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HomeMy WebLinkAbout0117 PARKER ROAD - Health 18 PEAKS DRIVE, OSTERVILLE A= 116 029 III a a i 4 � Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 PEAKS DR Property Address Fred Curran Owner Owner's Name information is required for OSTERVILLE MA 1-25-2021 every page. City/Town _ State Zip Code Date of Inspection .4 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out ;51*" 15 l e i forms on the T computer, use 1. Inspector. only the tab key a to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. D.A.BROWN INC Company Name r� P.O. BOX 145 Company Address CENTERVILLE MA 02632 /e"0f 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 - 1-25-2021 i ature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will,perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 ti Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments - �M 18 PEAKS DR Property Address Fred Curran Owner Owner's Name information is required for OSTERVILLE MA 1-25-2021 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: AT TIME OF INSPECTION SYSTEM MET ALL MINIMUM PASSING REQUIREMENTS. THIS. REPORT CAN NOT PREDICT THE FUTURE PERFORMANCE UNDER THE SAME OR INCREASED USAGE.THIS REPORT IS NOT TO BE USED FOR BEDROOM COUNT DETERMINATION AS WE ARE GOING OFF OF WHAT INFO IS AVAILABLE TO US AT TIME OF . INSPECTION. SYSTEM WAS INSTALLED IN 1996 AND AT THIS TIME IS 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 J Commonwealth of Massachusetts 4 u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 PEAKS DR Property Address Fred Curran Owner Owner's Name information is required for OSTERVILLE MA 1-25-2021 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 I 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts . W Title 5 Official Inspection Fo M Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 18 PEAKS DR Property Address Fred Curran Owner Owner's Name information is required for OSTERVILLE MA 1-25-2021 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 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 'h day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °,M s 18 PEAKS DR Property Address Fred Curran Owner Owner's Name information is OSTERVILLE M required for A 1-25-2021 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 PEAKS DR Property Address Fred Curran Owner Owner's Name information is required for OSTERVILLE MA 1-25-2021 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? ® El` 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): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 1,10 gpd x#of bedrooms): ' 550 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 PEAKS DR Property Address Fred Curran Owner Owner's Name information is required for OSTERVILLE MA 1-25-2021, every page. City/Town State Zip Code Date of Inspection D. System Information Description: ACCORDING TO AS-BUILT SYSTEM CONSISTS OF A 1000 GALLON SEPTIC TAND D-BOX AND A 5 BEDROOM S.A.S 46X10 f Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: SYSTEM NOT DESIGNED FOR USE WITH GARBAGE DISPOSAL. 2018--177 GPD 2019--209GPD Sump pump? ❑ Yes ❑ No Last date of occupancy: PARTIALLY SEASONAL Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes '❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ ' No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 18 PEAKS DR Property Address Fred Curran Owner Owner's Name information is required for OSTERVILLE MA 1-25-2021 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 PEAKS DR Property Address Fred Curran Owner Owner's Name information is required for OSTERVILLE MA 1-25-2021 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: UNKNOWN i Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet. Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1.25 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 18 PEAKS DR Property Address Fred Curran Owner Owner's Name information is required for OSTERVILLE MA J 1-25-2021 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TANK HAS NOT BEEN PUMPED IN THE LAST 3 YRS AND IS IN NEED OF PUMPING. I RECOMMEND PUMPING NOW AND AT LEAST EVERY 2-3 YRS THERE AFTER FOR MAINTNANCE 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 18 PEAKS DR Property Address Fred Curran Owner Owner's Name information is required for OSTERVILLE MA 1-25-2021 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 18 PEAKS DR Property Address Fred Curran Owner Owner's Name information is required for OSTERVILLE MA 1-25-2021 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): BOX WAS REPLACED IN 2017 PERMIT#2017-308 DUE TO CORROSION IN OLD D-BOX. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 PEAKS DR Property Address Fred Curran Owner Owner's Name information is required for OSTERVILLE MA 1-25-2021 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 5 flowdiffusers ❑ 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.): There were no clear signs of failure or back up at time of inspection. This report can not predict the future performance under the same,or increased usage exact age of system is unknown but appears to be pre 1995. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments- 18 PEAKS DR Property Address Fred Curran Owner Owner's Name information is required for OSTERVILLE MA 1-25-2021 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 PEAKS DR Property Address Fred Curran Owner Owner's Name information is required for OSTERVILLE MA 1-25-2021 _ 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 18 PEAKS DR Property Address Fred Curran Owner Owner's Name information is required for OSTERVILLE MA 1-25-2021 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: greater tha 4 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach'documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Attached as-built card from Ready Rooter septic inspection dated 7-18-2011. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 PEAKS DR Property Address Fred Curran Owner Owner's Name ` information is required for OSTERVILLE MA 1-25-2021 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, Ci 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 t56s•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTABLE LOCATION j� P�,e.�s �r:V� SEWAGE# VILLAGE ASSESSOR'S MAP&PARCEL 1Q�5�'rSt��iAME&PHONE NO•`c\�u Be.-rt`�+tiC. 8"3Y�6 f"4� , SEPTIC TANK CAPAcny (OC7C] �l5 LEACHING FACILITY:(type) rev.e NO.OF BEDROOMS S HC r X%O t X.3 r OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximan 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 Of any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY SL ,I r , I � I �. o a= 4r i ? O A � 3. 3, 8'` I i 3 g {t r https://town.bamstable.ma.us/Departments/Assessing/Property- Values/HMdisplay.asp?map... 2/2/2021 Assessing As-Built Cards Page 2 of 2 https://town.bamstable.ma.us/Departments/Assessing/Property_Values/HMdisplay.asp?map... 2/2/2021 t Commonwealth of Massachusetts 9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �a 18 PEAKS DR g ° Property Address IDD MARK CURLEY Owner Owner's Name information is required for OSTERVILLE MA 9-14-17 � every page. City/Town State Zip Code Date of Inspection ° r J� Inspection results must be submitted on this form. Inspection forms may not be altered in anyi way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information / forms on the computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not use the return Name of Inspector key. D.A.BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 City/Town State Zip Code 508-4204534 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 9-14-17 %fe-cpfs 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 ' Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M �< 18 PEAKS DR Property Address MARK CURLEY Owner Owner's Name information is required for OSTERVILLE MA 9-14-17 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: ® 1 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: AT TIME OF INSPECTION SYSTEM MET ALL PASSING REQUIREMENTS. D-BOX WAS REPLACED WITH A NEW H-10 DB3. THIS REPORT DOES NOT PREDICT THE FUTURE PERFORMANCE UNDER THE SAME OR INCREASED USAGE. 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 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 18 PEAKS DR Property Address MARK CURLEY Owner Owner's Name information is required for OSTERVILLE MA 9-14-17 every page. CitylTown 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 r ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 18 PEAKS DR Property Address MARK CURLEY Owner Owner's Name information is required for OSTERVILLE MA 9-14-17 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 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 '/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 18 PEAKS DR Property Address MARK CURLEY Owner Owner's Name information is OSTERVILLE MA 9-14-17 required for 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 or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 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 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 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 18 PEAKS DR Property Address MARK CURLEY Owner Owner's Name information is required for OSTERVILLE MA 9-14-17 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® 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): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments GM 18 PEAKS DR _ Property Address MARK CURLEY Owner Owner's Name information is required for OSTERVILLE MA 9-14-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: ACCORDING TO AS-BUILT SYSTEM CONSISTS OF A 1000 GALLON SEPTIC TAND D-BOX AND A 5 BEDROOM S.A.S 46X10 . Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: SYSTEM NOT DESIGNED FOR USE WITH GARBAGE DISPOSAL. 2015--2.7 2016--19.1 GPD. PROPERTY HAS HAD VERY LITTLE WATER USAGE OVER THE PAST 2 YRS. Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: ' Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 PEAKS DR Property Address MARK CURLEY Owner Owner's Name information is required for OSTERVILLE MA 9-14-17 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 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 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 PEAKS DR Property Address MARK CURLEY Owner Owner's Name information is required for OSTERVILLE MA 9-14-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1996 PER AS-BUILT 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.): E , Septic Tank(locate on site plan): Depth below grade: 1.25 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Sludge depth: VARYING LIGHT TO 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 w 18 PEAKS DR Property Address MARK CURLEY Owner Owner's Name information is required for OSTERVILLE MA 9-14-17 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness LIGHT AND CLUMPING 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? WOODEN 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.): IF TANK HAS NOT BEEN PUMPED IN THE LAST 3 YRS I RECOMMEND PUMPING NOW AND AT LEAST EVERY 2-3 YRS THERE AFTER FOR MAINTNANCE. 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 Forth:Subsurface Sewage Disposal System-Page 10 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 18 PEAKS DR Property Address MARK CURLEY Owner Owner's Name information is required for OSTERVILLE MA 9-14-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: p Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ' Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments CGM , 18 PEAKS DR Property Address MARK CURLEY Owner Owners Name information is required for OSTERVILLE MA' 9-14-17 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): BOX WAS REPLACED PERMIT#20127-308 DUE TO CORROSION IN OLD D-BOX. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 18 PEAKS DR Property Address MARK CURLEY Owner Owner's Name information is required for OSTERVILLE MA 9-14-17 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 5 flowdiffusers ❑ 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.): System has seen very low water usage over the past few yrs. There nwere no clear signs of failure of back up at time of inspection. This report can not predict the future performance under the same or increased usage. 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 18 PEAKS DR Property Address MARK CURLEY Owner Owner's Name information is required-for OSTERVILLE MA 9-14-17 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): T 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 Commonwealth of Massachusetts - Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 18 PEAKS DR Property Address MARK CURLEY Owner Owner's Name information is required for OSTERVILLE MA 9-14-17 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 f t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 18 PEAKS DR Property Address MARK CURLEY Owner Owner's Name information is required for OSTERVILLE MA 9-14-17 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: greater tha 4 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: attached as-built card from Ready Rooter septic inspection dated 7-18-2011. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 L 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 18 PEAKS DR Property Address MARK CURLEY Owner Owner's Name information is required for OSTERVILLE MA 9-14-17 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 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Assessing As-Built Cards Page 1 of 2 7 TOWN OF BARNSTABLE LOCATION S �.►.�.$ �r:vG. SEWAGE# VEU AGE ASSESSOR'S MAP&PARCEL l 16 I�4�R'6 NAME&PHONE SEPTIC TANKCAPACrrY (p©p �oe1S LEACH NG FACILrrY:(type) r\e,,;) NO,OF BEDROOMS _ L46 r X��r X s ' OWNER t ,�9t••r• ��1. - T c] __ PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: L Maximtm�AdjusW GrotmdwWw Table to AwBonow ofL&whWgFacimy y 7 Feet i 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�r_ A� ,i 1 aww ta....Gb r i o ? 0 A3� � g :; 36 ?> I http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=116129&seq=2 9/21/2017 i n No. Fee THE COMMONWEALTH OF YASSACHUSETTSEntered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 21pplication for Disposal *pstrm Construrtiun j3Prmit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or L No. �$ �e�k S r Owner's Name Address,and Tel.No. Assessor'sMap/Parcel j2 COd V1� Wk C 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 Boa alth. Signed Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. IL Date Issued �` 1—t � . : Y.R '�",Y;-1-Y- "w,.ti., m. ,r' , ='r' "1 "' •'T n-. r,^ns';--t..?-�'''^r',�r ,K.f r -E+. ""v7+" '�'.. No Fee 1 . THE.COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN-OF`SARNSTABLE, MASSACHUSETTS 01pplicatlon for Mistlosat 6pstem Construction Permit Application for a Permit to Construct( ) Repair.(tUpgrade( ) Abandon( ) ❑Complete System ❑Individual Components t_. Location Address or Lot No. I 0S r Owner's Name,Address,and Tel.No. 05vr(V t ) Assessor's Map/Parcel j (� � )Z pJ k"/ At(A e 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( ) l Other Fixtures Design Flow(min.required) gpd Design flow providediv/, 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) ; i 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 a Compliance has been issued by this Board-o'f-Health. • Signed Date / Q L / Application Approved by Date TomLool Application Disapproved by Date for the following reasons PemiitNo. Date Issued , 5 THE COMMONWEALTH OF MASSACHUSETTSr 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 acco dance with the provisions of Title 5 and the for Disposal System Construction Permit No L 1� 30�dated Installer Designer }#bedrooms Approved design flow gpd The issuance of this(p�ermit shall not be construed as a guarantee that the system it tip- �Jiigjd..e Date "( Inspector \ ---------- No. )1 30 �5 D ' yAe THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction permit Permission is hereby granted to Construct( ) Repair( l Upgrade( ) Abandon( ) System located at fir, C 11)P C f 11 R�� J 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. �' r Date Approved b �` 1 �_ PP Y THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA T �xu���"�* �� /�` ���u��lir�*twwo� xw��»�/��iioo� Works Towitrurt�wn Ppxuni4 Application is herebp5tnade for a Bermit.to Construct or Repair an Individual Sewage Disposal C. . Dwelling ............ ku ........... .. . ............... .. ........ . . . --t- - - - Bedrooms---- .. ----Expansion Attic ` ' Garbage . ~ ~- _'_-_ ` (]tbcc--Type of Building 44�� o6 persons-.---._-._.. Showers ( ) -- Cafeteria ( ) Septic Tzok4l_uyud 000-goUoox Length Diameter--�t0j�--- Depth------ Disposo Trench—No. --_.-_- Width-------------------- Total -------------------- Total area....................sq. ft. Seepage Pit Nu_.-.--_- Diaoetcr--.---- Depth below -.. --/�I' Total -----..sq. ft.Other D���ut�obox ( ) Dosing tank ( ) -- ^��L ~»�« - /,0- IS --7 4 - '- Percolation Test Results Performed by.......................................................................... Date_---.--------- Ies Pit No. l_--_..minutes per inch Depth of Test Pit.................... Deptbto -couuJ water-. ------- �14 Test Pit No 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water---_---' Oon ' ---''—'—'- .............. ' -uu_- ^���� ` --.--'''-'-------_''''-_---�_.----___--------_--------____--.-------__-- U Nature of Repairs or Alterations—Answer when ------------------------------------------------------------------------ ------------------- ----------------------------------- ________________________________'_____'______________'__- Agceemeot: The undersigned agrees to install the uforodeooribcd Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary C/ije—The ridersigned further agrees ot to place the system inD&he boaDo� hea Date Date � Application Disapproved for the following reasons:................................................................................................................ � ...................................................... .......................................................... ----_---_'___----._-----'_---- PermitNo......................................................... ....................... ................................ Date Vill THE COMMONWEALTH OF MASSACHUSETTS t `. BOARD OF HEALTH ...........OF............ �....................... Appliration -fur Uiipuiittt Works Towitrurtiutt Vrrnift Application is hereby�Me r affermit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at,. / A 4/ o ly l ? Locatio •Addresor Loo. - W f f Owned Y�I. ......C �ddre ' fInst ter Address Q Type of Building Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms------------ --------------------------Expansion Attic ( ) Garbage Grinder ( �(/ Other—Type of Building / of persons____________________________ Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------------------------------------------------ W Design Flow----_-__�Q......................gallons per person per day. Total daily flow... Q---0.................----gallons. WSeptic '1'c.nk-/Liquid capacity/(L00_gallons Length Width.. U_.. Diameter_--.��..(J.a--- 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 ( ) — D �C - /O- IS -7 . aPercolation Test Results Performed by.......................................................................... Date..................................... a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water....---..----.-------. (4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water--.--..--__------------. 9 ------------------ -------- O �r---�---- Description of Soil------ •------- r� 1 �� ` - a ;i r W --------------------------------- ------------G...... -- -=---�---- ---- � .-c/= - �....... . ..�.? - �l/ . x --------------- --------------- -------------------------------------------------------- -------------------------------------------------------------------------------------------------- U Nature of Repairs o'r Alterations—Answer when applicable------------------------------------------------------------------------------------------------ ----------------------------------------------------- -•-------.--------.----------------------•----------------_---.•-.-------------.----•------..-.--.-•-------------.------------------------------- Agreement: it The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary C e—The ndersigned further agrees of to place.the system in operation until a Certificate of Compliance has b ssued by e boar hea01 I -•------!��---------�---�� �--- Date Application Approved B — !/G1L! l!l._ <. Date Application Disapproved for the following reasons:.--------------------------------------------------------------------------------------------------------------- .........................------•------.-----•----------------•-•---------•---•-----•-•-•------------•---------------------•-------•-•-•-•---------------••--•------------------------•-----------.----- Date PermitNo......................................................... Issued-------------------------------........................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....................... . .....�...OF............. . . ..G( . ( ��'�� - .. t (Irrtifiratr of fWIToutptitturr T S I TO CERTIFY hat the Individual Sewage Dissa ys e constructed ( or Repaired ( ) by . ............. - -- ------ . . ' In t 1 r n at ... .. has been installed in ac ordance with the provisions of Arti e 'I of The State Sanitary Code as described in the application for Disposal Works Construction Permit No..-.7......_. ------------ dated-.-... �... ._ ................. /� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................ 0, �.-----•......•. Inspector--.� ------------•-•---•---•-•---•--•--- THE COMMONWEALTH OF MASSACHUSETTS / BOARD O ALTH i` �/G• v- /2 -c�M... ..... OF.............1.�-HE c ...... ..........•---.. ..-� N ... FEE-4Q.............. Di-tiotitt ork duo rttrtiuttrro � Permission is hereby granted------------ ---------- --- = ----------- --------•- --.......... Constr or R.ep itIndiv'du e e D' posal S stem at No.-: .. . = �1/ �/��a as shown on the application for Disposal Works Construction P StitreetNo_____ ______ ____ Dated__.��_--L�_. - .............. -V .................... Boar of DATE.-—........�/ --__ ------------- --------------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS d TOWN OF BARNSTABLE LOCATION (� �s�s �r:v�. SEWAGE# VILLAGE ASSESSOR'S MAP&PARCEL 1 NAME&PHONE NO'.:�'N-C,p,,cS�at SEPTIC TANK CAPACITY LEACHING FACILITY.(type) (size) 5 .C­y"3` !9'N_cV,� NO.OF BEDROOMS L4C r X`®, X r OWNER C k'► 2,^a ft PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) / Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY��•A '�l � .3— try ��.� i r y i � o � � !� Commonwealth of Massachusetts Title 5 Official Inspection Form = Al .i: Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 18 Peaks Drive 4M . • Property Address . a Elizabeth Cameron Owner Owner's Name information is Osterville MA 02655 July 18, 2011 required for u y ' every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. I nspection,forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Patrick T. Sullivan cursor-do not Name of Inspector use the return key. Ready Rooter, Inc. Company Name P.O. Box 371 Company Address Sandwich .MA 02563 . City/Town State Zip Code 508-888-6055 SI 12843 Telephone Number License Number f 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 r`✓�uC � °�V July 25, 2011 Inspector's Signature a 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. VV t5ins•09106 Title 5 Official Inspection Form:Subsurface Sewage Dis osal System•Page of 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 18 Peaks Drive Property Address Elizabeth Cameron Owner Owner's Name information is required for Osterville MA 02655 July 18 2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: f F 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 infilt,ration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is re aced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspecti if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank i ess than 20 years old is available. ❑ Y ❑ N ❑ N (Explain below): t5ins,-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Peaks Drive Property Address Elizabeth Cameron Owner Owner's Name information is required for Osterville MA 02655 July 18, 2011 every page., City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or breakout 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 Boar/d [:] ❑ broken pipe(s)are replaced ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or rep ❑ N ❑ ND (Explain below): ❑ The system required pumpin more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection ' (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 B rd of Health: ❑ Conditions exist which require further ev uation by the Board of Health in order to determine if the system is failing to protect public he th, safety or the environment. 1. System will pass unless Board Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not nctioning in a mannerwhich will protect public health, safety and the environment: ❑ Cesspool or privy is withi 50 feet of a surface water ❑ Cesspool or privy is wit in 50 feet of a bordering vegetated wetland or a salt marsh t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ti 18 Peaks Drive Property Address Elizabeth Cameron Owner Owner's Name information is Y Osterville MA 02655 Jul 18 2011 required for , every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and/an n system (SAS) and the SAS is within 100 feet of a surface water supply a surface water supply. ❑ The system has a septic tank and SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS aness than 100 feet but 50 feet or more from a private water supply well's*. Method used to determine distance: *"This system passes if the well water an ysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the prese a 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 clogged SAS or cesspool 0 ® Discharge or ponding of effluent to the surface of the,ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 4 Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 18 Peaks Drive Property Address Elizabeth Cameron . Owner Owner's Name information is Osterville MA 02655 Jul 18 2011 " required for y + every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ,❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion,of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. El ® 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- 1 0,000g pd. ❑ ® The system fails. l 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" s°or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is wit in 400 feet of a surface drinking water supply ❑ ❑ the system is ithin 260 feet of a tributary to a surface drinking water supply ❑ ❑ ~the system ' located in a nitrogen sensitive area (Interim Wellhead Protection Area, IW A) 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 Sectio above the large system has failed. The owner or operator of any large system considered a signifi ant threat under Section E or failed under Section D shall upgrade the system in accordance wit 310 CMR 15.304. The system owner should,contact the appropriate raginnal office of the De artment, t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5 I Commonwealth of Massachusetts Title 5 Official Inspection Form 'r• Subsurface Sewage Disposal System Form -Not for Voluntary;Assessments 18 Peaks Drive Property Address Elizabeth Cameron Owner Owner's Name information is required for Osterville MA 02655 July 18, 2011 every page. City/Town State Zip Code Date of Inspection. C. Checklist Check if the following have been done. You must indicate "yes"or"no:' as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? . . ® ❑ Has the system received normal flows in the previous two week period? ❑ ® 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. ® 0 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): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 650 GPD t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 6 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Peaks Drive Property Address Elizabeth Cameron Owner Owner's Name information is required for osterville MA " 02655' July 18 '2011. every page. City/Town ; State Zip Code Date of Inspection D. System-Information Description: ` *Permit for install states"3 Bedrooms". System design wasfor 650 GPD which can accommodate_ up to 5 bedrooms. Number of current residents: r 3 Does residence have a garbage grinder? ®. Yes ❑ No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No A. Laundry system inspected? _ *' ❑ Yes ❑ No. Seasonal use? ® Yes ❑ No 2009= 82 GPD Water meter readings, if available.(last 2 years usage (gpd)): 2010= 57 GPD Detail: , Recommend removal of garbage disposal, system not designed to handle. Sump pump?, ❑ Yes ® r'No Last date of occupancy: Current Date Commercial/industrial Flow Conditions: Type of Establishment: " Design flow(based on 310 C/ry A Gallons per day(gpd) Basis of design flow(seats/peGrease trap present? ❑ Yes ❑ NoIndustrial waste holding tank ❑ Yes ❑ No Non-sanitary waste dischargem? ❑ Yes ❑ No Watermeter readings, if avai t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 18 Peaks Drive Property Address Elizabeth Cameron Owner Owner's Name infre quired forts Osterville . MA 02655 July 18, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy%use: Date Other(describe below): General Information Pumping Records: • Source of information: No records found Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons $ How was quantity pumped determined? a 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): I t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Peaks Drive Property Address Elizabeth Cameron Owner Owner's Name infeouired for ration ls Osterville MA 02655 July 18, 2011 every page. City/Town State Zip Code Date of Inspection ryP 9 D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: System installed 05/13/1988. Certificate of Compliance-on file at Board of Health. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2'4" Depth below grade: feet Material of construction: ❑ cast iron . ❑ 40 PVC ABS ®other(explain): Distance from private water supply well or suction line: N/A feet" Comments (on condition of joints, venting, evidence of leakage, etc:): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5'X 4.5'X 4.5' 1000 gallons Sludge depth: 3" t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 I Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage'Disposal System Form -Not for Voluntary Assessments M 18 Peaks Drive Property Address Elizabeth Cameron Owner Owner's Name information is required for Osterville MA 02655 July 18, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 35" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Tape measure and dip tube. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet concrete baffles in place. Liquid level at outlet invert. Recommend mainenance pumping next year(2012) and every 2-3 years there after. Risers bring covers within 6" of grade. 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/toboftomri t tee or baffle Distance from bottom of sc of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 18 Peaks Drive Property Address Elizabeth Cameron Owner Owner's Name information is required for Osterville MA 02655 July 18, 2011 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 grader Material of construction: ❑ concrete El 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 pumpin : Date Comments (condition of'alarm and float switches, etc.): "Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Peaks^Drive Property Address Elizabeth Cameron Owner Owner's Name information is Osterville MA 02655 Jul 18 2011 required for Y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert oil 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.): One inlet,two outlets. Equal flow. No solids carryover. No sign of high water staining over outlet inverts, No sign of leakage. Riser brings cover within 6" of grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition /umppmber, condition of pumps and•appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 x P Commonwealth of Massachusetts .4 Title 5 Official Inspection Form; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y< 18 Peaks Drive ' Property Address Elizabeth Cameron - Owner Owner's Name f, i information is Osterville MA 02655 Jul 18 2011 required for Y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.). Type: ❑ leaching pits number: ® leaching chambers number: 5-flow diffusers w/3 of stone. ❑ 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.): Flowdiffusers are 8'X 4' end to end w/T of stone around and 1' below. Camera used to inspect - diffusors. No sign of past hydraulic failure. Cesspools (cesspool must.be pumped as part of inspection) (Iodate 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Peaks Drive Property Address n Elizabeth Cameron Owner Owner's Name information is required for Osterville MA 02655 July 18, 2011 • every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition/signsdraulic failure, level of ponding, condition of vegetation, etc.): t5ins-09/08 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 18 Peaks Drive Property Address Elizabeth Cameron Owner Owner's Name information is Osterville MA , 02655 July 18'2011 required for _� ' every page. Cityfrown State Zip Code Date of Inspection ' D. System Information (cunt.) Sketch Of Sewage Disposal System: Provide aview of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks.'Locate all wells within.10.0 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below E drawing attached separately Alf L( `PL . ; -10 f • - � It 3.. o. y � I t- J Wins•Ogg Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 18 Peaks Drive Property Address Elizabeth Cameron Owner Owner's Name information is required for Ostery Y ille MA 02655 Jul 18 2011 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: >4 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: May 4, 1988 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: ma.water.usgs.gov terraserver-usa.com You must describe how you established the high ground water elevation: Letter from engineer states ground water is 4' below base of SAS. (Letter from Baxter& Nye dated May 4, 1988). Accessed local ground water contours and topo mapping. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 16 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Peaks Drive Property Address Elizabeth Cameron Owner Owner's.Name information is required for Osterville MA 62655 July 18 2011 ' every page. City/Town State Zip Code - Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 e A n Commonweaith of Massachusetts f_" )LUM Executive Office of Environmental Affairs Department of Environmental Protection WUliam t3a..ma F.Weld Trudy.Coxe sa+wry. Argeo Paul Celluxl v David B.Struhs li Gowmor cortunbslorwr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 4.% PART A ; CERTIFICATION SO, '99 PropertyAddross: 18 Peaks Drive Osterville,Mass . Address of Owner. Date of Inspection: 3/12/9 6 (If different) Name of Inspector-Joseph P. Macomber Jr. ° Company Name,Address and Telephone Number. J.P.Macomber & Son Inc. Box 66 Centerville,Mass . 02632 508-775'-3338 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: f�Pasaes� ' _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signaure: Date: The System Inspector skXR submit a copy of this inspection report to the Approving Authority within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY. Check A,B, C,or D: A] SYSTEM PASSES: _ZI have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CUR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: ,tJP� One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal,cracked,structurally unsound, shows substantial infiltration or exMtration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One Winter Street 0 Boston,Mas►achusetts 02108 Is FAX(617)556-1049 • Telephone(617)292-SW SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 18 Peaks Drive Osterville,Mass . 026,55 Owner. Edward F. & Sarah Andresen Date of Inspection: 3/1 2/9 6 B]SYSTEM CONDITIONALLY PASSES(continued) • Sewage backup or breakout or hr static water level observed in the distribution boat is due to broken or obstructed pipe(s) or due to a broken,settlad or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Afy Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic,tank and soil absorption system and is within a Zone I of a public water supply well. .LD The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is fee from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) PropertyAddres.: 18 Peaks Drive Osterville,Mass . 02655 Owner. Edward F. & Sarah Andresen Date of Inspection: 3/1 2/9 6 s D) SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. )"+ 6('z'd } Liquid depth in cesspool is less than 6"below invert or,available volume is less than 1/2 day flow. AD Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). . Number of times pumped a_ AD Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: ,NO The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 H of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for Anther information.. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST I Property Address: 18 Peaks Drive Osterville,Mass . 02655 owner. Edward F. & Sabah Andresen Date of Inspeotion: 3/12/96 ' Check if the following have been done: Pumping information was requested of the owner, occupant,and Board of Health. LNone of the system components have been pumped foi at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A ZThs facility or dwelling was inspected for signs of sewage back-up. 2The system does not receive non-saaitary or industrial waste flow ZThe site was inspected for signs of breakout. ZAll system components,eluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge,depth of scum. -Z The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. , The facility owner(and occupants, if different firom owner)were provided with information on the proper maintenance of Sub. Surface Disposal System. (revised 11/03/9 ) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PropertyAddreaw 18 Peaks Drive Osterville,Mass . 02655 Owner. Edward F. & Sarah Andresen , Date of Inspection:3/12/9 6 FLOW CONDITIONS RESIDENTIAI: + Design flow Alone per��Y • Number of bedrooms: Number of current residents:,Q_ Garbage grinder(yea or no):AX Laundry connected to system(yes or no):29 Seasonal use(yes or no): Water meter readings,if available: - ��� L ? n CL-A&A Last date of occupancy: lei COMMERCIAL/INDUSTRIAL. Type of establishment: L A Design flow:_-gallons/day Grease trap present: (yes or no)_A�6 Industrial Waste Holding Tank present: (yes or no)-" Non-sanitary waste discharged to the Title 5 system: (yes or no)AL Water meter readings, if available: ti019 w Last date of occupanry:- OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECO#DS and source of inform`s�ion: gad , �l�[ s fA-1 System pumped as part of inspection: (yes or no) 6S If yes,volume pumped: CSC) ons J - / . , Reason for pumping• 4e� Ll.t'>CC�rt> � Ilt1y' y[�1�i 4- je")S TYPE 9F SYSTEM Septic tank/distribution box/soil absorption system /LjZ'. Single spool 4 Overflow cesspool d'4 Privy _AP Shared system(yea or no) (if y.e�as++ attach�revious ins )ction records^if any) ! Other(explain) APPROXIMATE AGE of all components, date installed(if known) and source of information: Sewage odors detected when arriving at the site: (yes or no)_ (revised 11/03/95) 6 I, TOWN OF BARNSTABLE 1 LOCATION `�' �k« � - �.7, SEWAGE VILLAGE` L �1 (iL'�« —' ASSESSOR'S MAP & LOT� �� INSTALLER'S NAME & PHONE NO Cap ,4 %J _lL To 3 SEPTIC TANK CAPACITY .LEACHING FACILITY:(type)��-y�-L& —(size) NO. OF. BEDROOMS ,-,, OR PUBLIC WATER BUILDER OR OWNER �!1, �'� C,t4n- M1 r DAT$:PERMIT ISSUED: DA,TE.; COZIPLIANCE ISSUED• , 1 R VARIANCE GRANTED: iwV No .......... ___.._y.... . (T►' w • +Zi b b SUBSURFACE SEWAGE DISPn4AL SYSTEM INSPECTION FORM C SYSTEM INFO it,'ti"T10N (oontinued) PropertyA.ddress: 18 Peaks Drive Osterville,Mass . 02655 Owner. Edward F. & Sarah Andresen Date of Inspectlon: 3/1 2/9 6 SEPTIC TANK,L-11X0044,�'j- 7 r��. • (locate on site plan) Depth below grade: r _ Material of construction:ZODUCrete_metal_FRP other(ei p,;:;r) Dimensions: Sludge depth ) Distance from top of sludge to bottom of outlet tee or baffle:_ Scum thiclmess: _ Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baIIle:-D _ Comments: (recommendation for pumping,condition of inlet and outlet tees or b0n1es, depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.)- PUMp tank every 2— a ' and are structurally sou ;No ; ._o. h e septic tan is structurally sound. No repairs are needed at—the present time. GREASE TRAP-_ 4e-, (locate on site plan) Depth below grade: Material of construction:4/±concrete_metal_FRP_other(expLsin) Dimensions: Scum thic]<neSa: IVR Distance from top of scum to top of outlet tee or baffle:.A�L Distance from bottom of scum to bottom of outlet tee or baffle:" Comments: (recommendation for pumping, condition of inlet and outlet tees or bafn",depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) No comments . (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . j PART C SYSTEM INFOItXATION (oontlaued) i • Property Address: 18 Peaks Drive Osterville,Mass 02655 Owner. Edward F. & Sarah Andresen Date of Inspection:3/12 9 6 TIGHT OR HOLDING TANK:tidA1�i e �I (locate on site plan) • I Depth below grade:A,� Material of construction. --.metal �> �other(�Pl�:n) ' f � /U I' Dimensions: AM . Capacity: A?/4 gallons Design flow:. ona/day ; Alarm level:�/ Comments: (conditio of inlet tee,condition of alarm and float twitches,etc.) tttiJ,1 1 /L ' DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert:_ Comments: (sofa if level and distribution is equal,evidence of solids Carryover, of leakage into or out of box,etc.) yj trli,•t; �„ t,av f� ,,., No evid� carry ea a e}'inec�r o-It of PUMP CHAMBER) , (locate on site plan) i Pumps in working ordar:(yes or no).& Comments: y (note condition of pump chamber,condition of pumps and appu!: "n ^r, etc.) i - - , �(,Z4t,�+}it t Frtre•.i vv3:�- 7 (revised 11/03/95) ICY I SUBSURFACE SEWAar MSP09AL SYSTEM INSPECTION FORM SYST-• . '. -': .. (oontlnuod) F,,ope1.ty Adder Edward F. & Sarah Andresen Owners 18 Peaks Drive Osterville ,Mass . 02.6.k5 Date of Inspections 3/1 2/9-6 SOIL ABSORPTION SYSTEM (locate oa rite plan,if possrol ;excavation not requ*but may be arnroximatod by non-intrusive methods) If not determined to be present,explain: Type: leaching pits,numbsrQ i1`YJ leaching chambers,number- T �/�jlt Cli�FG!Si"5 gelleriet,numbar.Q - leachh, trenches,number,length: leaching fields,number,dimensions: [1 — overflow cesspool, aumber.-CL Comments:(note condition of soil,signs of hydraulic failure, 1 dition of ve tation,atc.) Hard pan 2+ 6" then fine sand. No signs of hydraulic fai ure or pon ing: All vPgPtation is normal. No repa.irs._-a.re needed at this time. CUSPO0IS: (locate on sits plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer. Depth of scum layer: VA Dimensions of cesspool: Wi Materials of construction: Indication of groundwater. AA- inflow (cesspool must be pumped as part of inspvct:,:: !_ Comments: condition of soil,signs of hydraulic faili-P, '..nv-1 - condition of.vegvtation,etc.) — --------- j PRIVYs i (locate on site plan) . Materials of construction: i1/A Dimensions Depth of solids: _ - - -----.�_ Comments: (note condition of roil,signs of hydraulic failu. n of vegetation,etc.) /Z4 i (revised 11/03/95) s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontinued) PropertyAddresa: 18 Peaks Drive Osterville ,Mass . 02655 Owner. Edward F. & Sarah Andresen Date of Inspection: 3/12/9 6 SKETCH OF SEWAGE DISPOSAL SYSTEM: • include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' Centerville Osterville Marstons Mills Water Company 428-6691 � V�` � - " DEPTH TO GROUNDWATER Depth to groundwater.9' + feet i method of determination or approximation; Hand aug e y e d test hole 6' below flow d i f f u s s o r s V 4T'a+a-r encountered -ffussors at 1 i n T grave 'They are In - Ferrcable satis. Past the hard pan (revised 11/03/95) 9 ll r 'I'ONN OF Barnstable BOARD OF HEALTH S011SURFACF SFNACE DISPOSAL SYSTEM INSI'FMON FORM - PART D - CERTIFICATION ...._...-T......_-.::-...--:.r..--:•r.:--:—r.—:r..—'—__..._:.--........ ..---rrrr_,.....--rr--.•—r_.=—rr_rm...--rr�rsta:nrsrrrr.-rrsr-rrrrrr•rr.•.—rrr•r.�..... -TYPE: OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 18 panirs I)riue nsterville,Mass Q2655 ASSESSORS MAP , BLOCK AND PARCEL •# 116-029 OWNER' s NAME Edward F 'Rr Sara l!_ndr-esen _ — PART D - CERTIFICATION 1 NAME OF INSPECTOR Joseph P. Macomber Jr_ . COMPANY NAMEJ.P.Macomber & Son INc. COMPANY ADDRESS Box 66 Ce"n:terville ,Masss. 02632 Street Town or City State LIP COMPANY TELEPHONE ( ) FAX ( ) - Rs 508 = 7� 508, 290L 1 578 ro CERTIFICATION STATEMENT I certify that I have personally -inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the ti.rne of :inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : XXxxx Systeui PASSED The inspection which I. have conducted has not found any information which indicates that the system fails to adequately protect public health or Lhe. environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I have conducted has found that the system fails to Protect the public health, and the environment in accordance with 'Title 5 , 3.10 CMR 15 . 303 , . and as specifically noted on PART C - FAILURE CRITERIA of this inspection form , •r 1 Inspector Signature r Date _ 3/12/96 One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF IIEALTII. * If the inspection FAILED, the owner or operatorshall upgrade • the eyetem within one year of the date of the inspection , .unlelss allowed or required otherwise as provided in 310 CMR 15 , 305 . C W . j'V 3r THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has. satisfied the..Department"s. qualifications as required and-is he authorized, to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. . Issued by The Department of Environmental Protection. June 8. 1995 ' Acting Director of the ' ion of Water Pollution Control 18 Peaks I_.ane Osterville, NIA AuC11lion Boalcrs oml Gardeners: This n1nq lc ('u/re. with pecks of the lien•is lttsi .slcps /rota drep !miler dockage(.1rld has • chin'ntin!;ltcrcrtrtia/erne/ a t'(1S7)he'rt.v 1)aleh). HCIFIdsurne lh'md- r4 cra/Icd clrlclil 1110Ms;houl. faxes: $2,358 Acrcage: .26 Assessment: $181,000 Price: $299,000 Summary: Total Rooms ,- :`5 Bedrooms. 2 Baths First Floor windo\vs, Berber carpeting, two closets with (lower level), built-in Shelves, paneled wall, wainscotting. BEDROOM #1: (8'f x I I FOLIr Third Floor windows, built-in desk and drawers, closet with built-in shelves, Berber carpeting. LIVING ROOM: (14't x 24't) Pegged pine floor, chimney and hearth wood stove, BEDROOM #2: (12'6"J-- x 13'1 irreg.) wainscotting, picture window, cathedral Three win(IowS, fllll ICngtll Wall oh built-in Ceiling, full length custom built-in cabinetry, desk and drawers, Berber carpeting, closet built-in wet bar with mirrored wall and with built-in shelves. recessed lighting. C#n FAMILY ROOM: (14'3"± x 21's) Tile DINING ROOM: (I I 'i x 1 1'f) Oak and carpet floors, full length built-in floor, vaulted ceiling, chair rail, two cabinet/Mitch, Window seat, closet, one wall oversized windows, Drench door to deck. paneled, one window and Drench door out to brick patio, recessed lights. I�fTCIIEN: ( I I'=1- x 12'j:) Pegged wide pine loor and vinyl, wooden cabinets, GE Second Floor dishwasher, gas stove and oven, Whirlpool (entry level) built-in rnicrowave, laminated counter tops, the back splash over sink, breakfast bar, f OYEH: (3'6"J- x 12'±) Tile and wood tracl< lights. (door, \wainscotting, paneled walls, two closets. Fourth Floor BATH #l: (4'.-J- x 5'f) Vinyl floor, tiled BEDROOM 05 (Master): (10'± x 15':1-) walls, fiberglass ' tub/shower with tile Carpeted, three windows, slanted ceiling, surround, ceiling trine. skylight, two closets with built-in shelves. BEDR001N1 #3: (9't x 12'i) Pegged wide pine floor, two Windows, closet with built-Ill BATI1 112: (8'6"t x 10'±) Tile floor, full shelves. Ieingth vanity with oversized sink, laminated BEDROOM. #4: (I2'i x 12'4"=-) Three counter top with wood trim, window and ® Directions: Main Street.to Wcst Bay Road. Icft on Bridge Succl, right onto Cockachoisci (private entrance). Icfl onto Peak's Lane. horlse al end.Coffon REAL ESTATE rt> 851 Main Sheet, (lsterville, MA 02655 Phone(508) 428-9115 Fax(jQ8) ./20-3161 .S'c�hool Sireel, Colrril, 3,111 02635 Phone(:508) -/28-9503 Fax(.508)j-128-0758 t >> t t t t NlA f full EXTERIOR. 10 x 23 deck 10 x 23 brick BATH #2: (8 6 t x 10 ) Tile floor, , length vanity with oversized sink, laminated patio, lattice and arbor, window boxes, fenced counter top with wood trim, window and yard, storage shed, shingle siding, asphalt skylight, heat lamp, linen closet, tiled walls, roof, stonewall, perennial and vegetable fiberglass tub/shower Nvitli tiled walls and gardens, raspberry patch. ceiling. - AGE: 1976t LAUNDRY ROO1\'1: Washer and dryer SQUARE FOOTAGE: 2,016t* (*according to Town of Barnstable Assessor's records) hook-ups. TAX MAP: 116 PARCEL: 029 ATTIC: Access from Fourth Floor, All information contained herein is obtained from the owner • and is assumed to be correct. All measurements are Unfinished. approximate and along with the information contained herein, it is believed to be accurate but is not warranted. All brokers/salespersons represent the seller,not the buyer in BASEMENT/GTILITIES: Part full, solar the marketing, negotiation and sale of property, unless otherwise disclosed. However,the broker/salesperson has an and oil hot \\ater, oil and electric heat, town ethical and legal obligation to show honesty amid fairness to water, Title V septic. Monitored underground the buyer in all transactions. o i 1 tank. t ; � s N u _ \\ O i Z, vo. o I N a Pr o nr 9 prQ L ti rQ o-r, c n q Q aC „ TOWN OF BARNSTABLE L`,'3CATiON d� �� �i 1G`P� SEWAGE # "I NALLAGE 0 rr/Z' 1,9 ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type} 6^ (size) 4eg NO.OF BEDROOMS a� BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: 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 1 aching facility) Feet Furnished by ( � "i L � r � TOWN OF BARNSTABLE 'x z. LOC-,ATION l �� rte= SEWAGE # C� VILLAGE ,� � �-`-dL�'�°���� ASSESSOR'S MAP & LOT � INSTALLER'S.NAME & PHONE NO ,L � �� r�SEPTIC TANK CAPACITY It LEACHING FACILITY:(type)i NO. OF BEDROOMS F44VAMEAMLL OR PUBLIC WATER r BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: 5- VARIANCE GRANTED: No I g I � � r '�(��i/ 9. . z, TOWN OF BARNSTABLE v � �� . --UNDERGROUND FUEL WAND CHEMICAL" STOR_ AGE 'SYSTEMS t A 3ESSORS MAP NO. I `A PARCEL NO._ V �J -?DRESS. (v VILLAGE. e�✓tJ NAME;_. l .a . 1..__.F .. I"�Vor 1'f CONTACT PERSON yL PHONE NUMBER ' LOCATION OF TANKS: CAPACITY: TYPE OF FUEL. AGE: TYPE: LEAK OR.CHEMICAL: DETECTION - - ., SYSTEM! I le DATE OF PURCHASE OF..EACH: 1. 3. 4. 5. DATE OF° FIRE DEPARTMENT PERMIT: �� 7 TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS PLEASE PROVIDE A SKETCH SHOWING THE LOCATION OF TANKS ON THE BACK OF THIS CARD. i . , L�-Q ���.. b �i 5.• ` CENTERVILLE - OSTERVILLE FIRE DEPARTMENT PERMIT FOR STORAGE OF FUEL OIL In accordance with provisions of Chapter 148, G. L., and Regulations w made under authority thereof. Name .. ................ ........................ Name Ne.l...s..o...n....Co.a...l.)..........O..i...l...t (owner or occupant) (In sta.11er ....C...o• Address ..Cackacho.isset.. Zn.... Address .Hyannis......... .... Burner Storage Make Carlin Water Heater Steel .......................................... Type of Tank ........................................ Manufacturer .. parlin...C.o................ Capacity .275..... gals. (or) Size............ Model No. or Size .....1.00..CRD Location .Undez ,rou2ld Type....C?un............ Mass, Approval No. Permit issued ....3. !I ?. .................... ..J.ohn.. M. Farrington, Chief (Head 4 P' %Depa-tment B (THIS PERMIT MUST BE CONSPICUOUSLY POSTED ON THE PREMISES) n ' I � t r 4 k 7 f � f , 71-------------------------------- � Job 1 ti C. kiley . .1r. I N 450- 55-00 YV � � ® � ► 9305• - - r o I zQ x 20 T 7 CA J000 r " S.C,�'�i M aQ �v f rat mk 1 d 0) CO ' 3z f iN , -- 2® o� g' 7 4 ,� 1 /627 %,fiELSON At S�� •1 BJ$@IRSE � � Craoi S .0 suaV��t y Ali f fhot the foun(joll;� ' Sl�ouun�,i s �a,��►'�e� •�r�� P �a r,, OF b,a NO IN 05 T F.PY i LLF- -&Aeivs 7A#4t MASS DooGLAS Kk MARILYN HIGHAM J`t frc.,•�r r 6 s��c �fe;t�NA L• c , ,v .Y�: