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HomeMy WebLinkAbout0023 PICASSO PLACE - Health 23 �+ aso.- . r Osterville FIR Moll 145 080 Hazardous Materials Inventory Sheet Checklist Date hysical Street Address-Check database to ensure it-exists �-� Working Phone Number ram- . Actual Amounts -( ie. gas being used to fuel machines,thinner to clean brushes all count as hazardous materials) //k Storage Information - location of storage, how long is storage for? If none, note that. Disposal Information -where and who? If none, note that. Applicant Signature - understand what is listed and noted Staff Initial -any questions, know who to ask Vehicle Washing/Rinsing? - provide a vehicle washing policy and am it - note that it was given Attach the Business Certificate with your sign off and comments **The inventory form should explain what the business consists of and the procedures they are doing. Notes need to be left to explain what you discussed with them. YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A'business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. - DATE:/ :5 Fill in please: c y ` APPLICANT'S YOUR NAME S: BUSINESS YOUR HOME ADDRESS: Sa v� e TELEPHONE # Home Telephone Number 7711 /l NAME OF CORPORATION: - NAME OF-NEW BUSINESS P TYPE OF BUSINESS G�� IS THIS A HOME OCCUPATION? Y NO ADDRESS OF BUSINESS.13 5, 4521 MAP/PARCEL NUMBER /4/S d (Assessing) When starting a new business there are several things you must do in order to be in with the rules and regulations of the Town of ' Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. — (corner of Yarmouth ' Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. - .1. BUILDING COMMISSIONER' -OFFICE ' MUST COMPLY WITH HOME OCCUPATION This individual has bee for of er it requirements that pertain to this type of business. RULES AND REGULATIONS, FAILURE TO "COMPLY MAY REMLT INS FIDE€: uth e Signature* S COMMENTS: a add, 2. BOARD OF HEALTH This individual �en or ed of the er�nit r ments that pertain to this type of business. Aud ignature** MU t OOMP,#.Y Wl'rH"Ali COMMENTS: RIM ,; ZP.: ,lU TER DNc 3. CONSUMER AFFAIRS [LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain,to this type of business. _rAuthorized Signature** COMMENTS: Date: TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF"BUSINESS: BUSINESS LOCATION: v,/ INVENTQIRY MAILING ADDRESS: lvle ltlle ,I 6 TOTAL AIMOUNT- TELEPHONE NUMBER: CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: Z711' W MSDS OWSITE? TYPE OF BUSINESS: INFORMATION / RECOMMENDATI S: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED a Cesspool clean q Automatic transmission fluid islnfectants Z n Engine and radiator flushes Road salts(Ha Hydraulic fluid (including brake fluid) (? Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Q Gasoline, Jet fuel,Aviation gas p Photochemicals (Fixers) Q Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Q Photochemicals (Developer) Q lubricants, gear oil ❑ NEW ❑ USED - o Degreasers for engines and metal t1 Printing ink (� Degreasers f e qRs�&garages (7 Wood preservatives (creosote) Caulk/Grou Ccux) Swimming pool chlorine 0 Battery acid (electro a /Batteries o Lye or caustic soda n Rustproofers o- Miscellaneous Combustible 0 Car wash detergents Leather dyes Car waxes and polishes 0 Fertilizers Q Asphalt& roofing tar PCB's r/�Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, air �& SEEh removers, deglossers hydrochloric acid, other acids) ous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &st ' m vers (including bleac /� /_ S'� ► o/ r�� Spot removers ea t/ (dry Cie (Other cleaning Bug and tar removers 2 Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary'Assessments - , 23 Picasso Place Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Osterville MA- 02655 6-10-11 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form., A. General Information 1. Inspector: I Shawn Mcelroy Name of Inspector Upper Cape Septic Service Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 Citylrown State Zip Code 1-508-495-0905 S13971 Telephone Number license.Number B. Certification 3 p I certify that I have personally inspected the sewage disposal system at this,addressl and that the CD information reported below is true, accurate and complete as of the time of the inspection. The4nspe0on_ was performed based on my training and experience in the proper function and Maintenance Won si sewage disposal systems. I am a DEP approved system inspector pursuant to S O ction 15-3,40 W, Title 5(310 CMR 15.000).The system: - -y ® Passes ❑ Conditionally Passes ❑ Fails ern ❑ Needs Further Evaluation by the Local Approving Authority 6-10-11, spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 L Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 23 Picasso Place Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Osterville MA 02655 6-10-11 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: System is in good working order with no sign of failure. 13) System Conditionally Passes: ❑ One or more system components as described in the Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by Y-othwBoard of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts :, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments k °M 23 Picasso Place Property Address b . Bank Owned (Contact David Holt @ Today RealEstate,1-800-966-2448)•, Owner Owner's Name information is required for every Osterville MA 02655 6-10-11 page. City/Town State Zip Code Date of Inspection B. Certification (cost:) 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 0 Y ❑ N ' ❑ ND (Explain below): r ❑ 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�.R' N 1D3-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 We environment: ❑ Cesspool or privy is within 50 feet of a surface water El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 9 P y rY °7M 23 Picasso Place Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Osterville MA 02655 6-10-11 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1.of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 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 '/day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts t. ; Title 5 Official Inspection .Form 1 Subsurface Sewage Disposal System Form -Not for,Voluntary.Assessments 23 Picasso Place Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Osterville MA 02655 6-10-11 page. Cityfrown 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. El - 1 11 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'desc(bed 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 atributary 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 shalt upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsur ace 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 r� • ^M 23 Picasso Place Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Osterville MA 02655 6-10-11 . 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 thefollowing: 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 (f 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): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 330 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Picasso Place r Property Address Bank Owned (Contact David Holt @ Today Real Estate.1-800-966-2448) Owner Owner's Name information is required for every Osteryille MA 02655 6-10-11 page. City/Town State Zip Code Date of Inspection D. System Information �r Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? [f yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes 0 No Seasonal use? - ❑ Yes ® No .Water meter.readings, if available.(last 2 years usage (gpd)): Detail: Sump pump?, ❑ Yes ® No Last date of occupancy: 5-2011 Date t-Commercial/Industrial Flow Conditions °. Type of Establishment: Design flow(based on 316 CMR 15.203): :} f Gallons per day(9Pd) Basis of design flow(seats/persons/sq.ft., etc.): Grease.trap present?. , r r ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Picasso Place Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Osterville MA 02655 6-10-11 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: N/A 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 P � P Y ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (f yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a co of the current operation and 9Y PY P maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑. Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Picasso Place Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Osterville MA 02655 6-10-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (f known) and source of information: 2004 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24' feet, Material of construction: ❑ cast iron E 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints,venting,evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: - 8 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 gal Sludge depth: 12" t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 'I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 23 Picasso Place T Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Osterville MA 02655 6-10-11 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 20 Scum thickness 1 0 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape 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 is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ; 23 Picasso Place Property Address Bank Owned (Contact David Holt(0 Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Osterville MA 02655 6-10-1.1 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.): F 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 f„ Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract (required)_ Is copy attached? ❑ Yes ❑ No t5ins•11/10 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 23 Picasso Place Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Osterville MA 02655 6-10-11 aage. 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.): Good condition with water at working level and no sign of back-up from chambers. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts . . W Title 5 Official Inspection Form9 _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments' ; . 23 Picasso Place Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Osterville MA 02655 6-10-11 page. Cityrrown State Zip Code Date of Inspection D. System Information(cont.) Type: y ❑ leaching pits number: ® leaching chambers number: 2-500's ❑ 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.): Leach chambers in good condition and empty at inspection with stain line at 4"off bottom of chamber. 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-11110 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 23 Picasso Place 'M Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Osterville MA 02655 6-10-11 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.): f 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -, 23 Picasso Place Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Osterville MA 02655 6-10-11 . 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 , o � 10 .L3 A syr` r .6 t - 61S1- /4- =0 -60 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 23 Picasso Place Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Osterville MA 02655 6-10-11 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: 20 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: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I , Commonwealth of Massachusetts a Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 23 Picasso Place Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Osterville MA 02655 6-10-11 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 ^" TOWN OF BARNSTABLE P'AInON 03 P-cet s5 o rle l e SEWAGE #- GE O fefu;��e. ASSES SOWS MAP&LOT 'I INSTALI-E 'S NAME&PHONE NO. CSEPTIC TANK CAPACrrY Z(M LEACHING FACILITY: (type} Cja.,L —(size) 5 00 �S NO.OF BEDROOMS t BiT DER OR OWNER PERMff 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 knehing facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet o eaehing facility) 4 Feet ' Furnished by aGih �E/�v y e � 1 1 U, U1 qj o � TI Ti1 N CIZ 0 TOWN OF BARNSTABLE .� ��`�/�✓4'.d�/'e'.LOCATION SEWAGE # pp iiYILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. �'� ©70 SEPTIC TANK CAPACITYX��T� � LEACHING FACILITY: (type . (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: �"�f ®� 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 ® "� co V No. v'Zy�4 .30- Y Fee CJ� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: kLi � Yes PUBLIC-HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0[pprication for Diopozal *pgtem Congtruction 3permft Application for a Permit to Construct( )Repair( -)Upgrade(.*)Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ;2 3 ��/c,(, ""� ��.�G� Owner's Name,Address and Tel.No. Assessor's Map/Parcel �� _6> Installer's Name,Address,and Tel.No. — Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 3-3 o gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 19;5e;XZ " /a o,p Type of S.A.S. 6 u r', Description of Soil Nature of Repairs or Alterations(Answer when applicable) DateAlast inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date Application Disapproved for th following reasons Permit No. 100g &Z Date Issued ��� U No. d` �1 ' .3�a pr" Fee� J THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: V _ Yes - PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS A Ztpprication for Die;pozal bpztem Construction Permit Application for a Permit to Construct( )Repair( ^)Upgrade(40)'Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. .��/C�(.'{�'0 ��.�CF' Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. a• Designer's Name,Address and Tel.No. yy Type of Building: y �+ Dwelling No.of Bedrooms 3 Lot Size sq.ft. ' Garbage Grinder( ) Other Type of Building `s No.wof Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ¢©'y gallons per day. Calculated daily flow 3 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank AW;X2n! � /o o 0 24-e Type of S.A.S. 2 G 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 Certifi- cate of Compliance has been issue by this Board of Health. Signed Date 7 �l�y Application Approved by 2.� Date Application Disapproved for 4 following reasons Permit No. a 0�q",�6-� Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACH`6-SETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( )Repaired ( )Upgraded Abandoned( )by -e at 4`»G.�,rr'v /� '�� a,J'T has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 2 60 y-3t dated 'G L� Installer -Designer d/O fo�1. /�✓: The issuance of is permit shall not be construed as a guarantee that the sy 11Li nction as sig d. Date d o Inspector 1/ ---------------------------------------- No. a co 3 6) Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS ltzpo$ar *pgtem Construction Permit Permission is hereby granted to Construct( )Repair( )Upgrade( ✓Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes 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 t e 10 r ef Date:_. 1 t1 Approved by Town of Barnstable Regulatory Services Thomas F.Geiler,Director snFwsTnBLe, 3 Public Health Division . i6 �' .0 ArED Thomas McKean,Director 200 Main.Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer &Designer Certification Form Date: 4J V6 i Designer: 1 Installer• (� Address: . Address: On was issued a permit to install a (date) (installer) septic system at 3 �►L''���- G� based a design drawn by (address) Vto L dated (designer) t. �Tlginertify that the septic system referenced above was installed substantially according to ,the design, which may include minor approved-changes such as lateral relocation of the 'distribution box and/or septic tank. _ I certify that the septic system referenced above was installed with major changes (i.e. greater than 10 lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State&Local Regulations. Plan revision or certified as-built by designer to follow. (Installer's Signature) (Designer's Signature} (Affix Des' gner_zsStamp Here) PLEASE RETURN TO. BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/SepricMesigner Certification Form l TOWN OF BARNSTABLE LOCATION �' SEWAGE # _ o VILLAGE ASSESSOR'S MAP & LOT �o INSTALLER'S NAME 8;PHONE NO. j SEPTIC TANK CAPACITYx�'�T/� '��® `�1• J LEACHING FACILITY: (type (size) NO.OF BEDROOMS ZIV ` BUILDER OR OWNER PERMITDATE: ®f/ 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 leAt:hing facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I /'4 ,C A / /1 AG9 ® k41' 86 �'� r COMMONWEALTH OF.MASSACHUSETTS f R1gSTA8 tE EXECUTIVE OFFICE OF ENVIRONMENTAI2�'.dXQkIR-S DEPARTMENT OF ENVIRONM L PROTECTIONS Z v N i ,O•' SRO VO ® .. .. � - ! ��� ASSESSORS MAP N0: PARCEL NO• O ` TITLE 5 — OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A p' CERTIFICATION Property Address: 23 PICASSO PLACE OSTERVILLE,MA 02655 M145 P080 Owner's Name: RHODA BOHRER Owner's Address: 1301 TADSWORTH TERRACE HEATHROW FLORIDA 32746 AM Date of Inspection: 6/10/04Lj LOPY Name of Inspector: (please print) JOHN GRACI,INC. Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: _ Passes _ Conditionally sses _ Needs Furth r aluation by the Local Approving Authority X Fails Inspector's Signature: Date: 6/10/04. The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspec ' n. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner s all submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments_ SYSTEM FAILED TITLE V INSPECTION. SOIL AROUND LEACH PIT WAS PONDING,INDICATING LEACH PIT IS IN HYDRAUCLIC FAILURE AT TIME OF INSPECTION. ****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. Titla 5 Incnantinn Fnrm 6/1 5/?nnn 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 23 PICASSO PLACE OSTERVILLE,MA 02655 M145 P080 Owner, RHODA BOHRER Date of Inspection: 6/10/04 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: SYSTEM FAILED TITLE V INSPECTION.SOIL AROUND LEACH PIT WAS PONDING,INDICATING LEACH PIT IS IN HYDRAUCLIC FAILURE AT TIME OF INSPECTION. B. System Conditionally Passes: ; _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)tis structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will'pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed. pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a r n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a r 5 Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 23 PICASSO PLACE OSTERVILLE,MA 02655 M145 1`080. Owner: RHODA BOHRER Date of Inspection: 6/10/04 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is.within 100,feet of a.surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the.SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance n/a "This system passes if the well water analysis,performed at a DEP certified-laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a Page 5 of 11 , OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 23 PICASSO PLACE OSTERVILLE,MA 02655 M145 P080 Owner: RHODA BOHRER ` Date of Inspection: 6/10/04 Check if the following have been done.You must indicate "yes" or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health _ X Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period X Have large volumes of water been introduced to the system recently or as part of this inspection,? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS,located on site? X _ Were the septic tank manholes uncovered,opened,and the 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? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location.of the Soil Absorption System(SAS).on the site has been determined based on: Yes no X _ Existing information.For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] Page 6ofII OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 23 PICASSO PLACE OSTERVILLE,MA 02655 M145 P080 Owner: RHODA BOHRER Date of Inspection: 6/10/04 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 d x#of bedrooms 330 gP ) Number of current residents:3 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): iV& 3 — MOOD pump(yes or no): NO V/ � Last date of occupancy: n/a a DO COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sqft,etc.): n/a Grease trap present(yes or no):NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no):NO . Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information:NOT IN THE LAST YEAR PER OWNER Was system pumped as part of the inspection(yes or no):NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system , _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy.of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1984 PER OWNER Were sewage odors detected when arriving at the site(yes or no): NO, 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 23 PICASSO PLACE OSTERVILLE,MA 02655 M145 P080 Owner: RHODA BOHRER Date of Inspection: 6/10/04 . BUILDING SEWER(locate on site plan) Depth below grade:22" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 16" Material of construction: Xconcrete_metal_fiberglass._polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: L 8' 6" H 5' 7" W 4' 1011" Sludge depth:3" Distance from top of sludge to bottom of outlet tee or baffle:31" Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle: 0" Distance from bottom of scum to bottom of outlet tee or baffle: 0" How were dimensions determined: MEASURED Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND-THE.LIQUID LEVEL IS OVER TEE IN TANK--RECOMMEND PUMPING NOW AND EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP: _(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 23 PICASSO PLACE OSTERVILLE,MA 02655 M145 P080 Owner: RHODA BOHRER Date of Inspection: 6/10/04 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass._polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level:N/A Alarm in working order(yes or no):NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: OVER PIPES 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.): DID NOT EXPOSE D-BOX; LIQUID LEVEL IS FULL OVER PIPES. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 23 PICASSO PLACE OSTERVILLE,MA 02655 M145 P080 Owner: RHODA BOHRER ` Date of Inspection: 6/10/04 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): DID NOT EXPOSE LEACH PIT.LIQUID LEVEL IS OVER TEE IN SEPTIC TANK-SOIL WAS PONDING WHEN DIGGING AROUND LEACH PIT,INDICATING LEACH PIT HAS NO EFFECTIVE LEACHING LEFT AT TIME OF INSPECTION. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc:): n/a PRIVY: (locate on site plan) Mate]lials of construction: n/a Dimsions: n/a Dept}of solids: n/a Comr.ients(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): n/a i 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 23 PICASSO PLACE OSTERVILLE,MA 02655 M145 P080 Owner: RHODA BOHRER Date of Inspection: 6/10/04 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the build'inl . W 6 ti� 0 2-7 AV� 35 hC 5�1 Zq 3 in Page 11 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 23 PICASSO PLACE OSTERVILLE,MA 02655 M145 P080 Owner: RHODA BOHRER Date of Inspection: 6/10/04 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 12+FT. 11 A T ION SEWAGE. PERMIT NO. >L C VILLAGE INSTA lLE VS3X ME 6 DRESS 1 �R U I L D E R OR OWNER , DATE PERMIT ISSUED v K 3 - ®DAT E C 0 M P L I A N C E ISSUED - M s:n / 4ho. P_ ,a:,2 q6 LOCATION N OT 4 VILLAGE 0%1S9%41LLff DATE 07 IT APPLICANT FEE 23 y ADDRESS C.E1.tTE<ZVtLL TELEPHONE (Non-refundable ENGINEER 15 LOAD GCE _1=_Nl�L� 1Nts TELEPHONE :NO. "I' - 1., 1. ,..�......o. DATE SCHEDULED' JVL 0 Z E Applicants signature • • • owe • • • • • • • • • • • • O O�• •,e • • •.• • • • • O 1 /.• • •/ /C1./ O• / • /• • 1 • O O O •• •9 • • •.•.• O • 1 • • 1.• •1 ••,•• • • ! SOIL LOG 3e SUB-DIVISION NAME ! OSTE&u.t. •'-DATE o 78 L-TIME 9 EXPANSION AREA: YES ✓ NO J O.H W Q ELL.{I ENGINEER TOWN. WATER✓ PRIVATE WELL j lm Ft N J A CA Fb 1 BOARD OF HEALTH .. Jim _ ,Un t SCOT. EXCAVATOR SKETCH: (Street -name,etc..,dimensions of lot, exact location. of, test holes and percolation tests,, locate wetlands .in proximity to test holes ) NOTES: (ate! _ L=r 7FM7 PERCOLATION RATE: 2 M I TEST HOLE NO: ELEVATION: TEST HOLE NO: E:LE:VATION: 1 o I E3 L O�cM T'5 1 2 2 3 3 4 4 - 5 5 .-6 6 . S ) 8 9 �/ 9 10 10 11 11 12 12 13 W5 U_> :4- 13 14 14 15 15 16 16 SUITABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELD LEACHING PITS LEACHING TRENCHEST. iUNSUITABLE FOR SUB-SURFACE SEWAGE. ;", REASONS: A- L NOTE: ENGINEERING PLANS MUST .SHOW'NUMBER ASSIGNED ON PERC TEST APPLICATION ORIGINAL: COMPLETED N T RNED 10 BOARD OF HEALTH COPY• RETAINED BY APPLICANT' a ASSESSORS MAP : Y, -- -- - TEST HOLE LOGS �XS PARCEL : SOIL EVALUATOR : c/ �j G�7 �� FLOOD ZONE: ids 1 �4 QPt�1C�}- fir..., _- WITNESS : �_ (,( � NOSES: REFERENCE: �ET✓d� ' , c�SeIU DATE: . _____ �- ` PERCOLATION RATE: .0 'ZIA,)�k,4, 1 1) The installation shall comply with Title V and Town of Barnstable Board of Health Regulations. 2) The installer shall verify the location of utilities, sewer inverts and septic TH- 1 7H-2 components priortoinstallation. 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. G•1(�/ln/Et�°2rS �Sv�UV yI�� i_, 4) This plan is not to be utilized for property line determination nor any other /-� purpose proposed Y u ose other than the ro osed system installation. �► ` '' 5) All septic components must meet Title V specifications. LOCATION MAP(> k7 6) Parking shall not be constructed over H10 septic components. 7) The property is bounded by property corners and property lines as depicted. 8) The property owner shall review design considerations to approve of total number of bedrooms to be considered for design. Receipt of payment for the plan and installation based on the plan shall be deemed approval of the number of bedrooms. 9) The existing leach pit shall be pumped and backfilled per Title V Abandonment Procedures. • � ��-�D, Ili i 10)Proposed leaching is to be within 36 inches of grade or provide venting or cut grade as permitted by the Board of Health. 11)System components to be 10 feet from water line. 2 SEPT C S�'S T EM DES I GN FLOW ESTIMATE d..�•--�' ;. N� / BEDROOMS AT � GAL/DAY/BEDROOM -` GAL/DAY I SEPTIC TANK s � GAL/DAY x 2 DAYS GAL USE \N"O GALLON SEPTIC TANK SOIL ABSORPTION SYSTEM NA i I SIDE AREA: Z�-1 -+ 13 ..�C J7ZD BOTTOM AREA: ? �c l�j y- b ,r7 Mq flu SEPTIC SYSTEM SECTLION (,�,-r,�� r� ----- n �A1W, w�uAX. �I 11b 2�7 I� 1, l/ ,/ W"YVW I��TJ�'•�'Y ` ► "r 5I I , — /OCi b GAL SEPTIC TANK TZ�fj CDP 10 � S 1 TE AND SEWAGE PLAN ( LOCATION : I l PREPARED FOR : SCALE: 0 w DAV I D B . MASON, DATE: Z DBC ENVIRONMENTAL DESIGNS DATE HEALTH AGENT EAST SANDWICH . MA ( 5O8 ) 833- 2177