE l .ZCppYuationArVrf l Co gtructionPermit j Application is hereby made:for a permit to Construct (/_ Alter ( ) or Repair ( .)an individual Well at: /ad 670 s5 ---- - - --- - -- -- -- -- - - -- -- -- -------- Location Address r*" Assessors Map and Parcel v� Owner Address `f_3__a mod ' , - 'r Installer• Driller y • . Address r. TYPe of:Building `Dwelling-— - --- ------- -. -- i Other -Type of Building-`-- --- - No. of Persons-- ------- --------- ------- - i Type of Well- -= �� .'. - — -- - Capacity--- f - �-� — f - Purpose of.Well �i�_cf Agreement: ' The undersigned agrees to install the'aforedescribed individual well in accordance with the provisions of The x } Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to } place the.welkin operation-.until %C rtific of Co plian e has.been'issued by the Board of Health. 7 -r �s i Signed - ------ ------ ! date r Application Approved l — date Application Disapproved for the following reasons --- =--------- - f-----___—_ ' date. .ram ` �� Permit No.= ' '�7 -- Issued—R`n �_------ ------—---------. date . BOARD OF HEALTH 'TOWN OF BARNSTABLE certificate �f ;�Com��iance . , a �; THIS IS TO ERTIFY That the Individu'I Well Constructed (.Altered or Repaired by nstal' I ler has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation,as described in.the application for Well Construction Permit 11�f--A?0k, V--Dated 9='Zn '?� THE-ISSUANCE OF THIS,CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE :THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY: s= iw - DATE Inspector-- ------ ---- ---- f .'.ia pp?isi Q�4i@llL3i,4,iAil�/aSe_S!u'`'i4ia+,app4uSewg9e4a!'s•3vRG`SbD5TaOGr84iT39i4tSYltS�Tllitillil¢d9.fiTYTS!,6eL6i4fTGl6TilaliBitsTdl4SlsT.kti!i^LlisifiSeTPFiT6Ti4'�'Sa'tst'Yt1?.i!s?el+s� w; BOARD .OF.HEALTH TOWN _OF BARNSTABL.E ' ' P[I �ontruct ion hermit :. No. A-'=- Fee-" Permission is he b ranted • to Constivct (l� Alt y g r (. ), or Repair ( . ) an dividual Well.. t"' No: fir . � _�,cl f9/Zirr Street. - as shown on the a plication for a Well-Construction Permit j No.-- �"- �'.J+ J'� -- Dated—2 /S a<J 3 d v Board of Health -- DATE — -- r�-/........_ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH n .._................OF...... Q 1�+. ,.-------_--.------------------ �, pfliratiou for UhipusFal Works Tonstrurtion Prrmit Application is hereby made for a Permit to Construct ( or Repair ( an Individual Sewage Disposal System at -------------------------------------------------- Location-Address _/ .........or Lot \o..._.____.. --�`�.-••-_.la.-A------------------------�-•- ...!.-�!1... _ �'`�.� caner Address ----•---- •-----••-----•--------------------------------•-•---- Installer Address UType of Building Size Lot____•----_-----_----.•-_._Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a'4 Other—Type of Building No. of_persons............................ Showers YP g -----=-------•-------------- P ( ) -- Cafeteria fixtures ----------------•--------------------------•-----------------•-------••••--------•----.........-----------••-----•-- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-__----.-_--_--____-_--. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--.--._____-___--------. C4 •------------------------------------------------------------..................................... O Description of Soil.........C .Q......S. 19y ...---...--•-•------�--. ------------- at --------------------------- x . ------------------------------------------------------------------------------------------------ -------•--••. •-----•---••-- U Nature of Repairs`�� p n �ti�� G 4LP `- if --�-�2 x . ------ rs or Alterations—Answer when applicable- _�1S-T[Rl ._.: S ._.. `b_�.�__Q_...�..................5}- tip? jt --------- _ 1s i�!.... ......�.�t- --------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with TT�'lx the provisions of'THE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance h been iss d b th board of health. Signed. . . ••.= t, t-z-lZ�aq � Date Application Approved By__ _ ______ ______ _____ Date Application Disapproved for the following reasons _ ..... . . . ...... ................................•--_.___._-_._..__.._:__-___..._..._. � Date "' Permit No.--- C -•- ................. -------. Issued_......-................................................ Date r .4"" ; --- V No.Cj.. ...... Fps.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �fi w.ry..................OF........... +f� ----------.- -------_----- Appftratioat for Dhipaaal Workii Toatstrurtiou runfi# Application is hereby made for a Permit to Construct ( �yRepair ( ,4....�n Individual Sewage Disposal System at: ......... - -•----------------------------------------•------......_.__...------------•---•------- ``Location-Address or Lot No. --...--•..............-----•-•----------------. .....------...._.........---•----•------.._..._ -•---...:.1.C!_E..,� .-•---•--..........------.....-----••----•......---- Owner Address ---t-�i�'r�-`..._....cQ�15 ........ Q = . --..�1 -u�2 a----------------.....------------------..........._..._.._..........._. Installer Address UType of Building Size Lot----------------------------Sq. feet �. Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type e of Building No. of persons............................ Showers — Cafeteria a YP g P ( ) ( ) Otherfixtures -----------------------------------------------------.-------------------•--------------------------...----------••--------------•--•---•------------ W Design Flow............................................gallons per person per day. Total daily flow.......:....................................gallons. 1:4 Septic Tank—Liquid capacity............gallons Length-----------_-- Width................ Diameter---------------- Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------_...... Diameter.................... Depth below inlet..........-:........ Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_________-___•---.-_.__. fr Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water._.-.______-_____--____ 0 Description of Soil.......0.2 ._._..C--P_- x ........................ ...................................... -ry"..��- { >> °/--------- �1 ------/7,0ns0-------��Lc[� ------d.s�ctL---- �'=-------� -------� U Nature of Repairs or Alterations—Answer when applicable s;' *&I------- ?�P---- " `�f 1`. --------- - \S � `-------p` ------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'I T Lip i of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance 4s been is ued�by t e board of health. Signed , = �`�= - — n, { -------•------------------------- ....4� Z l $.----- r y � Date Application Approved By. .....--•-•- --•----•------------•--- ` A, Date Application Disapproved for the f olloiving reason :_. ________________________________________________________ --------•---•-•----------•-................... -------- ----------------------------------- -------------- sf� Date Permit No.--- ._(1...---... --=`�... ---------------•--•-- Issued_....................................................... THE COMMONWEALTH OF MASSACHUSETTS BO RD OF HEALTH IN") .............I..........I.................OF............... ........................................................................ :....................---............... Tatif irFatr of Tootpli attre 7*�J,\&TO C R1 3 P, That the Individual Sewage Disposal System constructed (ke�or Repaired ( ) by..j.4 j7.�............. ��-----------------t}-- ----------------------------------------------------------------------- at-----------------------•--••---•••-•--••--••--•-----•---•--------------- •----••--•••--•:::-------•-•-------------••----•-•----------••••-•----••--•-----------------•-•-•- I has been installed in accordance with the prq isions of i I T` of The_aa e Sanitary Code descr' ed the application for Disposal Works Construction Permit �'o..__._ , _"�__ � .__t_ dated....-_ _ � 1 ___.__._ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUA ANTE/E THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......................a,. �..3. g ....................... inspector..................... t .............................................. THE COMMONWEALTH OF MASSACHUSETTS BOAR F HEALTH w � 13", �y /...........................................OF...................................................................................... /.� FEE....... .:......... /(((' Permission. _hhereby granted..............-............................................................................................................................... to ConstrAc?'- ) of air ( 9,,Jan _Dldti&a ..SS A�Disposal System atNo.................................................................................................................. ......- Street as shown on the application for Disposal Works Construction mit No._ _ra__._ ated..__ ._ ........ p Board o ealth DATE------../ I/W -------- FORM 1255 HOBB & WARREN. INC., PUBLISHERS T"E' Town of Barnstable U.S.POSTAGE>>PITNEY BOWES of �.� i ��. Y•• Public Health Division ,k ® RARNSfAFILE. 1 200 Main Street •{ y v� MASS. 0P � O �p�FD MP��O Hyannis,MA 02601 •.''•�_•. Zip.02601 $ 006.6 / � 02 4VY 455 APR. 03. 2018. 7015 1730 0001 4987 7046 I - POWELL, GILBERT TR 1 z� 3 31 DE 1 0 OtO 4/13.11.8 I RETURN TO SENDER j ➢Vjj- SUCH STREET UNABLE TO FORWARD r; U 0'a�L '� �I��Ii..�91.9��I1�a1ai:I�lE$➢9::i �1�3��i.:i1��f� aeio,�3A9 .' F - 1 .............. ® Print our name and address on the reverse J M Complete items 1,2,and 3. A. Signature 1 I y X [3 Agent I — I so that we can return the card to you. ❑Addressee I I M Attach this card to the back of the mailpiece, B. Received by(Printed Name) C. Date of Delivery or on the front if space permits. I D. Is delivery address different from item 1? ❑Yes I If YES,enter delivery address below: ❑No I I I POWELL, GILBERT TR 1 448 BOSS STREET 1 I Jl P' TER, FL 33408 I I 3. Service Type ❑Priority Mail Express@ 1 II I�III�I ICI �I I II II II I I I IIII III I II I II III ❑Adult Signature ❑Registered Mall TM ❑ R I I duR Signature Restricted Delivery ❑Registered Marl Restricted I I jertifled Maile Delivery 1 9590 9402 1933 6123 1780 40 ❑Certified Mail Restricted Delivery 1t Return Receipt for ❑Collect on Delivery Merchandise I 2--Article Number(Transfer from service labeq ❑Collect on Delivery Restricted Delivery ❑Signature ConflrmatlonT" I — _! _Insured Mail ❑Signature Confirmation 7 015 1730 11001 49877046 ( Restricted Delivery , I ul Restricted Delivery ( t�� d PS Form 381 1,July 2015 PSN 7530-02-000-9053 Domestic Return Recelpt Ti?�►N OF B R 7,— STABLE LOCATION --" ° SEWAGE # �,�:' VILLAG EL' -• J �l� y1L,L ASSESSOR'S MAP Cz LOT j�/2o L,os-- INSTALLER'S NAME St PHONE NO. SEPTIC TANK CAPACITY I C C'l..`> 6 ,f LEACHING FACILITY:(rYPe) L �7/ (size) 6 G NO. OF BEDROOMS�_PRlVATE WELL OR PUBLIC :VATER. �� Tc tj BUILDER OR OWNER •T� I •, �► DATE PERMIT ISSUED: -------------- DATE COLIPLIANCE ISSUED. NICE GRANTED: Ye YARId s No �/� 6 Un Vy 0 Y IVY 4$ Note: Falmouth Roo Route 28 See "Site Plan in Osterville"• &6 '' dated May 6, 2020 5k2• � i prepared b Hayes Engineering, Inc Locus Map 121 p P Y Y , Parcel 27 {�� , for entire site dimensions. Existing gas lines 36".Pine t..� to be relocated < (} Tree .50 ^ —� #3 TP ` 36" Pine ` N O9 16 �' o N #4 ��, Tree ��N OF�4 _ n o - tam s 6$ See Note o:.` T ss:_ o —Co' r 0o P ` r pl_ Proposed Vent Qy G .pr • . -G�i l #19 !(3 -- �1'*#i, Q ! See Excavation °� D i p116" /` �'�?.� Notes O / k, STree e o/ \ + ++37, F o I ` pry �t Deck \ i + \ { q / ` s sre1P OSTERVILLE, MA \tJ Bldg 182 - SAS c► ! -' 3 Bedroom 2� DB ; r 11.0' I SITE LOCUS 10, Min, NOT TO SCALE \. TOF = 50-0 �' SST a+l c \ ! install Tee on lnlet �` ' \ Existing Greenhouse Outlet tr `� �• \ Existing outlet #2l I .. Plant Han in \ , '--Existing4'PVC Outle Structure g \ Existing outlets to' t\\ 1.) Assessor's Map 120 Parcel 005 be abandoned and I \ 2.) Book 31685 Page 80 \ W k connect to existing h- \ \ \ 1 Top of Foundation Septic Outlet #1 1 e \ 3.) Plat Book 338 Page 09 TSM Elev. - 50.0 W t Existing - \\ \ `4 rn Pavement \ \ - o Zone itWellhead:, \ ) Protection District 4_ Zo (� 5. This ro ert is in Flood Zone 'X Gsove� Existing \� , \ ) P P Y .a '" �' �f��l -' -� \ \ Workshop Firm Map 25001C0544J 7/16/14 rr rr i f \\ \ Parcel 1 & 2 Employee \\ Existing ;I ar l' —°h� \ \ \ Bathroom \\; Garage �\ ' 1.97± Acres Existing r ` v / r \ \ \` - Greenhouse \ \ \ \ 48- Existing \ \ \ \ \ \-- \ Greenhouse \ Proposed Sewage Disposal System r \ . , Existing Greenhouse \ \ \ �3, 182 Osterville—ll�est Barnstable Road V\ rill MA 4st ev e ' Prepared for: Existing \ \ / Pavement Pour La Table LLC PO Box 865 Ma 120 Osterville, MA r o Parcel 006 Prepared by: r GRAPHIC SCALE All Cape Septic and Survey 618 Route 28 10 Z West Yarmouth, MA 02673 / LOCATION OF UTILITIES IS APPROXIMATE AND ALL 20 ° i0 20 40 80 (508) 771-4200 UNDERGROUND ANQ OVERHEAD UTILITIES MUST BE clicapeseptic®gmoil,com -' DETERMINED IN THE FIELD PRIOR TO COMMENCEMENT OF ANY WORK, THIS INCLUDES, BUT NOT LIMITED TO, Dote 06/09/20 REQUESTS TO DIGSAFE, ANY PRIVATE UTILITY COMPANIES ( IN FEET ) I AND THE LOCAL WATER DEPARTMENT. ; 1 inch = 20 fL nwrl diAr-249 31j _ t . I RAISE MIN. 20," DIAMETER COVER RAISE MIN. 24" DIAMETER CAST IRON CONSTRUCTION NOTES TO WITHIN 6"'OF FINISH GRADE EL=50.0t COVER TO WITHIN 6" OF FINISH GRADE 1.) ALL WORK SHALL CONFORM TO THE STATE ENVIRONMENTAL CODE, TITLE 5(310 CMR 15.000): 4$.5t 4$.5f STANDARD REQUIREMENTS FOR THE SITING, CONSTRUCTION. INSPECTION, UPGRADE, AND EXPANSION OF ON-SITE SEWAGE TREATMENT AND DISPOSAL SYSTEMS AND FOR THE TRANSPORT �/ \/ �� ' 1 \ �� / �/ \� AND DISPOSAL OF SEPTAGE, AND THE LOCAL BOARD OF HEALTH REGULATIONS. /\ \\/ 2.) ANY SEPTIC SYSTEM COMPONENT INSTALLED IN A LOCATION WHERE THERE IS POTENTIAL FORVEHICLES HEAVY EOUIPMENT To TO WITHSTD AN H-20 LOADING. OR UNDER AN IMPERVIO SPASS SURFACERSYSTEM ALLOVE IT SHALLDESIGNED BE VENTED TO THEAN ATMOSPHERE. CONCRETE o CONCRETE RISER g a) TO MINIMIZE UNEVEN SETTLING. SEPTIC TANKS AND D-BOX SHALL BE INSTALLED ON A STABLE - / n / RISER MECHANICALLY-COMPACTED BASE ON SIX INCHES OF CRUSHED STONE. 47.8t M GEOTEXTILE 4.) COVERS OVER THE INLET AND OUTLET TEES OF THE SEPTIC TANK, THE DISTRIBUTION BOX, AND 45.6 FABRIC THE SOIL ABSORPTION SYSTEM SHALL BE RAISED TO WITHIN 6"OF FINAL GRADE. LEACHING 47.3t FIELDS, TRENCHES, AND OTHER SOIL ABSORPTION SYSTEMS WITHOUT ACCESS MANHOLES SHALL M HAVE AT LEAST ONE (1)INSPECTION PORT CONSISTING OF PERFORATED 4" PVC PIPE PLACED Existing VERTICALLY TO THE BOTTOM OF THE SOIL ABSORPTION SYSTEM WITH A CAP, TIED WITH MAGNETIC MARKING TAPE', ACCESSIBLE TO WITHIN 3" OF FINAL GRADE. 46.2 J 5.) PIPING SHALL CONSIST OF 4" SCHEDULE 40 PVC OR EQUIVALENT. PIPE SHALL BE LAID ON A 46.4t O 45.57 45.4 ++ MINIMUM CONTINUOUS GRADE OF NOT LESS THAN 2%FROM THE BUILDING TO THE SEPTIC TANK, Existing 45 1 _ T 3/4" to AND NOT LESS THAN 1%OTHERWISE. Existing �, it 1-1/2" STONE 6.).DISTRIBUTION LINES FOR THE SOIL ABSORPTION SYSTEM SHALL BE 4' DIAMETER SCHEDULE 40 GAS BAFFLE DB-3 H-20 (Double wash) PVC(OR EQUIVALENT) LAID AT 0.005 FT/FT. UNLESS OTHERWISE NOTED. LINES SHALL BE CAPPED AT END OR AS NOTED, D-B�X THREE (3) 500 GALLON H-20 PRECAST 7.) LINES FROM THE DISTRIBUTION BOX TO BE.LEVEL FOR THE FIRST TWO (2)FEET BEFORE 43.2 CONCRETE LEACH CHAMBERS WITH 4' OF PITCHING TO THE SOIL ABSORPTION SYSTEM. DISTRIBUTION BOX SHALL BE WATER TESTED To ASSURE EVEN DISTRIBUTION. 1,000 GALLON STONE ON ENDS AND 4" ON SIDES 8.) GROUT TO BE USED AT ALL POINTS WHERE PIPES ENTER OR LEAVE ALL CONCRETE STRUCTURES �---12't -- t 16't---� 8"t IN ORDER TO PROVIDE A WATERTIGHT SEAL. SEPTIC TANK LEACH CHAMBERS 5 1' 9.) HEAVY EQUIPMENT SHALL NOT BE ALLOWED TO OPERATE OVER THE LIMITS OF THE SEWAGE (EXISTING) (END VIEW) DISPOSAL FIELD DURING THE COURSE OF CONSTRUCTION OF THE SYSTEM. FLOW [� 10.)IN ACCORDANCE WITH 310 CMR 15.221, ALL SYSTEM COMPONENTS SHALL BE MARKED WITH f LO YV PROFILE LE 1.)NETICTHERE MARKING TAPE. NOT TO SCALE EL=38.0 Bottom Test Hole 71.) THERE ARE NO KNOWN WELLS OR WETLANDS WITHIN 150. OF THE PROPOSED SOIL ABSORPTION.SYS LIVInC� - �(NQF� _ - 12.) FROM THE DATE OF THE INSTALLATION OF THE SOIL ABSORPTION SYSTEM UNTIL RECEIPT OF THE CERTIFICATE OF COMPLIANCE. THE PERIMETER SHALL BE STAKED AND FLAGGED TO PREVENT USE OF THE AREA THAT MAY CAUSE DAMAGE TO THE SYSTEM. 9 Family �O� V SYSTEM DESIGN CALCULATIONS - 13.) THE DESIGNER WILL NOT BE RESPONSIBLE FOR THE SYSTEM AS DESIGNED UNLESS CONSTRUCTED AS SHOWN ON PLAN. ANY CHANGES SHALL BE APPROVED IN WRITING BY THE ENGINEER. FloF H SEWAGE DESIGN FLOW: THREE BEDROOM DWELLING ® 110 GPD/BEDROOM = 330 GPD 14.) THE BOARD OF HEALTH REQUIRES INSPECTION OF ALL CONSTRUCTION BY AN AGENT OF THE FACTORY/INDUSTRIAL/WAREHOUSE: 8 EMPLOYEES ® 15 GPD/PERSON = 120 GPD BOARD OF HEALTH AND THE DESIGNER. THE DESGNER SHALL CERTIFY IN WRITING THAT THE Kitchen Bath I TOTAL DESIGN CAPACITY = 450 GPD SEWAGE DISPOSAL SYSTEM WAS INSTALLED IN ACCORDANCE WITH THE TERMS OF THE PERMIT SEWAGE DESIGN FLOW PROVIDED: THREE 3 500 GALLON H-20 CHAMBERS AND THE APPROVED PLANS. 48 HOURS ADVANCE NOTICE IS REOUESTEO. �G�STE� WITH 4' STONE ON THE ENDS AND 4' STONE)ON THE SIDES - DETERMINING TON HE LOCATIONES 1OF APPROXIMATE ALLL UNDERGROUND ANCONTRACTOR OVERHEAD UTALL ILITIES PRIOR PRIORR TOE FOR Mgt Floor Plan 1- s'4NITA \P /J/) Vt = [(33.5 x 12.83) + 2(33.5 + 12.83) (2) x .74 = 455 GPD PROVIDED COMMENCEMENT OF ANY WORK. THIS INCLUDES. BUT IS NOT LIMITED TO, REOUESTS TO DIGSAFE, N.T-S. V`r 455 GPD PROVIDED > 450 GPD REQUIRED ANY PRIVATE UTILITY COMPANIES, AND THE LOCAL WATER DEPARTMENT. 16.) CONTRACTOR SHALL VERIFY THAT ALL WASTELINES ARE CONNECTED BY WATER TESTING SEPTIC TANK CAPACITY REQUIRED: 450 GPD X 200 = 900 (MINIMUM) WITHIN THE DWELLING PRIOR TO INSTALLATION OF ANY SEPTIC COMPONENTS. Bedroom SEPTIC TANK CAPACITY PROVIDED: 1.000 GALLON.SEPTIC TANK EXISTING 17.) CONTRACTOR SHALL VERIFY EXISTING INVERT ELEVATIONS PRIOR TO INSTALLATION OF ANY Bedroom (EXISTING) SEPTIC SYSTEM COMPONENTS. #3 #2 18.) TEST HOLES COMPLETED PER STATE ENVIRONMENTAL CODE; TITLE 5. SOILS CAN BE if 7f VARIABLE AND TEST HOLE DATA IS NO GUARANTEE OF SOIL CONDITIONS IN OTHER AREAS. IF EXCAVATION NOTES SOILS DIFFER FROM THOSE SHOWN IN THE SOILS LOGS, DESIGN ENGINEER IS TO INSPECT THE SOILS PRIOR TO PROCEEDING WITH INSTALLATION OF ANY SEPTIC COMPONENTS. 1) EXCAVATE ALL MATERIAL ABOVE SOIL HORIZON CI (SEE DEEP OBSERVATION 19.)EXISTING SEPTIC COMPONENTS TO BE LOCATED, PUMPED DRY, FILLED WITH CLEAN SAND AND Bedroom IN HOLE LOG)FOR A LATERAL THE ISTOUI'ER F 5'(W ERR OF PTHEOSSIBLE )ACHING AREA. Proposed Sewage Disposal System ABANDONED IN COMPACTED'PLACE*OR REMOVED AS REQUIRED. AREA TO BE COMPACT TO MINIMIZE SETTLING. Bath #q 1 2) FILL MATERIAL SHALL CONSIST OF CLEAN GRANULAR SAND. FREE FROM ORGANIC (INCLUDING EXISTING SEPTIC TANK) - MATTER AND,OTHER DELETERIOUS SUBSTANCES.WHICH MEETS THE TEXTURAL 1.8 2 0 s t e.r v i I I e-West Barnstable- Road CRITERIA PUT FORTH IN SECTION 15.255(3)OF TITLE 5. TEST HOLE LOGS 3) SCARIFY THE BOTTOM SURFACE OF THE EXCAVATION PRIOR TO PLACEMENT Test Hole 1 (EL-48.5t) 2nd .Floor Plan 4) PLAOF N FILLOONLY WHENNING BO7 OMUSURFACE IS DRY. Depth Elev. Lover Soil Class SOII Color N.T.S. 0 S t e r v i I I e, IVI A , p Test Hole 3 (EL=48.5t Prepared for: 0"-47" 44.6 Fill Fill Depth Elev. Layer Soil Gass Soil Color I CERTIFY THAT I AM CURRENTLY APPROVED BY THE DEPARTMENT OF 47"-126" 38.0 Ct Med Send 2.5Y6/6 0"-48" 44.5 Fill Fill ENVIRONMENTAL PROTECTION PURSUANT TO 310 CMR 15.017 TO CONDUCT Pour La Table LLC 48"-126" 38.0 Cl Med Sand 2.SY6/6 SOIL EVALUATIONS AND THAT THE ABOVE ANALYSIS HAS BEEN PERFORMED p0 Box S65 BY ME CONSISTENT WITH THE REQUIRED. TRAINING. EXPERTISE, AND EXPERIENCE Test Hole 2 (EL-48.5t DESCRIBED IN 310 CMR 15.017. 1 FURTHER CERTIFY THAT THE RESULTS OF MY SOIL EVALUATION AS INDICATED ON THE ATTACHED SOIL EVALUATION FORM Os t ervi l l e, Ni A Depth Elev. Layer Soil Class Soil Color Test Hole 4 (EL=48.5f SOIL LUATION, AS INDICATED ON THE ATTACHED SOIL EVALUATION FORM, ARE C RATE AND IN CCO VICE WI i0 CMR 15.100 THROUGH 15.107 0"-48" 44.5 Fill Fill t0YR3/2 Depth Elev. Layer Soil Class Sol Color Prepared b P Y: 48"-126" 3810 Cl Med Send 2.5Y6/6 0"_47" 44.6 Fill Fill All Cape Septic and Survey DATE OF TESTING: 06/03/20 47"-126" 38.0 Cl Med Send 2.SY6/6 DAVID FLAHERTY JR, CERT IED SOIL v UATOR 618 Route 28 SOIL EVALUATOR: DAVID FLAHERTY JR West Yarmouth, MA 02673 WITNESS: DAVE STANTON BARNSTABLE HEALTH AGENT (508) 771-4200 PERCOLATION RATE: LESS THAN < 2 MIN/INCH 60" DEPTH I ollcopeseptic®gmoil.com PERC IN "Cl" SOILS Dater 06/09/20 NO GROUNDWATER ENCOUNTERED Sheet 2 of 2 Project No. AC-242-2 I .