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0030 PARKER ROAD - Health
30 Parker Road,1~, �Osterville V A = 117 107 e t ` Commonwealth of Massachusetts Pirtle 5 ®ffidal Inspection Form a s Subsurface Sewage Disposal System Form-Not for Voluntary.Assessments 30 PARKER RD !uR Property Address PANTAZOPOULOS akp! Owner Owner's Name "X, information is required for OSTERVILLE MA 3=6-17 every page: CitylTown State. Zip Code;. Date of Inspection u + -0 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 i A. General Information / When-filling out forms on the computer,use I.. 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 RO. BOX 145. Company Address. CENTERVILLE MA 02632 n City/Town State Zip Code 1 508-420-4534 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 sexperience in the proper function and;maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5;(310 C M R 15.000):The system: 0 Passes 0. :Conditionally Passes ❑ Fails` Q Needs Further Evaluation by the Local Approving Authority 3-6-17 Inspe 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 1 0,000 gpd or greater, the inspector and the system owner shall submit the report,to the appropriate regional office of the DER'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 thie 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•BH3 Title 5 Ofiiciai Inspection Form°Subsurface Sewage Disposal System-Page 1 of V i Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form Not for Voluntary Assessments 30 PARKER:RD Property.Address PANTAZOPOULOS Owner Owners Name information is required for OSTERVILL'E MA 3-6-17 State. Zip Code Date of Inspection every page,_ CitylTown p p B. Certification (tong) Inspection Summ.Wy. Check A,B,C,D or /always complete all of Section D A) System Passes: Z I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 31.G,CMR 15.304 exist. Any fail.ureL criteria not evaluated are indicated below. Comments_ I AT TIME OF INSPECTION SYSTEM MET ALLjPASSING REQUIREMENTS. THIS.REPORT DOES NOT PREDICT THE FUTURE PERFORMANCE UNDER THE SAME OR INCREASED USE. 13) 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 - r Commonwealth of Massachusetts Title 5 Official 'Inspection Form s Subsurface,Sewage Disposal System,Form-Not.for Voluntary Assessments p 30 PARKER RD Property Address PANTAZOPOULOS Owner Owner's Name information is required for OSTERVILLE MA. 3 6-17` every page. City/Town Stater . Zip Code: Date of Inspection B. Certification (cont.) El Pump Chamber pumps/alarms not operational.System will pass,with Board of Health approval if pumps/alarms are repaired. B) System.Conditionally Passes (cone.): ❑ 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): El The system required pumping more than.4 times a yearAue to broken or obstructed pipe(s). The, system will pass inspection if(with approval of the Board of Health): broken pip replaced ❑ Y ❑ N ❑ ND(Explain below):. ❑ obstruction is removed ❑ Y ❑. ,N ❑ ND (Explain.belowj: 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 i.s 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 thesystem is notfunctioning 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. 5.ins o 3M.I Title 5 Official InspechonFow Sbbsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal:System Form -Not for Voluntary Assessments 30 PARKER RD Property.Address PANTAZOPOULOS Owner Owner's Name information is OSTERVILLE MA 3-6-17 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of (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, urface water supply; ❑ The.system has a septic.tank and SAS and the SAS is.within a Zone 1 of a publicwater 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,but50 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 DLP 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) SysternTailure Criteria.Applicable to AllSystems: 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 El Z clogged SAS or cesspool Discharge or ponding of effluent"to.the.surface of the ground o.r surface waters El M due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution:boz above,outlet invert due to an overloaded or clogged;SAS or cesspool Liquid depth in cesspool is less,than 6"below invertor:available volume is.cress: than '/day`flow t5ins=:3113. Title 5'OHicial Inspection Form:Subsurface.Sewage Disposal System-Page 4 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection dorm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 30 PARKER RD Property Address PANTAZOPOULOS Owner Owner's Name information is 0STERVILLE MA. 3-6-17 required for every page.a e. CitylTown 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 watersupply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone:1 of a public well. El 0 Any portion of a cesspool or privy iswithin:504eet of a private--water supply well: ❑ Z 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 r 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: Ei z The system fails. l.have determined.that one or more of the above failure criteria exist as described in 3:10.CMR 15.303,..therefore the system fails. The system owner should contactthe.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 15,00.0.,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 11 of a publicv.ater 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. &ns 3/13 Titles OffclalAnspoction Form:Subsurface Sewage Disposal System•Page;5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form V' m Form Not for Voluntary Assessments. a Sewage Disposal $ ry I� Subsurface se ste g p y .30 PARKER RD Property Address PANTAZOPOULOS Owner Owner'S Name information is required for OSTERVILLE MA 3-6-17 9 every page. City/Town State Zip Code Date.of inspection P C. Checklist. Check if the following have been done. You must indicate"yes"or"no"'as to each.of the following Yes No EJ 2., Pumping information was provided by the.owner;occupant; or Board-of Health ❑ Z 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 El 0 this inspection? ElWere.as built plans of the system obtained.and examined? (,If they were not. available.note as N/A) 0 ❑ Was the facility or dwelling inspected for signs of sewage back up? Z ❑ 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? ❑ Z 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 th&site has been determined based on: Z ❑ 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 15.3U(5)] D. System Information Residential.Flow Conditions: Number of.bedrooms(design): 3 3 Number of bedrooms(actual): DESIGN based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 D 15ins,3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of;17 Commonwealth of Massachusetts Tithe 5 Official Inspection Form. Subsurface Sewage Disposal:System Form Not for Voluntary Assessments 30 PARKER RD Property Address PANTAZOPOULOS Owner Owner's Name information is required for OSTERVILLE MA 3-6-17 - ` every page. CityrFown State Zip.Code Date of Inspection D. System Information Description: According to design plan and permit system consists of a 1000 gallon tank d-boz antl 7 c.ultec rechaMers`with stone. Plan by Weller and Associates dated 10/27/03 Number of current residents: Does residence have a.:garbage grinder? Ell Yes ❑ No. Is,laundry on a:separate sewage system? (Include Laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? 0 Yes ❑ No Water meter readings, if available(last.2 years usage(gpd)): Detail 2015`and 2016 averages were 307 gpd. Sump pump? ❑ Yes ❑ :No Last date of occupancy:. seasonal part time Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons,per day<(gpd) Basi&of design flow(seatslpersonslsq.ft, etc.):. Grease trap present? ❑. Yes ❑ No Industrial waste hold.ing.tank present? ❑. Yes ❑ No. Non-sanitary waste discharged to'the Title 5 system? ❑ Yes[]. No Water meter readings, if available: i C$irisr 3113. Title-5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7-of.17 r Commonwealth of Massachusetts Title 5 Official Inspection Form - rVolunta Assessments Farm Not for' osal System Voluntary Subsurface:Sewage Disposal y �;. 30 PARKER RD Property Address PANTAZOPOULOS - Owner Owners Name information is required for OSTERVILLE_ MA 3-6-17 every page. City/Town State Zip Code Date of Inspection D. System Information (coat.) Approximate age of all components, date installed(if known) and source of information 1-20-0.4 per septic.permit Were sewage odors detected when arriving at the site? ❑ Yes No, Building Sewer(locate..on site;plan): Depth below grade: feet Material of construction: cast iron ❑40 PVC ❑other(explain)-, Distance from private water'supply well or suction line feet Comments(on:condition of joints, venting, evidence of leakage etc:); Septic Tank.(locate on site plan): t5 Depth below grade feet Material'of construction: concrete. ❑ metal ❑fiberglass ❑ po.lyethylene ❑other(explain) If tank is,metal„list ag'e;: years is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes. ❑ No 1000 gallon Dimensions: moderate Sludge.depth: i Title 5 Official Inspection Form Subsurface Sewage Disposal System=.Page 4 of 17 t5ies=31.13 Commonwealth of Massachusetts: Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary.Assessments' M eVy 30 PARKER RD Property;Address PANTAZOPOULOS Owner Owners Name information is required for OSTERVILLE MA 3-6-17 every page. Cityfrown state Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: seasonal part time Date Other(describe.below): General Information Pumping Records: Source of information: Was.system pumped as part.of the inspection? ❑ Yes .0 No If yes, volume pumped; gallons How was quantity pumped determined? Reason for pumping Type;of System, Septic tank, distribution box. soil absorption system . ❑ Singletesspool ❑ Overflow.cesspool Privy ❑ Shared system (yes or no) (if.yes,attach previous<ins pection 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 l/A system by system operator under contract. Tight tank.Attach a copy of the DEP approval. Other(describe):. t5ins'•3/11 Title 5Official Inspection Form:,Subsurface Sewage Disposal System•0646 8'of'17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface.Sewage Disposal System Form -Not for Voluntary Assessments 30 PARKER RD Property Address.. PANTAZOPOULOS Owner Owners Name information is OSTERVILLE MA M-17 required for ever y.page. City/Town State Zip Code Date,of Inspection D. System Information (cont.) Septic Tank(coat,) Distance from top of sludge to...bottom of outlet,tee or baffle. light Scum thickness Distance from top of scum to top of outlet'tee or baffle Distance from bottom of SCUM.to bottom of outlet tee or baffle How were dimensions;determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to.outlet invert,evidence of leakage, etc.). recommend pumping at time of transfer and at-least every 2=3 yrs there after for maintenance Grease Trap:(locate on site plan): Depth below grade: feet Material of construction' ❑ concrete ❑ metal. ❑fiberglass: El polyethylene ❑other(.explain):; Dimensions` Scum thickness Distance from top.of scum to,top of outlet tee;or.baffle Distance:from bottom ofscum.to:bottom of outlet tee or baffle Date of last pumping: Date t5ins•.313 Title 5 Official Inspection Form:Subsurface Sewage,Disposal System•Page 10 of 17. Commonwealth of Massachusetts Title 5 official Inspection Form c Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 PARKER.RD Property.Address PANTAZOPOULO.S Owner Owner's Name information is OSTERUILLE MA 3 6-1`7 required for every page: CitylTown 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 leakages 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 El No Date of last pumping date Comments(condition of:alarm and float switches etc.:): J -Attach copy of current pumping contract(required)..Is copy:attached? ❑. Yes ❑ No {Sins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 19 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form Not for Voluntary Assessments 30 PARKER RD Property Address PANTAZOPOULOS Owner Owner's Name information is required for OSTERVILLE MA 3-6-117 every page. CitylTotivn State Zip.Code Date of Inspection D. System Information (cony) 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 t0 outlets equal, any evidence of solids carryover,:any evidence of leakage into or out of box, etc.):. no Solid.carry over or signs of failure at.time:of inspection Pump Chamber(locate on site plan): Pumps inworking`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.n..ot 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: Even though the ias built Shows.an observation port we were unable#,o locate it from the swing ties given: i l5in5.All 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal Sptern;•Page;12 of 17 commonwealth of Massachusetts - -- Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 30 PARKER RD Property Address PANTAZOPOULOS Owner Owner's Name information is OSTERVILLE MA 3-6-17ate required for every page. Citylrown St Zip Code Date of Inspection D. System Information;(cont:) Type` leaching`pits number: leaching chambers num 7 cultec re ber; chargers leaching.galleries number leaching trendies nurnber,length:.. ❑ leaching fields number,_dimensions: ❑ overflow cesspool number: El 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.): We were unable to locate the observation port shown on as built:card; but I,did probe in.the:area.of. the s.a.s:.ond found only clean dry soils:acid stone in the area of the s:a-s. 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 t5ins•3113 Title 5 Official inspection Form:?Subsurface Sevrage,Disposal System•ago 13 of 17 i Commonwealth of Massachusetts Tithe 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary'Assessme'nt5 M 30 PARKER RD Property'Address PAN:TAMPOULOS Owner Owners Name information is OSTERVILLE MA required for 3-6-17 every page. City/Town State Zip Code Date of Inspection D. System information (cont.) Comments (notecondition of soil; signs of hydraulic failure, level of.ponding,:condition of:vegetation, etc.). Privy(locate on site plan); Materials.of construction: Dimensions Depth of solids Comments(note condition. of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc;)- 15ift 3113 Title 5 Official Inspection Form:Subsurface.Sewage Disposal System•Pa ge;l4sof 17 I Commonwealth,Of. Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form, Not for Voluntary Assessments 30 PARKER RD �e Property Address PANTAZOPOULOS Owner Owner's Name _ information is OSTERVILLE MA 3-6-17 required for _ every page- City/Town state Zip Code Date of Inspection D. System Information (cont.) ,Sketch Of Sewage Disposal System; Provide a view of the:sewage disposal system, including ties to at least two,permanent reference landmarks or benchmarks. Locate-all wells within 100 feet. Locate where public water supply enters the building. Check one of"the boxes below: ❑ hand-sketch in the-area below drawing attached separately ,15ins=3113 Title 5 0ffidal Inspe6on Form:Subsurface--Sewage Disposal System-Page 15 of 1.7 TOWN OF BARNSTABLE LOCATION 30. %tek e R R p, SEWAGE Uo L d a VB.d.AGE- - d S f e R t/r LL e" ASSESSOR'S MAP&LOT f !a INSTALLER'S NAME&PHONE NO:; SEPTIC TANK CAPACfi'Y l 00 O IfACH NG FACUIW- ,. O.OF BEDROOMS UILDER OR OWNER 6 t Pl RM DATE: 2 U CaMPL1ANCE DATE SePamon.Distance Between the. Maximum{Adjusted GrotmdwaterTable to the Btittiim of Leaching Facility Feet. :Private Water Supply Well and Leaching Facile OR sft or within 200 feet of leaching facilityty (if any wells.ezisf Feet Edge of Wetland and Leaching Facility{If any weilands'exest within 300 feet of leaching facility} Fegn €r Ftitnished by. i E - - A 'V` ..9 IC .,. htfp( u+Y;iaUrraftaarn5fahte.a�fRssessi7 /Hcvfisptai.a5 ?sriapar=9k3yti7gxgv= [f'19,17 9 27 FITA . .. '3 i 2 of �_.._ TOWN OF BARNSTABLE , LOCATION .J.9 A0/Pk'fie 00 SEWAGE # -VILLAGE G S/ ASSESSOR'S MAP & LOT 1 IIER'S NAME&PHONE NO. /T le SEPTIC TANK CAPACITY J to 7,—, ," �''r')� r C 7-/.A- L^BEACHING FACILITY: (type) (size) . NO. OF BEDROOMS BUII DER OR OWNER ✓G yc -PERmrr DATE: C8#i� CE""DATE. .:Separation Distance Between the: r. -�-.Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water-Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by p�170 O /3R/C!� t�4 TOWN OF BARNSTABLE c LOCATION 20 Z'A lk e R . SEWAGE # �2yo tl— V a 2 LVr,',LAGE r� S re ii I/iY4 e ASSESSOR'S MAP&.LOT 117407 INSTALLER'S NAME&PHONE NO. J 1*f ,44 A C O./yl e-e f s �� I SEPTIC TANK CAPACITY I CJ 0 O .LEACHING FACILITY: (type) '�7 e CR A ff eD (size) zq/ ill NO.OF BEDROOMS ZC -1BumDER OR OWNER Ll PERMrrDATE: T)�a COMPLIANCE DATE: a 0 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 30 �fF/' k R !PZ a ?o,— U a O Fee THE COMMONWEALTH OF MASSACHUSETTS , Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Yes 2pprication for Zigozal bpztemc Construction 'Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System Individual Components Location Address or Lot N Owner's Name,Address and Tel.No. 30 P Assessor's Map/Parcel 7 $00�7 � 117Jo Installer's Name,A dress,an Tel. o. 2nDes' is Name,Address and Tel.No. Type of Building: ael l r1. etc. Dwelling No.of Bedrooms -5 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building Due-1 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow Lk 0 to?D o gallons per day. Calculated daily flow 3�� �,��� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank tCK_",,Q Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ry4 LeA4,11k j rt �i�j 4. 73)r6_jW^L6v1t_mn `max 47 Gslt�e�. 83Q g WIST Sur"— Date last inspected: ,,,ISTALLATI N-f4 0�1 AND CEFTIFY-II ?t'T 'il-IE SYSTEM WAS 1NSTALLE® 'tN,�7INS Agreement: �, 077'r �r,,0t �CETOPLAN. , ..l . , �� 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 Certifi- cate of Compliance has been iss d by this Bo f Heal Signed ---Datei�'L Application Approved by Date Application Disapproved forZe following reasons Permit No, )U o t_1' 0 2] Date Issued a _ _ ' (AOld r"���� s�, f Nu��, 2 3A L / Fee Jv Entered in computer: V s THE COMMONWEALTH OF MASSACHUSETTS rw, PUBLIC HEALTJHTDIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes �Ropricat on for Zigogal bpgtem Congtruction Permit Application for a Permit to Construct( . )Repair( Upgrade( )Abandon( ) ❑Complete System 'Individual Components Location Address or Lot No. /_F O ner's Name,Address and Tel.No. Pv Assessor's Map/Parcel ®� -1O o} �. Ins aller's Name,Address,an Tel.No. / Cy Desi ner's Name,Address and Tel.No. c,,Ll i, rt or �� �s�j � � u,tc�> u4 A%,9�V Type of Building: 14 Vxd!'eS nc .60 Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building T)L4 U& No.of Persons Showers( ) Cafeteria( ) Other Fixtures 1.1 Design Flow Lk O to 7 gallons per day. Calculated daily flow =' � ��'•��� ' gallons. 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) Orv\A t 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 Certifi- cate of Compliance has been issued by this Bo d•,of Heal . le Signedr'rF�i' Date Application Approved by k_�//. f Date I Application Disapproved for a following reasons Permit No. Q U U L-J- U 2'-7 Date Issued '2 0 " 0 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,�that the On-site Sewage Disposal System Constructed( )Repaired ( A Upgraded( ) Abandoned( by .fit • 0y -�.fJUF k" U,A 45�r'i n : at 2,CG $c J— ( d n5FQ_ v i H..?. Mjx has been constructed i accordance with the pr�ov_isions of Title 5 and tl e for Disposal System Construction Permit No. a20o Y 6 )7 dated l a v o z/ Installer MIC.:O U,�4' Designer kj (OC, ..AqA The issuance of this permit shall not be construed as a guarantee that the s stem ih function as designed. Date Lf/0 Inspector ' V i�-/ --------------------------------------- No. U fi LJ o)_ Fee ,5 U THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Digpogar 6pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair O Upgrade( )Abandon( ) System located at %0 ?0,r kPr 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:Con truction must be completed within three years of the date of thi er its Date: t Approved by � ti s 11 TOWN OF BARNSTABLE c LOCATION. © ���k RIP, SEWAGE # a oo Zl— V a 7 VILLAGE r� S f-e K V r"LL E ASSESSOR'S MAP &LOT /I 740 INSTALLER'S NAME&PHONE NO. J A-4 A C O 1K SEPTIC TANK CAPACITY ` d 0 LEACHING FACILITY: (type) /e e CRfl9 �D (size) l !/ �3 ,g NO. OF BEDROOMS -� 3 BUILDER OR OWNER P(A t, PERMITDATE: 2 n COMPLIANCE DATE: a Ll Separation Distance Between the: Maximum Adjusted Groundwater Table to tho Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i i �p a e. I 021 . 1994 22:16 508-790-1578 J.P.MACOMBER & SON PAGE 02 ` Bic 18108 P*49 01662 01-03-2004 a 03 2 16P BARNSTA8LE REGISTRY OF DEEDS DEED RESTRICTION WHEREAS, BARRY P. NEAGLE and MARY LOU NEAGLE Of 1119 Main Street, Cotuit, Barnstable County, Massachusetts 02635, are the Owners of 30 Parker Road, located in Barnstable (Osterville) , Barnstable County, Massachusetts 02655 . WHEREAS, BARRY P. NEAGLE and 'MARY LOU NSAGLE as the owners of said property have agreed wi-h the Town of Barnstable Board of Health to a restriction as to the number of bedrooms which can be included in the home on to obtaining a � pre-condition g s a re c located on said lot a p disposal works construction permit in compliance with 310 CMR 15. 000 State Environmental Code, Title v, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage; WHEREAS, th_ -own of Barnstable Board of Health, a.s a pre-condition tc granting a disncsal works construction permit for a septic system in compliance with 310 CMR 15 . 200, State Environmental Code, Title v, M,nitnum Requirements fer the Subsurface Disposal of Sanitary Sewage, and authorizing the issuance of a building permit for the renovation of a single-family home on this property, is requiring that t-'e agreement for the restriction on the number of bedrooms in the house on the lot be put on record with the Barnstable County Registry of Deeds by recording this document . NOW, THEREFORE, Barry P_ Neagle and Mary Lou Neagle do hereby place the following restriction on their above referenced land _n accordance with their agreement with the Town of Barnstable Board of Health, which restriction shall run with the land and be binding upon all successors in title : 30 Parker Road, Barnstable (Csterville) , MA may have upon the lot a ';souse containing no morF_ than three (3) bedrooms . 02f1 V311994 22: 16 508-790-1578 J.P.MACOMBER & SON PAGE 04 Barry P. Neagle and Mary Lou Neagle acgree that this shall be a permanent deed restriction affec�ing 30 Parker Road, Barnstable (Osterville) , MA. For title of Barry P. Neagle and Mary Lou Neagle see Deed recorded with the Barnstable County Registry of needs in Book 17950, Page 328 . EXECUTED as a sealed instrument this % day of January, 2004 . _ Barry P'. N agl Mary 1 ou Neagle THE COMMONWEALTH OF. Mr7SSACHUSETTS BARNSTABLE, SS . January y , 2004 Then personally appeared be-fore me, the ::nder.signed Notary Public, =ar,y P. Neagle and Mary Lou Neagle proved to me through satisfactory evidence of identification, which was a driver' s license, to be the persons whose names are signed on t e preceding document, and ackhow. ,dged t�- me that they signed it voluntarily for its ed purp Notary n lic My commission expires : C:\MyEiles\Nedgledd.rest�;,CLion.doC Jan 28 04 02:23p Daniel E. Braman PE 508-362-6016 p. 1 • 01/28/2004 13:17 50187758754 WELLER ASSCC PAGE 02 ' Weller& Associates Bayberry Square Suite 4C 1645 Falmouth Rd. — P.O.Box 417 Centerville,MA 02632-0417 Date: January 29,2004 Bamstable Healtb Department 200 Main Street HY&ntus, MA 02601 Re: Nengle,30 Parker Rd.,Dstciwillt—.Assessors Map 117 Parcel 107 Dear Health Dept. Please be advised that we have inspected the soil removal and replacement,along with the installation of the septic system, at the above referenced Property,and find that it was done in substantial compliance with the approved plan. If you have any questions, please do not hesitate to contact us, Very truly-,, ; Daniel Et ant;P: -,C / o A,S-Q ¢ Fax (508)775.054 Phone(508)773.0735 r t Town of Barnstable ` Board of Health 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Susan G.Rask,RS. FAX: 508-790-6304 Sumner Kaufman,MSPH Wayne Miller,M.D. December 30, 2003 Mr. William Weller Weller and Associates P.O. Box 417 Centerville, MA 02632 Dear Mr. Weller, You are granted conditional variances on behalf of your clients, Barry and Mary Lou Neagle, to construct a replacement onsite sewage disposal system at 30 Parker Road, Osterville, Massachusetts. The variances granted are as follows: 310 CMR 15.211(1): The soil absorption system will be located three (3) feet away from the easterly property line, in lieu of the ten (10) feet minimum separation distance required. 310 CMR 15.211(1). The septic tank will be located four (4) feet away from the southerly property line, in lieu of the ten (10) feet minimum separation distance required. 310 CMR 15.211(1): The septic tank will be located six (6) feet away from the northerly property line, in lieu of the ten (10) feet minimum separation distance required. 310 CMR 15.211(1): The soil absorption system will be located four (4) feet away from the slab foundation wall, in lieu of the ten (10) feet minimum separation distance required. 310 CMR 15.211(1): The distribution box will be located three (3) feet away from the northerly property line, in lieu of the ten (10) feet minimum separation distance required. WellerNeagle These variances are granted with the following conditions: (1) No more than three (3) bedrooms maximum are authorized at this property. Dens, study rooms, offices, finished attics, sleeping lofts, and similar-type rooms are considered "bedrooms" according to the MA Department of Environmental Protection. (2) No additions or expansions to the existing footprint of the dwelling are authorized. (3) The applicant shall record a properly worded deed restriction, signed by the owner of the property, at the Barnstable County Registry of Deeds restricting the property to three (3) bedrooms maximum. A copy of the recorded deed restriction shall be submitted to the Health Agent prior to obtaining a disposal works construction permit. (4) Tees shall be installed within the septic tank in conformance with the State Environmental Code Title 5. (5) The designing sanitarian shall install stakes at the four corners of the proposed SAS location prior to installation. (6) The septic system shall be installed in strict accordance with the engineered plans dated October 27, 2003. (7) The designing sanitarian shall supervise the construction of the onsite sewage disposal system and shall certify in writing to the Board of Health that the system was installed in substantial compliance with the revised plans. These variances are granted because the physical constraints at the site severely restrict the location of the soil absorption system due to the small size of the lot of only 4,600 square feet. The proposed system appears to meet the maximum feasible compliance standards contained within Title V. Since r ly yours, W ynen iller, M.D. Chairm WellerNeagle DATE: O � FEE: + HABN61'ABLB, � NA88. 1679. tee$ REC. BY Town of Barnstable CHED. DATE: Board of Health `200 Main Street,Hyannis MA 02601 Office: 508-8624644 Susan G.Rask,R.S. FAX: 508-790-6304 Sumner Kaufman,M.S.P.H. Wayne A.Miller,M.D. VARIANCE REQUEST FORM LOCATION Property Address: .3 0 Assessor's Map and Parcel Number: ��� /y� Size'of Lot: $/6-o O 5� Wetlands Within 300 Ft. Yes Business Name: No �- Subdivision Name: APPLICANT'S NAME:AA2Z11/ �C'AG cc- Phone Sob �/Za — 31,51Z Did the owner of the property autlforize you to represent him or her? Yes / No PROPERTY OWNER'S NAME CONTACT PERSON CO Name:��.P„fT/ r/fA?y t!o J E,q� � Name: t c.'1E'e-<GP'L �P� Address:///�iyi, 1i cJ/, W o263S Address:,�00 D d-,? �/� � �o 26. Phone: .5—c>8 1zo— 3/�Z Phone: .5�0 7 7 S —c:>23s VARIANCE FROM REGULATION(list 1teg.) REASON FOR VARIANCE(May attach if more space needed) /A/U70,94-- C>.•� o�cS �� �'���ti��� ��Z a •�-��-r rT�v y NATURE OF WORK: House Addition ❑ House Renovation ❑ Repair of Failed Septic System hecklist(to be completed by office staff-person receiving variance request application) _ Four(4)copies of the completed variance request form _ Four(4)copies of engineered plan submitted(e.g.septic system plans) _ Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans) _ Signed letter stating that the property owner authorized you to represent him/her for this request _ Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense (for Title V and/or local sewage regulation variances only) _ Full menu submitted(for grease trap variance requests only) _ Variance request application fee collected (no fee for lifeguard modification renewals, grease trap v xiance__renewaals [same owner/leasee only],outside dining variance renewals[same owner/leasee only];;and�variances to repair failed sewage disposal systems [only if no expansion to the building proposed]) _ Variance request submitted at least 15 days prior to meeting date VARIANCE APPROVED Susan 0.Rask,R.S.,Chairman NOT APPROVED Sumner Kaufman,M.S.P.H. REASON FOR DISAPPROVAL Wayne A Miller,M.D. Q:\HEALTH\Application Forms\VARIREQ.DOC , �.f 30 Parker Rd., Osterville Variances required from 310 CMR 15.211 SAS setback to property line, 10' required, 3' requested SAS setback to property line, 10' required, 4' requested SAS setback to property line, 10' required, 6' requested SAS setback to slab (crawl space), 10' required, 4' requested Distribution Box setback to property line, 10' required, 3' requested LOdATION SEWAGE PERMIT NO. 30 Parker Road 84-808 VILLAGE Osterville, MA 026.55 'A & B CESSPOOL SERVICE 128 BISHOPS TERRACE, HYANNIS, MA 02601 '-BUILDER OR OWNER John Chasson 30 Parker Road Osterville, MA 02655 "DATE PERMIT ISSUED DATE'COMPLIANCE ISSUED 9/25/ t� .o 1 1 i �it a t r J � 1 t � 1 �4 r � ERECEIVEr' COMMONWEALTH OF MASSACHUSET z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS + d DEPARTMENT OF ENVIRONMENTAL PROTECTION F OqM SVO 350 MAIN STREET MAP A WEST YARMOUTH,MA 508-775-2800 PARCEL, LOT TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION MAP 117 PAR 107 Property Address: 30 PARKER ROAD OSTERVILLE,MA 02655 Owner's Name: CHASSON,JOYCE Owner's Address: 30 PARKER ROAD OSTERVILLE,MA 02655 Date of Inspection AUGUST 15,2003 Name of Inspector:(please print) JAMES D. SEARS Company Name: A&B Canco Mailing Address: 350 Main Street West Yannouth,MA 02673 Telephone Number: 508-775-2800 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the infonnation reported below is true,accurate and complete as of the time of the inspection. The inspection was perfonned 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 Needs Further Evaluation by the Local Approving Authority ✓ Fails Inspector's Signature: Date: The system inspector shall su mit 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 tot he 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 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 30 PARKER ROAD OSTERVILLE,MA 02665 Owner: CHASSON,JOYCE Date of Inspection: AUGUST 15,2003 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: N/A _ I have not found any infonnation which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CM 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A 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 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 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: Title 5 Inspection Form 6/15/2000 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: 30 PARKER ROAD OSTERVILLE,MA 02655 Owner: CHASSON,JOYCE Date of Inspection: AUGUST 15,2003 C. Further Evaluation is Required by the Board of Health: N/A Conditions exist which require further evaluation by the Board of Health in order to detenmine 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 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 I of 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: I Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 30 PARKER ROAD OSTERVILLE,MA 02655 Owner: CHASSON,JOYCE Date of Inspection: AUGUST 15,2003 D. System Failure Criteria applicable to all systems: ./ You must indicate"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool N/A Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in pit has been less than 6"below invert or available volume is less than '/z 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 N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone I of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A 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 or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) YES (Yes/No)The system fails. 1 have detennined that one or more of the above failure criteria exist as described in 310 CM 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: N/A To be considered a large system the system must service 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 I I 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 is 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. Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 30 PARKER ROAD OSTERVILLE,MA 02655 Owner: CHASSON,JOYCE Date of Inspection: AUGUST 15,2003 Check if the following have been done. You must indicate"yes"or"no"as to each of the following Yes No ✓ Pumping infonnation 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 nonnal 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 infonnation on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)has been deterrnined based on: Yes No ✓ Existing infonnation. For example,a plan at the Board of Health. Detennined 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)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 30 PARKER ROAD OSTERVILLE,MA 02655 Owner: CHASSON,JOYCE Date of Inspection: AUGUST 15,2003 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x#of bedrooms: 220 Number of current residents: I 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): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): N/A Sump pump(yes or no) NO Last date of occupancy: PRESENT COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CM 15.203): Basis of design flow(seats/persons/sqft,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 infonnation: N/A 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,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 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 Title 5 Inspection Form 6/15/2000 6 i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 30 PARKER ROAD OSTERVILLE,MA 02655 Owner: CHASSON,JOYCE Date of Inspection: AUGUST 15,2003 BUILDING SEWER(locate on site plan): ✓ Depth below grade: 8" Materials of construction: J 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 onsite plan): ✓ Depth below grade: 12' Material of construction: ✓ concrete metal fiberglass polyethylene _ other(explain) If tank is metal list age: Is age continued by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1,000 GALLON PRE CAST Sludge depth: 4" Distance from top of sludge to the bottom of outlet tee or baffle: 26" Scum thickness: I" Distance from top of scum to top of outlet tee or baffle: 12" Distance from bottom of scum to bottom of outlet tee or baffle: 17" How were dimensions detennined: ASBUILT AND TAPE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): MAIN TANK AT WORKING LEVEL.TWO INLET TEES,OUTLET BAFFLE.TANK AND COVERS 12' BELOW GRADE.NO SIGN OF LEAKAGE. GREASE TRAP(located on site plan) N/A Depth below grade: Material of construction: concrete metal fiberglass _ polyethylene other (explain): Dimensions: Scorn 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.): Title 5 Inspection Form 6/15/2000 7 I Page 8 of l i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 30 PARKER ROAD OSTERVILLE,MA 02655 Owner: CHASSON,JOYCE Date of Inspection: AUGUST 15,2003 TIGHT or HOLDING TANK: N/A (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 alann and float switches,etc.): DISTRIBUTION BOX: N/A (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: N/A (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.): Title 5 Inspection Form 6/15/2000 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 30 PARKER ROAD OSTERVILLE,MA 02655 Owner: CHASSON,JOYCE Date of Inspection: AUGUST 15,2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ./ leaching pits,number: 1 leaching chambers,number: leaching galleries,number leaching trenches,number,length leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) LEACHING IS ONE 1,000 GALLON PRE CAST PIT. PIT IS 26"BELOW GRADE WITH COVER AT 6". LEVEL IN PIT IS 12"FROM INLET. SHOWS SIGNS OF BEING FULL TO COVER.NOT LEACHING,NEEDS TO BE REPLACED. CESSPOOLS: N/A (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: N/A (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.) Title 5 Inspection Form 6/15/2000 9 Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 30 PARKER ROAD OSTERVILLE,MA 02655 e. Owner: CHASSON,JOYCE Date of Inspection: AUGUST 15.2003 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. w E N r P�r� «k" 34r O O I Title 5 Inspection Form 6/15/2000 10 Page I I of I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) , Property Address: 30 PARKER ROAD OSTERVILLE,MA 02655 Owner: CHASSON,JOYCE Date of Inspection: AUGUST 15,2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to no groundwater 12 feet Please indicate(check)all methods used to detennine the highground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observation 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: TEST HOLE 12' NO WATER. BOTTOM OF PIT 8' BELOW GRADE,4' ABOVE TEST HOLE. _jj/ G Y `V Title 5 Inspection Form 6/15/2000 I I r � I DRAWN BY t ` o • �,.t.tt.y r�'� ro o ' l m w m w Sr=P I x 4 tj ARCA D4,111-16 cA�ta O 1 3 - — �.oPE i WW2GZaF?E I O �� fI Ca3) � RAF I ays 1 I I cogs. I r� I y � a rc� P Gtoscr �{ C - Sao i 012, (IJtN( Cctn,.t is CD ( i1 I t = N 40 t I I rG 9 I a ca cry 1 p R SECOND FLOOR PLAN { ` FIRST FLOOR PLAN FRO LE NOT TO SCALE TD T I I O—E (..._OCR I LAYER OF g/S"PEASTOW EL= +%, FIRST PIPE LENGTH OVER 9/4"-I VZ"DOLADLE ' TOP FOI,WATION OVERS TSF D nlIN E. TO m FOR MI� LEVEt_ WASHED STONE DATE: c7C7; /OO TEST�)Y:/V. [� r�Ar s>, , FINISH eRADE WITNESS: .5; 57' / 3t:;"o PERG RATE: S�vi.✓�ir✓Gy/ wig w �.. pyG TOP 0 EL. 3Z, ti w Stitt AO rt4+•• �P G• A $A� Go �3,5� 32.e� ..•r• ._ "TOM ® EL3o.o bA5 PAr" DIST. DOS( T �/ ��v C• �. }t 3z.z� , 3z./o ,/ �(1 (� •`. SEPARATION a > �`Rs^ GALLON Z� TANK TONE bA5E S < Iit-�'��.�"1/�Cv J,�' C'7 St3iL +C��C/z C'.� ,�-i•c.T�, s' s�45L' , �.4c�" r,�i;` CIA,•/ -��9ND, Z,sy� 1204 zG.Gti PD5 ION dATA PA I LY PLOW: (3)15EDROOMS x 119&PD 33o Opp SEPT 6 TANK:3 30 C-PD x200%=GG o OPP USE:oo GALLON PRECAST SEPTL TANK LEAGHINO FAGILIfY: I, J$ Gi.G/�►.o GcJ/?/r/ /�b..G �7"�NE �'/OE"-� 4h�GY'' GAPA(ITY: + SIDEWALL:-/cx>✓G X c'. x &%2 I 130TTOM: . OEN RAL NOT S TOTAL: I. GONTRAGTOR TO M RESPONSI13LE FOR THE L06ATON OF ALL UTLITIES, c� I Af5OVE AND UNDERC-7ROUND,PROR TO ANY EXGAVATON OR GONSTRUGTON, 2. 6EPT6 SYSTEM TO PEE INSTALLED IN COMPLIANCE WTH 310 GMR 15D0:TOLE V I� .few' .; '•-c. �.L.'+ �..� � ,.."'� �;.., *�"�--,.,,aj'�. 3 THY:�7 Alr! v- �,!^rT%^r^fir`I k^r _-{_ I.. -��.� 4 ALL P6TURMP AREAS TO ME LOAMED AND SEEDED 5. GONTRA(TOR TO PROVIDE U HOUR NOTLE FOR ANY REQUIRED IN6PE67ONS/ 0 3- / l t \ �. / �-. �,,- r � l '� G ..�'�5+.`� .5'�TB�c,,� ra ..s"-rgr3, �o•.+ar�;o� y�j2����s;-�,r,. bll/ Y �3EVVAOE FLAN f 3`� AA LOCATION: 3O PARKER RP., 05TERVILLE, MA PREPARED FOR: JOYOE OI IA550N DRAWN I5Y: ® n t Zt1 OF I,{ A STEVEry .x `} `'qc JOB NUVIER: DATE: SHEET: IEL � o DAN F• c7 357 P CIVII. ss�a� 0. 32 �C n —)I8 IO-27—ZOOS �P—I o r ,� E P� - T WELLER & A5506/ I AT FS0NAI �'Z`'- � 'h P — SUITE 40 GENTERVILLE, MA 6WO3Z TEL.: (505) 775-0735 N FAX: (505) 775-0754 PROFESSIONAL ENGINEERS & LAND SURVEYORS