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0005 PINE LANE - Health
} x 4 � � A Va}LL # .red •1 pllle Lane` Osterville ,t. r ` '`� P 3. A= 118,—'091 r� s 4 k p s M4=F-A Dr No.2153LGN UPC 12134 HAMQ%MN '`fir i U i I fr iI 1 I 4Y No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for Misposal 6pstem Construction 'VPrmit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon A ❑Complete System ❑Individual Components Location Address or Lot No. Lot Owner's Name,Address,and Tel.No. Nast Wtwo Assessor's Map/Parcel Afit G W W(m Nffl pA Installer's Name,Address,and Tel.No. %, esigner's Name,Address,and Tel.No. EP-iC— 51-EVEA15 Type of Building: Dwelling No.of Bedrooms Lot Size t4 Garbage Grinder( ) Other Type of Building Ny��v No.of Persons 0 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: :I 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 Bo rd of Health. S. Date 0� 1 Application Approved by Date Z Application Disapproved Date for the following reasons ``-_Permit No Date Issued No. 3�Z Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:. Ies PUBLIC HEALTH DIVISION,-TOWN OF BARNSTABLE, MASSACHUSETTS 4plication for Disposal *pstem Construction permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon A ❑Complete System , ❑Individual Components Location Address or Lot No. �" �, Owner's Name,Address,and Tel:No. &B Assessor's Ma ��� PL4HL W�r •T A- G�k7 p t t 6q # Map/Parcel I Installer's Name,Address,and Tel.No. esigner's Name,Address,and Tel.No. � - R CgIJsC' -t� e 17 S Type of Building: Dwelling No.of Bedrooms Lot Size i�5 ft"k nAq Garbage Grinder( ) Other Type of Building No.of Persons O Showers( Cafeteria( ) Other Fixtures ' Design Flow(min.required) " gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title 5 Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: :I Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with theprovisions of Title 5 of the-E-n^viiroonmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Bo of Health. I S' �- Date 11 1 Application Approved by Date 2 Application Disapproved -Date for the following reasons Permit No. Date Issued ------------------------_------------------- ------ ------------- ------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE.MASSACHUSETTS , Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned(No by ritij� 1VAO- r a I nn4 .���M� lL-)_0 at 1-JU 0,41f,1�1� has been constructed in accordance // with the provisions of Title 5 and the for Disposal System Construction Permit No.Amy "37Z dated /©/2 77/-Zol a; Installer \C �VF��� Designer AA #bedrooms ✓..— Approved dePfun ' w tl '�"" gpd The issuance of his pe"it s,}iall not be construed as a guarantee that the system wion as design . r Date t Inspector G ------------------------ - . _: . - _ .------------- - -- -------------------------------------------- - No.G�J/J Fee *Z5 , y THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE, MASSACHUSETTS Disposal *pstetn Construction permit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date 2 7iD/5 Approved by No. I ' f Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 4plitation for Misposal 6pstem Construction permit Application for a Permit to Construct Repair(x) Upgrade( ) Abandon( ) El Complete System Individual Components Location Address or Lot No. 5 P!N c lAtj6 6s-,6R Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 1 12 �95 C-00W&S S CA 455 Installer's Name,Address,and Tel.No. ae—C -n—8�)T 7 Designer's Name,Address,and Tel.No. CA6 tsWclaC Sb-r 01A GO t P Type of Building: Dwelling No.of Bedrooms )jA Lot Size sq.ft. Garbage Grinder( ) 0 Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures p n Design Flow(min.required) gpd Design flow provided Ol�i� 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) Mkha 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 Bo d o a Signe Date "f Application Approved by Date ! f Application Disapproved b Date for the following reasons Permit No. ZJ t — Z I( Date Issued ,7 it /so/5 Ilk No. I / Fee �� dV THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC`HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplitation for -Misposal *patent ConeIfUCtion Permit Application for a Permit to Construct( ,) Repair()( Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. Q(N�-t �f E OS'jE�, Owner's Name,Address,and Tel.No. 100Nmr..n wu.,c Assessor's Map/Parcel a- <'00 S ST CA 14553 . Installer's Name,Address,and Tel.No. 5'oe-C -n-,Sg?7 Designer's Name,Address,and Tel.No. C O+ e 0 lDE s� .Pr2.15 act SHIP ; Type of Building: k. a Dwelling No.of Bedrooms A -'Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) f Other Fixtures Design Flow(min.required) (pp� � 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) RCTe,A-W D -ao K A4 JD 1Q5r*u, 4569 . RE�LACX a&fl Fes( 76wA�- �QK Date last inspected: ' 'v 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 Bo rd o a Sin, e Date Application Approved by GG/� Date �S ' Application Disapproved b Date for the following reasons Permit No. ZO t 7'— 2 1 Date Issued --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Cutifitate Of CDmpliante THIS IS TO CERTIFY,that the On-site Sewage Sewage Disposal system Constructed( ) Repaired(Y1 Upgraded( ) Abandoned( )by OAPetP>tp. (_i ipl9(15,�S �.QZ:_ at LAL,)G a!°r F)u(txZ— has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ��- ZI( dated `{' (ZOt5 Installer C4oELxnS iG0719t?O ISOSS L4--C- Designer t�.S1A #bedrooms NA Approved design fl,w gpd The issuance of t is p rmit shall not be construed as a guarantee that the system ilul�Jtion as designed. Date I Inspector 1 ----=----------------------------------------------------------- - - - -------------------------------------------------- - Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Disposal *pstem Const rtion 3dErmit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at C. 6tagyf i-L- and as described in the above Application for Disposal System Construction Permit. The applicant recognized hi er duty to comply with Title 5 and the following local provisions or special conditions. Provided:ConstLZcfion must be completed within three years of the date of this permit. Date f' Approved by i f un 18 1508:37p p,1 f Commonwealth of Massachusetts Title a Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments P 5 Pine Lane r 7 Property Address ' Don Williams t= Owner Owner's Name c. information required for every Osterville MA 02655 6-9-15 page. Cityrrown state Zip Code Date of Inspection Inspection results must be submitted on this form.inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. important:Whenfilling out forms A. General Information on the computer. ```���� OF 4,40 use only the tab 1. Inspector. ' key to move your '��:• JAMES cursor-do not James D.Sears use the return Name of Inspector :En U. _ key. CapewideEnterprises,LLC Company Name - ,���'J� 5 S IN 153 Commercial Street /'���r�bnlilnju11%%A%N ` Company Address Mashpee MA 02649__ _-_ Cityfrown State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification l 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 i E i �i 6-18-15 ,fifspeclor'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. t5im•3113 Title 6 Official inspection Form:Subsudaoe Sawaga Disposal System_•Page 1 Dr17 Jun 18 15 08:37p p.2 .,� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . 5 Pine Lane Property Address Don Williams Owner Owner's Name information required for every Osterville MA 02655 6-9-15 page. Citylrown State Zip Code Date of Inspection B. Certification (cost.) Inspection Summary: Check A,B,C,D or E 1 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: Conn Pass-D Box and line change. The system is a 1000 Gal.Tank D Box and pit_ 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 exfiitration or tank failure is imminent. System will pass f inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. i A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of II Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): `i I I 15ins•3l13 Title 5 OKdal hmpection Fomx Subs olece Sewage Disposal System.Page 2 of t i i i I Jun 18 15 08:38p p,3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 Pine Lane Property Address Don Williams Owner Owner's Name information is Osterville MA 02655 6-9-15 ` required for every _ page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumpslalarms 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): Need to replace D Box. Need to replace line tank to D Box. ❑ 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): i li I I i 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: . l ❑ Cesspool or privy is within 50 feet of a surface water I . I ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetiand or a salt marsh t5ins-3f13 Title 5 Official Inspection Form:Subsurface Sevrege Disposal System-Page 3 07 17 i i i Jun 18 15 08:38p p 4 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Pine Lane Property Address Don Williams Owner Owners Name information is Osterville MA 02655 6-9-15 required for every page. Cityrrown state Zip Code Date o;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. i Q The system has a septic tank and SAS and the SAS is less than 100 feet but 50 fleet 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: 4 i i i i D) System Failure Criteria Applicable to All Systems: �I You must indicate"Yes"or"No"to each of the following for all inspections: I 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 Q � Static liquid level in the distribution box above outlet invert due to an overloaded i or clogged SAS or cesspool Q Liquid depth in� y p is less than 6'below invert or available volume is less than Yz day flow P;i i t5ins+3M3 Tide 5 Official hapectio Fom�:Subsudace Sewage Disposal System•Page 4 of 17 Jun 18 15 08:38p p.5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 Pine Lane Property Address Don Williams Owner Owner's Name information is required for every Osterviile MA 02655 6-9-15 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. ❑ ® 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 I ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection ` Area—IWPA)or a mapped Zone 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.3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal Systen•Page 5 of 17 i i i i i Jun 18 15 08:39p p.6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 5 Pine Lane Property Address --— Don Williams Owner Owner's Name information is Qsterville MA 02655 6-9-15 required for every page. Citylrown 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? El ® 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?.11f 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? ❑ 0 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: i ® ❑ 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)1 - j D. System Information Residential Flow Conditions: Number of bedrooms (design):' NA Number of bedrooms(actual): 2 - DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 i I i t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 t i Jun 18 15 08:39p p.7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 5 Pine Lane _ Property Address Don Williams Owner Owner's Name information is required for every OSterville MA 02655 6-9-15 page. CitylTown State Zip Code Date of Inspection D. System Information Description_ The system is a 1000 Gal.Tank-D Box and pit. Number of current residents: 1 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 0 No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): 4,000GaIs 2 2013-2 013-2,000 Gaps Detail Sump pump? ❑ Yes 21 No Last date of occupancy; Present Hate Commercialllndustrial Flow Conditions: Type of Establishment Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seatstpersonslsq.ft.,etc.): -- i Grease trap present? ❑ Yes ❑ No • I s Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No i Water meter readings, if available: t5ins 3113 Title 5 Official inspection Form:Subsurface Sewage Disposel System•Page 7 of 17 1 i i i Jun 18 15 08:39p p 8 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 5 Pine Lane Property Address Don Williams Owner Owner's Name information is required for every Osterville MA 02655 6-9-15 page. Citylrown 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: 09/11 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 i inspection of the 1/A system by system operator under contract i ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5irts-3113 Title 5 official trupeclion Forth:Subsurface Sewage Disrosal System-Page 8 or 17 i Jun 18 15 08:40p p,g Commonwealth of Massachusetts Title 5 Official Inspection Form I. Subsurface Sewage Disposal System Form- Not for Voluntary Assessments r - 5 Pine Lane Property Address Don Williams Owner owner's Name information required for every Gisterville MA 02655 6-9-15 - page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: 1982 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 26"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: e2 Comments (on condition of joints, venting,evidence of leakage,etc.): Pipeing is 4" PVC SCH 40. Line tank to D Box holding water. Need to replace line. Septic Tank(locate on site plan): Depth below grade: 15" feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) I i I I I I If tank is metal, list age: years • i Is age confirmed by a Certificate of Compliance? (attach a copy'of certificate) ❑ Yes ❑ No i Dimensions: 1000 Gal.Precast H-10 I Sludge depth: 2" t5ins•3113 Title 5 Official Inspection Form:Subsurface%. wage Disposal System-Page 9 of 17 i 1 Jun 18 15 08:40p p.10 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 Pine Lane Property Address Don Williams Owner Owner's Name information fore Osterviiie MA 02655 6-J-15 required for every page. Cityfrown State Zip Code Date of?nspection D. System Information (cons.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28 Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 16" j How were dimensions determined? Asbuilt-Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank and covers at 15"below grade. Inlet tee,outlet baffle. No sign of leakage or over loading. Grease Trap (locate on site plan)_ i i Depth below grade; feet i { Material of construction_ r i ❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: I Scum thickness i i 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: gate 15ins-3113 Title 5 ORfdal Impe Won Form:Subaurfaoe Sewage Dispose:Sy-,tom•Page 10 of 17 i i i S 4 Jun 18 15 08:40p p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 Pine Lane Property Address Don Williams Owner Owner's Name information is required for every Ostervifle MA 02655 6-9-15 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.): l Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑ other(explain): Dimensions: Capacity: gallons i Design Flow: gallons per day i Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order_ ❑ Yes ❑ No Date of last pumping: Date I Comments(condition of alarm and float switches,etc.): i I "Attach copy of current pumping contract(required).. Is copy attached? ❑ Yes ❑ No j i ;sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 i i I Jun 18 15 08:41 p p.12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 Pine Lane Property Address Don Williams Owner Owner's Name information is required for every Ostervilre MA 02655 6-9-15 page. Cityrrown state Zip Code Date of Inspection D. System Information (cost.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert -- Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"xiT-30" below grade wlone line out Wall's are gone,need to replace D Box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" I Alarms in working order. ❑ Yes ❑ No` Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): jl } - I i, If pumps or alarms are not in working order,system is a conditional pass. i Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: i 15ifs-W13• Tnia 5 Oft;rial Inspection form:Subsurface Sewage Disposal System-Page 12 of 17 Jun 18 15 08:41 p p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form 1=, Subsurface Sewage Disposal System Form- Not.for Voluntary Assessments 5 Pine Lane Property Address Don Williams — Owner Owner's Name information is required for every Ostervirle MA 02655 6-9-95 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Type: 1 ®. leaching pits number: -- ❑ leaching chambers number: ❑ leaching galleries number: ---- ❑ leaching trenches number, length: ❑ leaching fields number, dimensions. ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: -- -- Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a 1000 Gal. Precast pit. Pit at T below grade w/cover at 22".Water level in pit at 4" below inlet. y 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 — i Depth of scum layer i Dimensions cf cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No I (Sins•3113 Title 5 Otrdal inspection Forrm SLbaurface Sewage Disposal System-Page 13 or 17 i i I Jun 18 15 08:41 p p.14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Pine Lane _ Property Address Don Williams Owner Owner's Name information is required for every Osterville MA 02655 6-9-15 page. Cityrrown state Zip Code Date of Inspection D. System Information (coat.) 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.)-. i t i i i i iS i j t5ins•3113 Tills 5 Official Inspection forth_Sibsurfam Sewage Disposal System•Page 14 of 17 i i t Jun 18 15 08:42p p.15 Commonwealth of Massachusetts Title 5 Official Inspection Form i= Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . 5 Pine Lane _ Property Acaress Don Williams Owner Owner's Name information required.for every Osterville MA 02655 6-9-15 page. Citylrown Slate Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately i y 4 0 AJT C T Rfir f I� L. I i 1 ISins•3113 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System-Page 15 of 17 i t c i ' j Jun 18 15 08:42p p.16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Pine Lane Property Address Don Williams Owner Owner's(dame information is required forevery OsterviU AA A A 02655 6-9-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells N� v Estimated depth to high ground water: 3 — 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: pate Observed site (abutting property/observation hole within 160 feet of SAS) ❑ Checked with local Board of Health-explain: i I ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: I z You must describe how you established the high ground water elevation: I Abutting property to rear drop's off. i i Before filing this Inspection Report,please see Report Completeness Checklist on next page. I i 15ins.3113 Title 5 Official Inspection Farm:Subs tape Sewage Disposal System-Page 16 of 17 i i Jun 18 15 08:42p p.17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not fior Voluntary Assessments 5 Pine Lane Property Address Don Williams Owner Owner's Name information is required for every Osterville MA 02655 6-9-15 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 l i /sins•303 Tille 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 17 of 17 f AsBuilt Page 1 of 1 I D TOWN OF BARNSTABLE LOCATION r 11k. 1/AAL SEWAGE#t VILLAGE OSru'd.14 ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) _ (size) �GGd NO.OF BEDROOMS a- OWNER GI►11,4MS 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 —Z-11rPty- �gn j t A Prom' a 38' PS http://issgl2/intranet/propdata/prebuilt.aspx?mappar=118091&seq=1 10/23/2014 ' COMMONWEALTH OF MASSACHUSETTS EXECUTIVE.OFFIC:E OF ENVIRONMENTAL AFFAIRS DEPARTMENT-OF ENVIRONMENTAL PROTECTION< TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM, PART A CERTIFICATION Property Address: 5 Pine Lane Osterville. MA 02655 Owner's Name: Don Williams q Owner's Address:.. 295 Coombs Street-� Nana. CA 94559 Date of Inspection: . - August 22, 2007 Name of Inspector: (Please Print) James M..Ford i t •0 l, Company Name: James M.Ford 4 Mailing Address: P.O.Box 49 Osterville.MA 02655-0049" Telephone Number: : (508)862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site-sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ . Passes Conditionally Passes 47,a Needs Further Evaluation by the Local Approving Authority. Fails <a c_a Inspector's_Signature:` C'.a Date: Augusf 29.2007 ' The system inspector shall sub t a copy of this inspection report to the Approving Authority($oardof Health;or DEP)within 30 days of completing this inspection. If the system is.a shared system or has a design flllllow 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 systdin.owner and copies sent to the buyer,if applicable,and;the approving authority. Notes and Continents ****This report only describes conditions at the time of.inspection and under the conditions of use at that. time. This inspection does not address how the system will,perform in.the_future under the same or different . conditions of use: Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE.DISPOSAL:SYSTEM INSPECTION FORM< PART A CERTIFICATION'(continued) Property Address: 5 Pine Lane a Ostervi'lle MA t Owner: Don Williams Date of Inspection: AuQust22, 20- Inspection Summary: Check A,B,C,D or E/ALWAYS'eomplete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303'or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes:' asses One or more system components as describedin.the"Conditional Pass"section need to be replaced or repaired. The system,upon be of the replacement orrepair,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",1 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 enfiltration or tank failure is imminent..System will pass,inspection if the existing tank is replaced with a complying septic p bnk y the Bord of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less`than 20 years.old is available. , ND:explain: Observation of sewage backup or break out or high static water-level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will'Pa inspection if (with . approval of Board of Health); "' ` broken pipe,(s)are replaced obstruction is removed` distribution box is',leveled or replaced: ' ND explain: `A The system requited pumping more than 4 times a year due to broken or obstructed-;pipe(s)i-The system will pass inspection if(with approval of the Board:of Health): s broken pipe(s)are replaced obstruction is removed ND explain: 2.: ` Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 5 Pine Lane Osterville MA Owner: Don Williams Date of Inspection: August 22. 2007 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 x . 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 aseptic 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`aseptic tank and SAS and the SAS is within a Zone 1 of a public water supply. f _ The system has a septic tank an&SAS and the.SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS.and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified'laboratory, for.coliform bacteria and volatile organic compounds indicates that the well'is free from pollution from that facility and. the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this fonn. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM:-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: S Pine Lane Osterville MA Owner: Don Williams Date of Inspection:. August 22, 2007 D. System.Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following:for all inspections: Yes No _ ✓ Backup of sewage into facility or system,component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground_or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than %day.flow . ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground:water elevation. ✓ Any portion of cesspool or privy is within 1.00 feet of a surface water supply or tributary to a surface water supply. _ ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool'or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less.than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system-passes if the well water analysis,_ performed at:a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to.or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as . described in 310 CMR 150303;therefore the system fails. The system owner should contact the Board of Health to determine.what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must.indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface.drinking water supply — the system is within 200 feet of a tributary.to a surface drinking water supply — the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone I1 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. r Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: S Pine Lane Osterville MA . Owner: Don Williams Date of Inspection: _August 22. 2007 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`SoilAbsorption System(SAS)on the.site has been determined based on: Yes No _ Existing information. For example,a plan at the Board of Health. ✓ Determined.in the field(if any:of the failure criteria related to Part C is at issue approximation of distance is unacceptable).[3l'0 CMR 15.302(3)(b)J. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION.FOR M PART C 'SYSTEM INFORMATION Property Address: , S Pine Lane Osterville MA Owner: Don Williams Date of Inspection: _ Aueust 22.2007 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 2 Number of bedrooms`(actual):` 2 DESIGN flow based on 310 CMR.15.203 (for example: 110 god x#of bedrooms): :. 220 Number of current residents: 2 Does residence have a.garbage grinder(yes.or no): . No Is laundry on a separate sewage system(yes or no): n1a [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(god)):` Unavailable Sump Pump(Yes or.no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL- Type of establishment: - Design,flow(based on 310 CMR 15.203): god Basis of design flow(seats/persons/sgft,etc.) Grease'trap present(yes or no): Industrial waste holding tank.present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: ' Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of info rmation: P um ed 2 ears a o- or ow ner 17 V P IJ Wass stem pum ped a s pa rt Y of the ins pection ect'10 p n e P p (yes or no): No .. If yes, volume pumped: _gallons 7-How was quantity Pumpeddetermined? Reason for pumping: TYPE OF SYSTEM ✓ Septic.tank, distribution box,soil absorption.system Single cesspool - Overflow cesspool Privy - Shared system(yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a.copy of the current operation and maintenance contract(to be obtained from system owner) . Tight Tank Attach a copy of the DEP,'approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed on 4127182-per as built card 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:. S Pine Lane R Osterville MA Owner: Don Williams Date of Inspection: .August 22. 2007 BUILDING SEWER(locate on site plan) Depth below grade:. .Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓. (locate on site plan) Depth below grade: 16" Material of construction: ✓. concrete. _metal _fiberglass polyethylene other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000,gal. Sludge depth: 2". Distance from top.of,sludge to bottom of outlet tee or baffle: 30 - Scum thickness: 6„ Distance from top of scum to top,of.outlet tee or baffle: 6pr Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levelsas related to outlet invert,evidence of leakage,etc.). Cement tees were present. The IL quid level was even.with the outlet invert: There did not appear to be any si ns of leakajze. GREASE TRAP: .None (locate on,site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene-:_other (explain): Dimensions:. Scum thickness: Distance from top of scum to top of outlet tee or baffle:. Distance from bottom of scum to bottom of outlet tee or baffler Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 . Page 8.of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM:INFORMATION(continued) Pro perty Address: S Pine Lane Osterville. MA Owner: Don Williams ` Date of Inspection: August 22. 2007 TIGHT or HOLDING TANK: None (tank must be`pumped at time'of inspection)(locate on site plan) Depth below grade: Material of construction: ._concrete metal- fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping; . Comments(condition of alarm and float.switches,etc:): : DISTRIBUTION BOX: V. (if present must be.opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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.): The D-box was level. No solids uvere present. PUMP CHAMBER: None (locate on site plan) y:' Pumps in working order(yes'or no): Alarms in working order(yes or no). Comments(note condition of pump chamber,condition of pumps and appurtenances,etc): 8 r♦ Page 9 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACKSEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C , SYSTEM INFORMATION(continued) Property Address: 5 Pine Lane Osterville MA ' Owner: Don Williams Date of Inspection: August 22 2007 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain.why: Type ✓ _leaching pits,number: -1 -6'x 6'1000 gal.) leaching chambers,number:, leaching galleries,number: F leaching trenches,number, length:; leaching fields,number,dimensions: overflow cesspool;number: Innovative/alte rnative system Type/na- me of technology, Comments(note"condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): The pit had Y o li uid on the bottom. The scum line was at the sa me r e level. Th e did not. " The bottom to rade was 8. A video camera was used or the ins ection: a ear to be an si ns o ailire. CESSPOOLS: None. (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth,-top of liquid to inlet invert: Depth,of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow.(yes or no):" Comments (note condition of soil,signs of hydraulic failure;level°of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: - Dimensions: Depth of solids: Comments (note condition of soil,signs of hydraulic failure;level of ponding;.condition of vegetation,etc.): 9 L ' Page 10 of 11. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 5 Pine.Lane . Osterville' MA . Owner: .. Don Williams Date of Inspection: August 2Z 2007. SKETCH OF SEWAGE DISPOSAL SYSTEM x Provide a sketch of the sewage disposal.systein 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.. q a 3a iw 3` y . . y ay 31 . 10 Page 11 of 11 . OFFICIAL.INSPECTION FORM-:NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.C f SYSTEM INFORMATION(continued) Property Address: S Pine Lane Osterville, MA Owner: Don.Williams Date of Inspection: August 22. 2007 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30+/ feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS). ✓ Checked with local Board of Health-explain: Tonogranhic and water contours roans Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours mans the mans were showing approximately 30'+/ to ground water at this site. This report has been prepared only for the septic system and components described herein. This septic system has been inspected and passed as of the date of inspection..This report is not a warranty or guarantee that the system will function properly.in,the future.. There have been no warranties or guarantees, either expressed, written or implied, relating to the septic`system, the inspection,this report and/or any components of the septic systemwhich have not been located and inspected. . 11 Town of Barnstable OY THE 1p� Regulatory Services Thomas F. Geiler, Director - 9�A Public Health .Division TFn ter" Thomas McKean, Director 200 Main Street,Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual p number of bedrooms approved at a articular roe would- ' ' pP p property rty uld-be fisted on the Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. G _ TOWN OF BARNSTABLE LOCATION � I PJU /,AAA- SEWAGE# VILLAGE OSTe nJA ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY UUL� LEACHING FACILITY:(type) P� (size) �GGd NO.OF BEDROOMS �l OWNER i 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 �i facility) ) Feet FURNISHED BY = 1'f tv i T� �OrC � 1 01 OD D f� 9LO CAT 1014 j,- ,� SEWAGE PERMIT p0• ,-VILLAGE IgSTA LL HAME L ADDOESS � � Q. AALTO BACKHOE SERVICE 156ftillul street West Barnstable, Mass. 02668 0UILDER OR OVUER DATE PERMIT ISSUED ;7,21 � DATE COMPLIANCE ISSUED IPi Y r � 1 No.. •- Fizs.......u ....... THE COMMONWEALTH OF MASSACHUSETTS ''- BOAR® OF HEALTH ...........................................O F.........................................---...----....................................... AVVIIrFa#ivaa for DWpos al Works Tow3trurtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal ,System at: �`� I r,: p Locaf n-A d r / or Lot No. I ...... d e{R � �? 'fad s� �•►.. � .... ... ......... ------------------------- .. ..- ... � .:� // � 4 ner � . �® f/�/9/� ,5 Ad r s� �6/edl!llf4/yt - :. .__ ------------------------------------- /. .......... ..."�._......--- .... ....... ......_.. ........... Installer Address QType of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms......—1.................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures --------------------------------- - --- --- W Design Flow............................................gallons per person per day. Total daily flow................................._..........gallons. WSeptic Tank—Liquid—Liqui&capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) �-' Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water......................... - (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -------------- ------- O Description of Soil...................... - = f x i w ¢¢ . UNature of Repairs or_Alterations—Answerh�n lica le______!' ._`�.0 t'd��j tad � s r .._ s aal�pp ------•••_•-. ----•••......-•--•--•••--... ................................................. ��0 S..........---- g'.. aao-- x %-_-----_----------...................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'MALL, 5 of the, State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b� 'ssue by the b .board of healt Signed----.-• . .•• ••. e DZe Application Approved BY .... :.. ;%� ------------------------- -- D Application Disapproved for the following reasons-----------------------------••-----------------------------------------------------------------------------_.:_ ......................-........................................................................................................................................................................ Date PermitNo......................................................... Issued....................................................... Date No.. ..../_...E' � FEs.......... .............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............... ...... ......---.------...O F.........................................----.------------................-_...--------_.. Appliratilan for Ditivaiial- nrkn Tonuunrulan famit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at P I Locat' n-A�d� or Lot No. .................. — ft r. .................................................� .............� .....•___... ,yam ! .............. (S� � l+� ne �J .................................... i1� j/ Ad�rps�! i9I'�I A74, a --- �!►. ...............................•...... ....... ......--� ...... -(/ ............................... Installer Address U Type of Building Size Lot............................Sq. feet � � Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ---------=---------------------• - W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench No. .................... Width.................... Total Length..................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit------- ............ Depth to ground water........................ Gz Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a --••---•-•- ------------------------------------------------------------------------------••.............•--•-••-•••-••--•-•---•----•..---- ODescription of Soil-------------•-•-----....' f' ' ....-----....-----•------------•---------------------------------------•-----------------------------------------••------•----- x U ----------------------------------------------------------------------------------------------•-------------------------------------------------------------------}-...------........-----•............•. U Nature of Repairs or Alterations—Answer hen Mica e..___.r �°' �. ;do... ..... » r U -•----•-•-----•----•-P-----------------------•-. .t3A------'.-i......-f-......I?.k ... ....... --..t.. ............................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b ssue by the board of healt -.1:2 Signed_.... ........................................ . -••••--•-•--------- Application Approved By . -Z��ti. L Date ...................... Date Application Disapproved for the following reasons:................................................................................................................ .........................•-----------------------------------•--•----•---.........---------•-----••------...----------------------------------------------------------------------------------------•---- Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............../VAV.Ae.......OF...........!.�. t�?!"f........................................................ �rr#ifiratr of Tantplianrr h THIS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) bY - �,�............. . I It at---------------------------s------- =----------- ---------------------------------------------------------------------------------•------------ has been installed in accordance with the provisions of TIT F 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.............. ............. dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............. ...... a 7� .................... Inspector......... —'---------------_--------------------•------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH P� ..........................................OF..................................................................................... No....................... FEE....----................ �ops �arkii Tonntrnr�ian rrntii Permission is hereby granted....... .. .......... ...... to Construct ( ) o Repair ( a Indivi ual Sewage Disposal System at No. -• ---•••••. "r ' ,' "` --••-- _. .............. ..............-...............................-........ ................................................... Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... �_'/-------------------------------------------_ Health DATE................ .......................FORM 1255 HOBBS & WARREN. INC., PUBLISHERS THE COMMONWEALTH.OF MASSACHUSETTS BOAR® OF HEALTH C>C .4.............OF.....6AaZa. ; .r.0.4, ....................................... Appliratidu for %Vviial Works Tonstrnr#iun ramit Application is hereby made for a Permit to Construct (1- or.Repair ( ) an Individual Seig & sposal;' System at: 3 {^p ll Loc(��tion-Address ` / p� 9 or Lot No. ..---------L...F: �.1.4 :... :J. .�?XafE.g.....� Y. _.... ..---••..........-+ :(�-d7L� ............... �- t A.? sg.. . FEN' Owner Addre Installer Address �;��¢' , �I�T . ; 117 Type of Building Size Lot Z4)..___.t U Dwelling No. of Bedrooms..........,..,, g— 3.............................Expansion Attic ( ) Garbage aOther—Type of Building __ e? l -No. of persons........6................ Showers ( ) — Cafeteria ( ) d Other fixtures -------------- ------------- W Design Flow..............................s� .S.�..gallons per person per lday. Total daily rflow........3.d3:�......................gallons. WSeptic Tank—Liquid capacityh!�!ggallons Length....._..... Width__.�.�..... Diameter.___.:...._. Depth------ ..... x Disposal Trench—No..................... Width.................... Total Length_........_..........Total leaching area....................sq. ft. s Seepage Pit No..........j........ Diameter....../...�........ Depth below inlet....._--...... Total leaching area... l..sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed ..... Date.... _'. ,............. Test Pit No. 1...:/-.,-..-Z--minutes per inch Depth of Test Pit---- - Depth to ground water..WA _ GZq Test Pit No. 2................minutes per inch Depth of Test Pit..............._.... Depth to ground water........................ .. ...--•-••--------------•-........_. ODescription of Soil � / -SC714 .. / .._ y - y:.1..-- t 4� - ---- w!- ------ ...... --------- U Nature of Repairs or Alterations— nswer when applicable............................................................................................... ---------------------------•---------•----------••------------•---•-----------------.......---•--------•------------•----------•--...------•----------------.......................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TI HE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the boar f health. /Signed. ...._�% /j Application Approved By_....... - e%'lrii'-�'---------•-•--•---•-- V gate ate Application Disapproved for the following reasons:................................................................................................................ --•---•••----•-------•-------------•-••-...----------••••...........--•--•-----••-•-••-••--•------•--••-.••--•-••----•-------•-••••-•--•----••••-•••-------•--•-•--------•-----•-------•-------....-•--- Date PermitNo......................................................... Issued......................................................... Date, No... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............................ ............... ........ .............................................................. Appliration for Disposal Works Tonstrurtion "Pamit 6 Application is hereby made for a Permit to Construct (1--7or Repair an Individual Se• 1; System at: All, ..................... ............................................ ...................................................................I�.j-X. ...... ra Lotion-Address -,i a, �;Lot No. --------------------------....................................................................... .............................................��r;..s............. s Owner A ........... ----------- ------_22a..... Installer......................................... ....... 1--Aress Type of Building Size Low,Z............... ... U Dwelling—No. of Bedrooms... . ..................................Expansion Attic Garbage Grinder Cafeteria Other—Type of Building .2.4�...... No. of persons....... ................. S11&wers ( ) Otherfixtures ................................................. ......................................................... -------------------------------------------- -'s .11 i�,F - Design Flow............................... ..gallons per person R�r flons. day. Total d�'�.--flow.............................................ga Liquid capacit .':.gallons Length................. Width-_ ........... Diameter. ........ Depth...1:4 Septic Tank y .......... Disposal Trench—No. ....._..... . Width.................... Total Length........_ ..... Total leaching area...................sq. f t. Seepage Pit No........_}......_.. Diameter........:........... Depth below inlet.....: ............ Total leaching area.............:....sq. ft. Z Other Distribution box Dosing tank Percolation Test Results Performed by-_"........................................................ ................ Date.. ...._.. ........................... Test Pit No. 1...Si.........minute's per inch Depth of Test Pit... .......... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit..__......._...._._. Depth to ground water.___._...._........._... 0 ................ .......------- ----------------------- .......... ...........;�.............................................. ✓ Desction of Soil.. ...............................................................................................1;------------------------------------------------------------ 14 6�1"? t ir it_rp U ....................................................; ........ . .............................. ................................................................................. ..... ...?.........C- ----------- ---------.............................................................................. ...... .r. -------- U Nature of Repairs or Alterations��nswerwhen applicable................................................................................................ ......................................................................................................................................... .............................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T I T 1Z 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been sued by the boar of health. .. ....................................Signe t Application Approved By.................. ...... - ... ........ . ... ... ................. ......� L....... Date Application Disapproved for the following reasons:.............................................................................................................. ........................................................................................................................................................................................................ Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH. .......... .........OF............ . .....j.................................................... (Intifirate of Tomplitturr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired by.............................. l7 ......... ..............................................................I.............................................................. Installer at-------_- ..............:;a"7_!...7m.,A.......................................................------ has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.___- ........... dated............................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......................................... v......... Inspector.. . ...................................................... THE COMMONWEALTH OF MASSACHUSETTS + BOARD OF HEALTH ............... ......................................................... No....... FEE.... . .. Disposal Vorko Tonstrurtion "nutit V Permission tis11creby granted.....1�......... S........................................................................................................ to Construct or Re elD�air an Indivj,4ual Sem*age is al System at No .........-: nzi.,t-�,et.�.. ..........P." .......... ------ ...........� ........................................ Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... ------------------7............ DATE............... ................................. Boa.4 of Health FORM 1255 HOBBS & WARREN, INC., PUBLISHERS Log Number: Date:- SA�t. . sa BARNSTABLE COUNTY HEALTH DEPARTMENT 7 SUPERIOR COURT HOUSE V BARNSTABLE, MASSACHUSEWS 02630 ' Algg9 DRINKING WATER LABORATORY ANALYSIS PHONE: aszsat t _ Exr. ssI Client: Pilgrim Colony Homes Collector: B��hori' Mailing'Address: 700 Washington St. Affiliation: P �m.Rim Go_ Hanover, MA j02339 '>iime 8r Date of . f Collawon. 5 z 00'P•M 3/22/82 Telephone: Type of Supply: wa1 i ma .gar Sample.Location: t 014 Date of Analysis: abird Lane Marstons Mills, MA Parameter Sample Result Recommended Limits Coliform'bacteria (organisms/100 ml) 0 0 pH 5,6 Conductivity 44. 500.0 Iron (ppm) .03 0.3 05 io.o Nitrate-Nitrogen (ppm) Sodium 5 20. Water sample meets the recommended limits of.all above tested parameters. Watei sample is drinkable but has higher than average levels of This does not represent a health hazard but future monitoring,is recommended (2 3 tunes per year). We will test for Sodium. Water'sample is drinkable but.-may present aesthetic pre5lems to users (staining, odor-or taste). Water sample is of poor.quality and is not recommended for human consumption. t � _ Resampling-and retesting is suggested. Results only; C t.REMARKS: 'rSx s " - cc: Barnstable Board of Health cc: Pilgrim Pump Co. ` Analyst:, ►��t 0. 11/18/81 LE rlc. /N pI *— ,z ,ray a)Kit U9 V �r �/ SCPrts" e s / a/1 Gyp(Zp 3,..5` a /vcuwc � E t/ I OGAit� lllCi � a :r r 73 SOIL LOG MOTES I. SEWAGE FLOW ,Corm _ ,Lon10 4` f !r ? 2. LEACHING AREA = Z4,Al - /(f e � ,L9 { 3. SEPTIC TANK = /add GAt,A 4 47C / C4x1 It- 4 ALL WORK MUST COMPLY WITH MASS.ENVIRONMENTAL Sfyt{;a - " CODE-TITLE 5 AND TOWN BOARD OF HEALTH REGULATIONS. 9a 5. _BRICK TANK, DIST. BOX S PIT COVERS TO WITHIN 12" SFttuGt 'OF GRADE 6. THERE ARE NO WELLS WITHIN 100' OF THIS PIT. ro 7. THERE IS NO SEWAGE LEACHING WITHIN 100' OF THIS id+)fish a WELL. folF N : SRrry SArty = I HARRISON ft 37493 PERC RATE DATE : 7-Zv- FINISH 94. 46 � 9� a - GRADE 9/. 7 0' ,�" "!vG PIPE 2„ 31 yd f1 X,�sJC PIPE �� zS:' � ,� +� 0 o ITCH I/4'%FT.MIN. = 2 `'`-f"�C- PIPE 2 -i/8 -I/2 WASHED PEASTONE• N :�. �y ? f PITCH 1/8/.FT. MIN. ELI' PITCH I/8%FT.MIAs ,�t ;�., 9/,!aJ o.aa"� 3/4!'-1 1/2 WASHED ?4.1f`/ � go..7Z go �.z % I ©V STONE FREE OF CI TEE DIST. BOX ,° FINES,DUST,IRON *� N O.OUTLETS s' FOUNDATION SEPTIC TANK OR B PRECAST .� OR BLOCK PIT �I LENGTH = S; WIDTH = LEACHING PIT 17- S EWER AGE SYSTEM PROFILE (NOT TO SCALE) WATER TABLE HARRISON SCALE ��a ' W SEWERAGE F3,;V PLOW PLAN ENGINEERING DATE Al.j� �� WITH SYSTEM AT : FLINT LOCKE DRIVE PLYMOUTH,MASS. 02360 PROJ. FORM