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Home My WebLink About0048 PINE LANE - Health 448 PINE LANE OSTERVILLE A 118 050 --ter y I` d � I I f Bk 26423 Ps237 w3421u 06-18-2012 & 03 2 14P DEED RESTRICTION WHEREAS,' of (owners name �,, A NF oSj-m-V L4, MA (address) is the.owner of P f ac LA located t (address) at 6 51r-►2v i LL, MA (hereinafter referred to as . and being shown on a plan entitled "Subdivision of Land in MA, Property of ' et at, duly recorded in Barnstable_County Registry. Of Deeds in Plan Book page 1 qa. Or on Land Court Plan Number WHEREAS, ��V�1j �'C.H� r�,— . -. as the owner of said lot has (owners name) agreed with the Town of Bamstable Board of Health to a restriction as to the number of bedrooms which can be included. in any home built.on said lot as a pre-condition to obtaining a disposal works construction permit in compliance with 310 CMR 15.000 State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage; WHEREAS, the Town of Barnstable Board of Health, as a pre-condition-to granting a disposal works construction permit for a septic system in compliance with 310 CMR 15.200, State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage, and authorizing the issuance of a building permit for the construction of a-single family home on this property, is requiring that the agreement for the,restriction on the number of ; bedrooms in any house,constructed on the lot be put on record with the Barnstable County Registry of Deeds by recording this document, dear r C ,, TOWN OF BARNSTABLE LOCATION i i l it 1-A ►' SEWAGE# I CJ 3 -, �. VILLAGE A S 3�+ ASSESSOR'S MAP& LOT 191 v f INSTALLER'S NAME&PHONE NO. J-(o b 11V 3d .� y SEPTIC TANK CAPACITY 'A-<b-0 ; LEACHING FACILITY: (type), C (size) X NO.OF BEDROOMS BUILDER OR OWNER 612 a /s PERMITDATE: % r/S-Q / COMPLIANCE DATE:��' Separation Distance Between the: Maximum Adjusted Groundwater Table/Faity m of Leaching Facility Feet- Private Water Supply Well and Leachi (If any wells exist on site or within 200 feet of leachin Feet Edge of Wetland and Leaching Facilitylands exist within 300 feet of leaching facility) Feet I Furnished by f - e I i �� ' ti ��d� ff I`� -�, � v; �` I. 1 --�' � /, � . � �, ,�: .�Y, - � _ _ fi No. — 0 J — _ w Fee 6-0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYtcation for Mfi5paal *ps�tem Cone;tructton Vertu Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 48 Pine Lane Ostervlle Estate of Sarah Walsh Assessor's Map/Parcel Installer's Name,Address,and/Tel.No. J Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P O Box 1089, Centerville; Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building J No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand Nature of Re a' or Alterations(Answer when applicable) Title-5 septic system con i g of a tank, D—box and 2 concrete leach chambers w s o e ail around. Date la ected: 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 issu d by s B and Tealth. Signed i v Date Application Approved by Dater/ Application Disapproved for the following reasons Permit No._�� 0 3 2— Date Issued d �� No li� - f' Fee i!cocr - -_ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 'k Yes PUBLIC-HEALTH DIVISION - TOWN dF BARNSTABLE., MASSACHUSETTS Zipplication for Mizpozaf *potent Con.5truction ermit" Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) El Complete System ElIndividual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Ass&8r''sRkff&ce1Lane, Osterv&lle Estate of Sarah Walsh Installer's Name,Address,LS Te.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service _. Type of Building: Dwelling No.of Bedrooms ! Lot Size sq.ft. Garbage Grinder( ) Other Type of Building 1 No. of Persons i Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons•.per day. calculated daily flow gallons. Plan Date Nuttjkr of:sheai "'r Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand �. f Nature of Repairs or Alterations(Answer when applicable) Title—Sseptle system ` leacb chambers a all arniincl - Date la LinsVed- Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system a 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 B and of Health. �.., Signed ► Date Application Approved by Date 7- �T Application Disapproved for a ollowing re son Permit No.� 4 _ „ v Date Issued 60 ------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Walsh Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ' )Repaired(g )Upgraded( ) Abandoned( )by W"- E Robins2n Septic Se;rvi Se m at 48 Pine r F; R �' - has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.! n�? dated Installer� _� _p� � j__ Designer / The issuance of this permit shallf not be c nstrued as a guarantee that the s,Cst m�will function as%designeld`. Date ! / Inspector f / . r ./l�f /I ✓j �/ � �/i/ 0 v,v ——————— No. _ Fe€S_ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Walsh lwigozar *pztem Construction Permit Permission is hereby granted to Construct( )Repair(X )Upgrade( )Abandon System located at 48 n , , _ �Pine Lane, ua e i j h y and as described in the above Application for Disposal System Construction Permit. The applicant recognes 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: / Approved by r I - dF NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. c CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) 1, William E. Robinson,S�Itereby cer*that the application for disposal works construction permit signed by the dated concerning the property located at 48 Pine Lane, o s to ry i 11 P meets all of the Mowing criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business uses associated th the dwelling. The soil is ed as CLASS I and the percolation rate is less than or.equal to 5 minutes per inch. There are no etlands within I00 feet of the Proposed>eptic a}stcnt — There urn private:wells within 150 feet e7i the proposed septic system • There is increase in flaw andlor change in use proposed There no variances requested or needed. • The m of the proposed leaching facility will n� less than located le than five feet above the ata mum adjusted groundwater table elevation.[Adjust the groundwater table using the Frimptor od when applicable) If the S.ALS.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following. A) Top of Ground Surhice Elevation(using GIS information) 8) G.W.Elevation _ +the MAX. High G.W. Adjusiment DIFFERENCE BETWEEN A and B SIGNED q e --� 1� ..,:� :L� DATE: [Sketch proposed plan of system on back). y:health folds:cen { e l � A t 7 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 48 Pine Ln. - Property Address] Trellis Bay LLC t Owner Owner's Name information is Osterville MA December 8 2010 required for every , 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. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your a cursor-do not Linda J. Pinto use the return Name of Inspector key. C Engineering �y Company Name P.O. Box 2030 Company Address Teaticket MA 02536 City/Town State Zip Code 508-299-3250 4432 Telephone Number License Number 1 B. Certification LU (—I I certify that I have personally inspected the sewage disposal system at this address and that the rd5 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 IfispedWs Signature V 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. (A16— t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Dispos System•Page 1 of 17 3 ' f f r { Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments yt 48 Pine Ln. Property Address Trellis Bay LLC Owner Owner's Name information is Osterville MA December 8 2010 required for , every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available.- ❑ Y ❑ N ❑ ND(Explain below): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Pine Ln. Property Address Trellis Bay LLC Owner Owner's Name information is required for Osterville MA December 8, 2010 every page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Commonwealth of Massachusetts "Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "r 48 Pine Ln. Property Address Trellis Bay LLC Owner Owner's Name information is Osterville MA December 8 2010 required for , every page. CityrFown 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. i ❑ 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 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 Y2 day flow Commonwealth of Massachusetts "Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Pine Ln. Property Address Trellis Bay LLC Owner Owners Name information is Osterville MA December 8 2010 required for - - -- -- - -- - - --- _ - '- every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 48 Pine Ln. Property Address Trellis Bay LLC Owner Owner's Name information is require!for Osterville MA December 8, 2010 every page. C i ty-1 T---w---n-------------------- ------------------ ---------- --- ---------------------- ---- 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 0 El 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? 0 El Has the system received normal flows in the previous two week period? El Z Have large volumes of water been introduced to the system recently or as part of this inspection? 0 E1* Were as built plans of the system obtained and examined? (If they were not available note as N/A) ' Z El Was the facility or dwelling inspected for signs of sewage back up? Z Ej Was the site inspected for signs of break out? Z 0 were all system components, excluding the SAS, located on site? 0 El 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: I Z [:1 Existing information. For example, a plan at the Board of Health. Z El Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 f Commonwealth of Massachusetts "title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Pine Ln. Property Address Trellis Bay LLC Owner Owner's Name information is required for Osterville MA December 8, 2010 .... .-.. --- - -- -.... every page. City/Town State Zip Code Date of inspection D. System Information Description: Number of current residents: 6 max Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Sept. 2010Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present?. ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "t 48 Pine Ln. Property Address Trellis Bay LLC Owner Owner's Name information is Osterville MA December 8 2010 required for .......... ----.......�.......... .. ... ......-. every page. Cityrrown State Zip Code Date of inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 48 Pine Ln. Property Address Trellis Bay LLC Owner Owner's Name information is Osterville MA December 8, 2010 required for - - - .-.-.....- - every page. CitylTown---------------------------------------------------------------------------------- State Zip Code 'bate-of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Approximately 10 years old per Town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 0.5 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: 1500 gallon tank Sludge depth: 1" Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M t 48 Pine Ln. Property Address Trellis Bay LLC Owner Owner's Name information is Osterville MA December 8 2010 required for ------------- , -----------------------..-------- - -. - --- - --- .................. ..----------- every page. CitylTown 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 29" Scum thickness 1/2 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 17.5 How were dimensions determined? Tape Measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,- liquid levels as related to outlet invert, evidence of leakage, etc.): The septic tank has a concrete cover 6" b.g. The septic tank appears to be structurally sound with no sign of backup or leakage. The outlet has a 4" PVC pipe with PVC tee and the liquid level is at the outlet invert. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M < 48 Pine Ln. Property Address Trellis Bay LLC Owner Owner's Name information is required for Osterville MA December 8, 2010 every page. City/Town State Zip Code "Date-din spection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): . Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Commonwealth of Massachusetts uTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Pine Ln. Property Address Trellis Bay LLC Owner Owner's Name information is required for Osterville MA December 8 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): The D-box appears to be in good condition with no sign of solids carryover. There is a concrete cover 16" b.g. There is one outlet and the liquid level is at the outlet invert. There is no sign of backup or leakage. 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: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M °�< 48 Pine Ln. Property Address Trellis Bay LLC Owner Owner's Name information is required for Osterville MA December 8 2010 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ 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.): The stone appeared clean and damp at the time of the inspection and there was no sign of hydraulic failure in the area of the SAS. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 't 48 Pine Ln. Property Address Trellis Bay LLC Owner Owner's Name information is required for Osterville MA December 8 2010 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments < 48 Pine Ln. Property Address Trellis Bay LLC Owner Owner's Name information is required for every Osterville MA December 8, 2010 page. Citylrown 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 2�•2 ►c1l ), I�AsJ , /,J i 50 i "e NdUjG �� A _ o I t5ins•(Y" Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Pine Ln. Property Address Trellis Bay LLC Owner Owner's Name information is required for Osterville MA December 8, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 16' below the bottom of the SAS 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: previous septic inspection report dated 01/26/01 ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS maps show the approximate elevation of the property to be 31+/-and groundwater elevation to be 10+/-, and the bottom of the system is approximately 5' b.g., so there is an approximately 16' separation to groundwater. Before filing this Inspection Report, please see Report Completeness Checklist on next page. Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Pine Ln. Property Address Trellis Bay LLC Owner Owner's Name information is required for Osterville MA December 8 2010 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file TOWN OF BARNSTABLE IV LOCATION SEWAGE # 3 �L VILLAGE 7r .S ir► ASSESSOR'S MAP & LOT S ' INSTALLER'S NAME&PHONE NO. Ka SEPTIC TANK CAPACITY . -� LEACHING FACILITY: (type)c;L (size) "r NO.OF BEDROOMS J BUILDER OR OWNER j:�A JA /,I �Y PERMITDATE: / -/Sy U J COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bo m of Leaching Facility Feet Private Water Supply Well and Leaching Fa ty (If any wells exist on site or within 200 feet of leaching f ility) Feet Edge of Wetland'and Leaching Facility any wetlands exist within 300'feet of;leaching facility), ". Feet Furnished by . . 1 COMMONWEALTH OF MASSACHUSETTS �1\ EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION w TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 48 Pine Lane Osterville, MA Owner's Name: Estate of Sarah Walsh Owner's Address: Box 62 "harl stownF MA Date of Inspection: 1—9 4 —0 1 Name of Inspector: (please print) William E_• . Robi_nson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA Telephone Number: (5 0 8) 7 7 5—8 7 7 6 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 Needs Further Evaluation by the Local Approving Authority , Fails Inspector's Signature:` ij Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Healthor 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. Notes and Comments - /liv''!�t/ ****This report only describes conditions at the time of inspection and under the conditions of use st 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 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 48 Pine Lane Osterville Owner: Estate of Sarah Walsh Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D Syste Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: S�v d 0 B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repa ed.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answe yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. e septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, xhibits substantial infiltration or exfiitration or tank failure is imminent System will pass inspection if the existing is replaced with a complying septic tank as approved by the Board of Health. *A metal eptic 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 expla' : Observation of sewage backup or break out or high static water level in the distribution box due to-broken or obstruct pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approva of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND a plain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass in ection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND ex Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 48 Pint-- T-ina n�tarvilla .. - Owner: of Sarah Walsh Date of Inspection:--,a C. Further Evaluation is Required by the Board of Health: Conditions exist which require flusher evaluation by the Board of Health in order to determine if the system is failin to protect public health,safety or the environment. 1. S stem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the s tem 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. ystem will fail unless the Board of Health(and Public Water Supplier,if any)determines that the syst m 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 froni a p ivate water supply well**.Method used to determine distance * This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform b cteria and volatile organic compounds indicates that the well is free from pollution from that facility and t e presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other ilure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 t OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 4 PART A CERTIFICATION(continued) Property Address: 48 Pine Lane Osterville Owner: Estate of Sarah Walsh Date of Inspection: 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 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 I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [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.] (Yes/No)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. L rge Systems: To be onsidered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 g Dd• You in indicate either"yes"or"no"to each of the following: (The fo owing criteria apply to large systems in addition to the criteria above) yes n the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped .. Zone II of a public water supply well If you ave answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"i i Section D above the large system has failed.The owns or operator of any large system considered a signifi ant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304 The system owner should contact the appropriate regional office of the Department. 4 f Page 5 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 48 Pine Lane Osterville Owner: Estate of Sarah Walsh Date of Inspection: /-- G —® I Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes INN o 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? L/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: Yes no �Z_ Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation' of distance is unacceptable)[310 CMR 15.302(3)(b)] " „ 4 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 48 Pine Lane Osterville Owner: Estate of Sarah Walsh Date of Inspection: %—,'t-4-d 1 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 45 Number of current residents: 8 Does residence have a garbage grinder(yes or no):A c) Is laundry on a separate sewage system(yes or no)vl,.a [if yes separate inspection required] Laundry system inspected(yes or no):_ Seasonal use: (yes or no):/L v Water meter readings,if available(last 2 years usage(gpd)): 19 9 9 3, 000 gal. Sump pump(yes or no): A-v Last date of occupancy: CO MERCIAL/INDUSTRIAL Type f establishment: Desig flow(based on 310 CMR 15.203): gpd Basis f design flow(seats/persons/sgft,etc.): Greas trap present(yes or no): Indus ial waste holding tank present(yes or no): Non-s itary waste discharged to the Title 5 system(yes or no): Wate meter readings,if available: Las ate of occupancy/use: OTH R(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as parf of the inspection(yes or no): L4,d If yes, volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYP OF SYSTEM eptic 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: 01 --g s -- O / Al r:' . 2 Were sewage odors detected when arriving at the site(yes or no):dip 6 Page 7 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 48 Pine Lane Osterville Owner: Estate of Sarah Walsh Date of Inspection: B LDING SEWER(locate on site plan) Dep below grade: Mate 'als of construction:_cast iron _40 PVC_other(explain): Dis ce from private water supply well or suction line: y Co ents(on condition of joints,'venting,evidence of leakage,etc.): SEPTIC TANK:Zoocate on siteplan) Depth below grade: T Material of construction: '�oncrete_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) 1 , L Dimensions: Sludge depth: 0 . Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: O Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle:LIZ How were dimensions determined: IL, L- .1 Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of.leakage,etc.): GRE SE TRAP:_(locate on site plan) Depth below grade: Mater al of construction:_concrete°" metal=fiberglass polyethylene_other (expl in): Dim sions: Scu thickness: Dis nce from top of scum to top of outlet tee or baffle: Di nce from bottom of scum to bottom of outlet tee or baffle: Dat of last pumping. Co ents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as r lated 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) Property Address: 48 Pine Lane Osterville Owner: Estate of Sarah Walsh Date of Inspection: )—AZ —O d T HT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Dep below grade: Mate 'a]of construction: concrete metal fiberglass_polyethylene other(explain): Dime ions: Capac ty: gallons Desig Flow: gallons/day Al present(yes or no): Al level: Alarm in working order(yes or no): Date f last pumping: Co ents(condition of alarm and float switches,etc.): DISTRIBUTION BOX.zlif 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.): /�✓t�u� 0 '2 S—a PU P CHAMBER: (locate on site plan) Purq s in working order(yes or no): Al s in working order(yes or no): Co ents(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued)' Property Address: 48 Pine Lane Osterville Owner: Estate of Sarah Walsh r. Date of Inspection: / r?,C - `t SOIL ABSORPTION SYSTEM(SAS): ✓(locate on site plan,excavation not required) If SAS not located explain why: Type aching 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.): 5!l - L�aC/ X ---/ L � � z�G �1> ; 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: 1,604 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.): PR (locate on site plan) , Mat ials of construction: - Di en sions: De of solids: Co ents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 ' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 48 Pine Lane Osterville Owner: Estate of Sarah Walsh Date of Inspection: <;-G D-1 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. i G d 71 d 10 n Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C , SYSTEM INFORMATION(continued) Property Address: 48 Pine Lane Osterville Owner: Estate of Sarah Walsh ` Date of Inspection: = ---CYr SITE EXAM Slope Surface water Check cellar Shallow wells ti Estimated depth to ground water 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: �bserved site(abutting property/observation hole within 150 feet of SAS) hecked 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: (, I lob - ' % "7 a r r ' r • °s. Y 11 A 1I I. _ 6 y , t • I 1 I I IN Fr Q i 1 rill Fit 71 i i _ E t r / f pi�� I _._ -