HomeMy WebLinkAbout0053 PINE LANE - Health 531'ire Lane, Ostervil►e
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usetts Commonwealth of Massach
. Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
53 Pine Ln.
Property Address
Ryan
Owner's Name
Osterville MA 02655 11/25/13
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.
A. General Information
1. Inspector:
Frank Nunes III
Name of Inspector
saa
Company Name
Box 841
Company Address
East Falmouth MA 02536
City/Town State Zip Code
508.272.6433
Telephone Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.34.0 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
11/25/13
Inspe s Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 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. ,
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 53 Pine Ln.
Property Address
Ryan
Owner's Name
Osterville MA 02655 11/25/13
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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:
Pumping suggested every 3 yrs to prolong the life of the system
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.
p
Answer yes, no or not determined.(Y,N, ND) in the❑ for the following statements. If"not
determined,"please explain.
❑ The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with 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 bid is available.
ND Explain:
n/a
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
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Commonwealth of Massachusetts
D. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
53 Pine Ln.
Property Address
Ryan
Owner's Name
Osterville MA 02655 11/25/13
CityfTown State Zip Code Date of Inspection
B. Certification-(cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
n/a
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
ND Explain:
n/a
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health; safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
El 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.
0 The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
El The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
web.mail.comcast.net•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
53 Pine Ln.
Property Address
Ryan
Owner's Name
Osterville MA 02655 11/25/13
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ 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:
n/a
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool '
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/Z day flow ,
❑ ® 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.
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Commonwealth of Massachusetts
Title 5 Official Inspection Form.
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M °r 53 Pine Ln.
Property Address
Ryan
Owner's Name
Osterville MA 02655 11/25/13
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
i
❑ ® 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 16,000 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.
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f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
GM 53 Pine Ln.
Property Address
Ryan
Owner's Name
Osterville MA 02655 11/25/13
Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
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III
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M Sve,� 53 Pine Ln.
Property Address
Ryan
Owner's Name
Osterville MA 02655 11/25/13
Citylrown State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440
Number of current residents: 0
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)):
Sump pump? ❑ Yes ® No
Last date of occupancy: Seasonal
Date
Commercial/Industrial Flow Conditions:
Type of Establishment: n/a
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:
Last date of occupancy/use: Date
Other(describe): n/a
web.mail.comcast.net•03108 Title 5 Official Inspection Form-Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
53 Pine Ln.
Property Address
Ryan
Owner's Name
Osterville MA 02655 11/25/13
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: No recent pumping per owner
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):
Pump chamber
Approximate age of all components, date.installed (if known) and source of information:
10/8/97 per BOH record
Were sewage odors detected when arriving at the site? ❑ Yes ® No
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 53 Pine Ln.
Property Address
Ryan
Owner's Name
Cisterville MA 02655 11/25/13
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 18"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >10'feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 12"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: 1500g
Sludge depth: trace
11
Distance from top of sludge to bottom of outlet tee or baffle >12
Scum thickness trace
>2°
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle ,211
How were dimensions determined? measured
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
53 Pine Ln.
Property Address
Ryan
Owner's Name
Osterville MA 02655 11/25/13
CityrFown 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.):
Pumping suggested every 3 yrs to prolong the life of the system
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
n/a
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
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert; evidence of leakage, etc.):
n/a
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):
n/a
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Commonwealth of Massachusetts
Title 5 Official Inspection Forme
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 53 Pine Ln.
Property Address.
Ryan
Owner's Name
Osterville MA 02655 11/25/13
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cont.)
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.):
n/a
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 011
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 18" beloiw grade, cover raised to 6", no adverse conditions
Pump Chamber(locate on site plan):
Pumps in working order: ® Yes ❑ No
Alarms in working order: ® Yes ❑ No
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
GSM 53 Pine Ln. - -
Property Address
Ryan
Owner's Name
Osterville MA 02655 11/25/13
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
n/a
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 6 infiltrators per
BOH record
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
I
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
SAS was probed and soils are dry and compact. No indication of past backup
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Commonwealth of Massachusetts
Title 5 Official Inspection Foam
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 53 Pine Ln.
Property Address
Ryan
Owner's Name
Osterville MA 02655 11/25/13
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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
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.):
n/a
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f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 53 Pine Ln.
Property Address
Ryan
Owner's Name
Osterville MA 02655 11/25/13
CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
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.
L Li
� 1
t
RS D-3
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r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 53 Pine Ln.
Property Address
Ryan
Owner's Name
Osterville MA 02655 11/25/13
Cityrrown 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: >12
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
per elevation of home
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TOWN OF BARNSTABLE
LOCATION (�r�a1� SEWAGE #
(C �®,
VILLAGE 0 25 `t -P�J��I ASSESSOR'S MAP & LOT
INSTALLER'S NAME&'PHONE
SEPTIC TANK CAPACITY Al
LEACHING FACILITY: (type)_.,k�xe- Dc4i!i�: ,e-,L(size)
NO.OF BEDROOMS
BUILDER OR OWNE p
PERMITDATE: 1glCOMPLIANCE DATE: O
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist,, ,
on site or within 200 feet of leaching facility) Y - Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300,feet of leaching facility) Feet
Furnished by
�_,
(� �i*'`�Y��'
�' !'i r.�'a�
� � .
c°
o -� � _.� \
� . . � �
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F�_.. -- _._ \
, . \
x`�
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No. �[O L Fee ��
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
2pprication for Migogat *p6tem Construction Permit
Application for a Permit to Construct( )Repair(i/)Upgrade( )Abandon( ) O Complete System ❑Individual Components
Location Address or Lot No. $3 P tq 1_(_0j-6 0ST5 -9—wner's Name,Address and Tel.No.
Assessor's Map/Parcel r r0-00(o Kr 1 S i lJ^P_/4 AS
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 440 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date ,
Title
Size of Septic Tank f� 5.T. 4 'T- Type of S.A.S. %I r� f t w a l
P L, C,r �rP' YP 1 h �{�-�-,--T t V
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) `5rA
tom CCkum px'c -60__5-!Zo 0,Q Sf]n6 C 4— /,(_,/
�c a
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 E vironmental Code a not t ce the system in operation until a Certifi-
cate of Compliance has bee o of
Signe Date RZ
Application Approved by Date 140 7 •-? 7
Application Disapproved for thgo7ow-A reasons
Permit No. Date Issued
/R i
dy
• :��" - ,,�. �. 6 ter.�' V t T Y'. , _ ..
(r'j '" c ;a Fee ..✓
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
r 2pprication for Mi5po',ar,6pzterri Con trurtion Permit,
Application for a Permit to Construct( )Repair(V)Upgrade( .; )Abandon( ) ❑Complete System ❑Individual Components
g
Location Address or Lot No. 55,3'P,N 1P__L'Ar-G C)SV0V Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
} 5�- 'As
O 03w--tf, VW
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow y�/ gallons.
Plan Date Number of sheets Revision Date
,
Title
Size of Septic Tank I j 0 5 T• (-Ctx (L�Pi r Type of S.A.S. 1A'0` C`ort)'-A .t-), ill vc-Ir
Description of Soil r� S r-
tr�C.�
4 yS7CVV
Nature of Repairs or Alterations(Answer when applicable) .="W 3r-gr ! .'s 1)0 d
In tm t D 0- 60)) 74,A- 5 i n T_- 4 /L0/
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 E vironmental Code a 6 not t ce the system in operation until a Certifi-
y ... >. i w
Cate of Compliance has beef i stae �. . 0 of•
Signed '! -,Date /d 6 �'I 7
^Application Approvedby K
- .: _ .Date a rI—
Application Disapproved fothe oreasons
Permit No. — Date Issued
----------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,`MASSACHUSETTS t
Certificate of Compliance
THIS IS TO CERTIFY, t} j the On-site Sewage Disposal System Constructed( )Repaired (� )Upgraded
Abandoned( )by v d✓ �- e
at L.>`1w � _ —(CV'i 1 h een constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. ' B ated
Installer I Designer , r t
The issuance of th' a h nol be construed as a guarantee that the s so "w'll u/n�ctio aI
iAr
Date Inspector //�X rasign/e-
�
---------------------------------------
No. / Itr Ll Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
nigotar *pgtem Congtrurtiort 3dermit
Permission is hereby granted to Construct( )Repair(✓Upgrade( )Abandon( )
System located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be
eeicompleted within-t ee years of the date of this permit.
Date: l — / Approved by r.��
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1 53 Pine Lane
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Os terVllle, MA
.Assess Atop Il d Parcel 066
__ A 4 M Land Senlm-, Inc. 33 Old Yvin Street. South Jarmouth, MA OF684 (608) 398-2LB1
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Assess MOP 118 Parcel 086
A & A! land Services, lac. 33 Old Mein Sttret South Yarmouth XA OR884 (508) 398-21pi
NOTICE: This Formis W In tl"Sed for the Repair of Failed • • ��'
Septic Systerns 0111y
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CERTICICA'I'ION OF SKETCH AND APPLICATION FOR A DISPOSAL
1VOIZKS CUNS'I'RUC'I-1ON PEIt(191'1•(1V1'1'110U'1' DESIGNED PLAN
hereby certify that the application for disposal works
construction permit signed by me dated ���� '�� , concerning the
property located at Qt _e_ o5tv:W 1 meets rill of the
following criteria:
There are no private wells within 150 feel of the proposed septic system
The observed groundwater fable is 14 feet or greater below the bottom of the leaching facility
There is no increase in flow and/or change in use proposed
a There are no variances requested or needed.
SIGNED DATE: /rO"2
LICENSED SEI"ric SYSTEM INS'rALLER IN TIE TOWN OF BARNSTABLE[NUMBER
[Attach a sketch plan of the proposed system. Also if the licensed Instailer posesses a certified plot plan,
this plan should be submitted).
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TOWN OF BARNSTABLE
LOCATION Prwa '�"� SEWAGE# �)Q =
VII,LAGE O �r U1�� ASSESSOR'S MAP & LOT - U
INSTALLER'S NAME&PHONE
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type)tL=k�xC fi2ci j - � Z (size) b?r`1�
NO.OF BEDROOMS
BUILDER OR OWNS
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom-of Leaching Facility,,,, Feet
Private Water Supply Well and Leaching Facility (If any wells exist;-
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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TOWN OF BARNSTABLE
BOARD OF HEALTH
ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION
Date 6 , Time: In Out
Owner Tenant Dp
Address Address
Complian,0 Remarks or
Regulation# Yes O Recommendations
2. Kitchen Facilities
3. Bathroom Facilities? :: ' '
4. Water Supply
5. Hot Water Facilities
6. Heating Facilities
7. Lighting and Electrical Facilities
8. Ventilation
9. Installation and Maintenance of Facilities
10. Curtailment of Service -
11. Space and Use -
12. Exits
13. Installation and Maintenance of Structural
Elements
14. Insects and Rodents
15. Garbage and Rubbish Storage and Disposal
16. Sewage Disposal
17.Temporary Housing
18. Driveway Width / P-U
19. Number of Tenants Observed
PART II
37. Placarding of Condemned Dwelling;
Removal of Occupants; Demolition
Number of Bedrooms Number of Vehicles Allowed (max)
Number of Persons Allowed (max)
Person(s) Interviewed Inspector
If Public Building such as Store or Hotel/Motel specify here
�
Approver!: 417116
TOWN OF BARNSTABLE MLD Cat
BOARD OF HEALTH
ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION
2
Date 2110 Time: In Out
Owner K- ���')�y I 1�V Tenant , //�
� , l ' l�
Address / r �(�g '��1�- �� AddressS,3 I!\I�i
Compliance Remarks or
Regulation# Yes NO Recommendations
2. Kitchen Facilities
3. Bathroom Facilities
4. Water Supply
5. Hot Water Facilities
6. Heating Facilities !MPO
7. Lighting and Electrical Facilities i
(3 SE
8. Ventilation
9. Installation and Maintenance of Facilities
10. Curtailment of Service a klWCH
11. Space and Use ,01 C Q
— G
12. Exits
13. Installation and Maintenance of Structural
Elements
14. Insects and Rodents
15. Garbage and Rubbish Storage and Disposal
16. Sewage Disposal �`y
17. Temporary Housing WIN—)_
18. Driveway Width V _q
ZQ
19. Number of Tenants Observed
PART II
37. Placarding of Condemned Dwelling;
Removal of Occupants]; Demolition
Number of Bedrooms "1 Number of Vehicles (max `J
Number of Persons Allowed (max)
Person(s) Interviewed Inspect
7 r,
..If Public Building such as Store or Hotel/Motel specify here
F
Muriel Hallet Res. (508)394-6883
OY9, TEQ-
; IZEAI�. TATE
829 Main Street,Box 1017 (508)420 1000
Osterville,MA 02655 FAX(508)428-1623
FRE
COMMONWEALTH OF MASSACHUSETTS
E,XECUTIVEOFFICE OF ENVIRONMENTAL AFFA �E
DEPARTMENT OF ENVIRONMENTAL PROTECTI"ON
' 7
�l S�ev
l , t TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 53 PINE LAN•E•OSTERVILLE,MA 02655 / �
Owner's Name: ROY ANDERSON
Owner's Address: 22 GROFFTT RD RIVERSIDE CT 06878
Date of Inspection: 9/18/02
Name of Inspector: (please,print) ;. JOHN GRACI
COPY
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Company Name: SEPTIC INSPECTIONS i
Mailing Address: ;) P,O.°I3QX 2119 TEATICKET,MA.02536
Telephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT
1 certify.that 1 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 10 CMR 15.000). T] e s st�ej�m��:
f �y�;'Ali ��/ �11Sf Qr �1 � V/"
Passes I' 6P;�'-1 f/ �i9✓t �ll/� 02per �rit�/ c7�Mrt. .SP��i��yCr/1icE��Pr �Uz /p(o%t'i
X Conditionally P s s rfp�tiee q ,� p„Q�- �� ?
_ Needs Fu`rthe nation by the LoPal pproving Authorits� � ' �'�P�rX "��+� Ile r
_ Fails f SSv wee Ca,j� CuPrz Cr1e�/ ���eT`,y�"1
• °' Dat� 9/18/02
Inspector's Signature: 1 I U✓.�-I�.� � k
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 ille 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 tie buyer, if applicable,and the approving authority.
Notes and Comments
SYSTEM CONDITIONALLY-PASSED TITLE V INSPECTION.ONE INLET INTO SEPTIC TANK IS UNDERWATER-
PUMP CHAMBER NEEDS,gNEW q;..O.V.ER-RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE. RECOMMEND RAISING INSPECTION PORTS.
0 } I r t
****This report only deceribec c�ndit,o4, at the time of inspection and under the conditions of use at that Buie.'Phis
inspection does not address If-- the syste will perform in the future under the same or different conditions of use.
Title S Incnartion Form
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Page 2 of 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 53 PINE LANE OSTERVILLE, MA 02655
Owner: ROY ANDERSON
Date of Inspection: 9/18/02
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: t
_ I have not found any information which indicates that any of the failure criteria described in.310 CMR 15.303 or in 310
CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
SYSTEM CONDITIONALLY PASSED TITLE V INSPECTION. ONE INLET INTO SEPTIC TANK IS
UNDERWATER-PUMP CHAMBER NEEDS NEW COVER-RECOMMEND PUMPING EVERY TWO YEARS TO
PROLONG THE SYSTEM'S,USEF,UL LIFE. RECOMMEND RAISING INSPECTION PORTS.
B. System Conditionally Passes:,;;
X One or more system components�as described in the"Conditional Pass"section need to be replaced or repaired.The
system,upon completion of the repl`aceinent or.Yrepair,as approved by the Board of Health,will pass.
:.t
Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain.
n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) 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,iris structurally sound, not leaking and if a Certificate of Compliance indicating
that the tank is less than 20 years old is available.
ND explain: n/a
n/a Observation of sewage backup-or break oiit 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
bb'striiction is"removed
-_q distribution.box is leveled or replaced
t ,
ND explain: n/a i
n/a The system required pumping Pnore than 4:times a year due to broken or obstructed pipe(s).The system will pass
inspection if(with approval of the Board of Health):
_broken pipe(s)are replaced
_obstruction is;removed
ND explain: n/a s;
f�'d40
Page 4 of I I
OFFICIAL INSPECTION 'FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
` CERTIFICATION(continued)
Property Address: 53 PINE LANE OSTERVILLE, MA 02655
Owner: ROY ANDERSON !
Date of Inspection: 9/18/02 ,l",!
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no".to each of the following for all-inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cessp6ol" .
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
_ X Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow
X Required pumping more than 4'tinles in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped NO PIJMPINGINFORMATION.
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool oy privy,is within 100 feet of a surface water supply or tributary to a surface water supply.
_ X Any portion of a cess ool,or privy is within a Zone 1 of a public well.
X Any portion of a cesspooPor privy is within 50 feet of a private water supply well.
X Any portion of a cessp6ol.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.colifurm bacteria and volatile organic compounds indicates that the well is free
from pollution from that facilfty'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 forma +
(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.
d• .
E. Large Systems: .4.
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 ib large systems`in addition to the criteria above)
yes no
1X the system is within 400,-fee't of-a surface drinking water supply
X the system is within 200 feetlof'a tributary to a surface drinking water supply
'�V I' '
X the system is located in`ia nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 11 of a public watersupp!ywelI
If you have answered"yes'I'to'any.question in Section E the system is considered a significant threat,or answered
"yes" in Section D above the large sysiem has failed. The owner or operator of any!arge system considered a significant threat
under Section I_;or failed under'Se4'1'6'1V,b s udii,upgrade file s},steili ill iicWIA,ilitt tk-11113 10 CNIIt 0.30]. I Il§Y, teiil (ll]l I'
should contact the appropriate regionaloff de of the Department.
v
Page 3 of I I
4
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 53 PINE LANE OSTERVILLE, MA 02655
Owner: ROY ANDERSON ;
Date of Inspection: 9/18/02
C. Further Evaluation is Requiredby 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..envifronnlent.
1. System will pass unless Board of wealth 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 within36feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Boar&of Health (and Public Water Supplier,if any)determines that the
system is functioning in a' nanner that protects the public health,safety and environment:
-1
_ 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 wak r'supply.
_ The system has a septic tank and SAS and the SAS is within a Zone I 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 sepfie;tarik and.SAS�and the SAS is less than 100 feet but 50 feet or more from a private water
supply well**. Method used, determine distance n/a
**This system passes if the well:water-analysis,performed at a DEP certified laboratory, for coliform bacteria and
volatile organic compounds indica't'p5 that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen isequ.,I to or less than 5 ppm, provided that no other failure criteria are triggered. A copy
of the analysis must be attached to this form.
3. Other: '
n./a
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Page 5 of 1 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 53 PINE LANE OSTERVILLE, MA 02655
Owner: ROY ANDERSON""
Date of Inspection: 9/18/02 -
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system componentg•pumped out in the previous two weeks
X Has the system received nlormal flows in the previous two week period
X Have large volumes of water been,introduced to the system recently or as part of this inspection?
X _ Were as built plans of the ystem obtained and examined?(if they were not available note as N/A)
IS}.
X _ Was the facility or dwellinehln bected for signs of sewage back up
X _ Was the site inspected for,signs of break out'?
X _ Were all system components,excluding the SAS, located on site'?
X _ Were the septic`tankmanholes'uricoJered,opened,and the interior of the tank inspected for the condition of the
baffles or tees,material of construction,dimensions,depth of Liquid,depth of sludge and depth of scum ?
X _ Was the facility owner('and occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal"systeins`?
The size and location of theSo:il.Absor;ption System(SAS)on the site has been determined based on:
Yes no 1
X _ Existing information. Fo'r`ezam'ple,a"plan at the Board of Health.
X _ Determined in the field(if any of the'failure criteria related to Part C is at issue approximation of distance is
unacceptable)[310 CMR 15.302(3)(b)]' $
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Page 6 of 1 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 53 PINE LANE'OSTERVILLE, MA 02655
Owner: ROY ANDERSON
Date of Inspection: 9/18/02
;FLOW CONDITIONS
RESIDENTIAL }
Number of bedrooms(design): 4 Number of'bedrooms(actual): 4
DESIGN flow based on 310 CMR 1.5.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: n/a
Does residence have a garbage grinder`(ye's or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or 6o) 'NO
Seasonal use: (yes or no): YES
Water meter readings, if available(fast 2 years'usage(gpd)): rr/ -
Sump pump(yes or no): NO' `'' 0 ,7-0J 60
Last date of occupancy: 8/31/02 t'
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a t, . `.
Design flow(based on 310 CMR1111,.203) ,n/agpd
Basis of design flow(seats/persons/sgft;etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste dischargedlid4 el itle 5 'system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
JGENERAL INFORMATION
Pumping Records ;" '
Source of information: NO PUMPING`INFORMATION
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons-- How was quantity pumped determined? n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank,distribution box,soiNbsorption system
_Single cesspool
_Overflow cesspool i1. ,
_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,D,EP approval
Other(describe): n/a s!;!
Approximate age of all coin pone'nts,46ie installed(if known)and source of information:
HOME 52 YEARS-SYSTEM 5•V-RS BY OWNER
Were sewage odors detected when arriving at the site(yes or no): NO
tc 1,
Page 7 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 53 PINE LANE OSTERVILLE, MA 02655
Owner: ROY ANDERSON
Date of Inspection: 9/18/02
1
BUILDING SEWER(locate on site plan)
Depth below grade: 18" !JL
Materials of construction:_cast iron;-X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 12"
Material of construction: Xconcrete Jmetal fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age coi firnied by a Certificate of Compliance(yes or no): NO'(attach a copy of certificate)
Dimensions: 150OG L 10' 6" H 5' 7" W 5' 8" P"
Sludge depth: 3"
Distance from top of sludge to bottom of outlet tee or baffle:31"
c '
Scum thickness: 4"
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: 14"
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
SEPTIC TANK IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.ONE INLET INTO TANK IS
UNDER WATER-NEEDS TUBE REPAIRED-RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG
THE SYSTEM'S USEFUL LIFE.
GREASE TRAP:_(locate on sifet'plain')
'711 Si "
Depth below grade: n/a
Material of construction:_concrete_metal fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendatibil`s,'inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc ,
n/a
1
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Page 8 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART C
SYSTEM INFORMATION(continued)
Property Address: 53 PINE LANE,OSTERVILLE,MA 02655
Owner: ROY ANDERSON Frl.
Date of Inspection: 9/18/02
TIGHT or HOLDING TANK: (tank most be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a : f
DISTRIBUTION BOX:X(if present,lmust be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
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 STRUCTURALLY.SOUND.
•j
PUMP CHAMBER: X(locate on site plan),
Pumps in working order(yes or no) 'YES
Alarms in working order(yes or no):YES..
Comments(note condition of pump chamber,'condition of pumps and appurtenances,etc.):
PUMP CHAMBER NEEDS NEW'COVER:
• F,
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 53 PINE LANE OSTERVILLE, MA 02655
Owner: ROY ANDERSON
Date of Inspection: 9/18/02
SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required)
t•
If SAS not located explain why:
n/a
Type r '
n/a �,p , leaching pits, number: n/a
INFULTRATORS leaching chambers, number: 6
n/a leaching galleries, number: nla
n/a leaching trenches, number, length: n/a
n/a f,;, leaching fields, number: n/a
n/a __ overflow cesspool, number: n/a
n/a ;a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil,signs`of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
DID NOT EXPOSE INFULTRATORS,APPEAR TO BE STRUCTURALLY SOUND AND FUNCTIONING
PROPERLY. FIELD SHOWS NO SIGNS OF FAILURE
CESSPOOLS: (cesspool must be pumped as,part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or r o): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,'etc.):
n/a F
PRIVY: (locate on site plan)
Materials of construction: n/a ,: •; ;
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
Page 10 of 1
4�
OFFICIAL INSPECTION FORM =NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
ti
PART C
SYSTEM INFORMATION(continued)
Property Address: 53 PINE LANE OSTERVILLE, MA 02655
Owner: ROY ANDERSON
Date of Inspection: 9/18/02
SKETCH OF SEWAGE DISPQSAL 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.
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Page I 1 of 11
OFFICIAL INSPECTIO".4 FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 53 PINE LANE OSVRVILLE, MA 02655
Owner: ROY ANDERSON
Date of Inspection: 9/18/02
\
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board'of Health-explain: n/a
NO Checked with local excavators;, aistallers-(attach documentation)
NO Accessed USGS database explain: n/a
You must describe how you established tie Nigh ground water elevation: ,
HAND AUGER- 12+ FT.
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F TER REAL ESTATE PHONE NO. 508,428 1623 NoV. 04 2002 04:49PM P2
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Roy and Leslie Widmer.
22 Gros"
Riverside,CT 06973
November 4,2002
Assumes Excavation ,
550 willow ingot u
West YuInAutfl,MA 02673
Ae: 53-Pitse Law f.
O tw&le,MA 02655
4l.
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Dear Sim
Attached is �u si work f fsal.�I undavm d that)vu will be this woric
{ your l�p�'.
as soon as possible so as t4`be ready far a bard of Health inspection of this work ors
`Thbaieday,Novem���As
you Jamov,w `are planning fox a closing on this property on
Friday,so time is of the essence.
Tank you for td*g this s®l;on"s w®appremate your amerce.
5 z r F • Y Y
.Y a r •f �. o.r' Andersen
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DATE: _9/ 9
MCEIVFFE7)
PROPERTY ADDRESS: 53 Pine* Lane
Osterville,Mass .
SEP .18 1997
KALT
02655 TOWNC:
1
On the above date, I Inspected the septic system at the -above address.
This system consists of the following:
1 . 1 -6 '.x8 ' block cesspool .
2 . T-5 ' x6 ' block cesspool .
Based on my Intuo-actlon, I certify the following conditions:
1 . This is not a title five septic—systein.
2 . This is a sewage system.
3•. The sewage system is in proper working
order at the present time.Both cesspools _are dry.
4 . yThe system passes Conditionally. The Board of_Health 7
will make final rub..i.ng. Cesspools are_ within 50 and 41
) from the pond.
V GNAT UR!7 fo
Name : J . P . Macomber Jr.,
----------------------
Company: J . P_Macomber &- Son•_Inc ,
Address :_ Sax-6b------- _- --
__Cen.ervilLe LMass__02632
Phone : 5CZ-77S-.333a------- - 1
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
a
JOSEPH P. MACOMBER. & SON, INC,
Tank&-C*upool&-Lerchflald&
. Pump+d ra Installtd
Town Sewer Connectlon&
P.O. Box 66 ' Centerville, MA 02632.0066
775-3335 775-6412
TOWN OF BARNSTABLE
LOCATION /d; SEWAGE#
VILLAGE � AID E� ASSESSOR'S MAP& LOT -
INSTALLER'S NAME A PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility ` Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Le ching Facility(If any w dands exist
w� iin' �fee f ac /acility)
' Feet
Furnished b y
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON, MA 02108 617.292.5500
WILLIANI F u ELD TRL D1 CO
GoNcmor sc;rct
ARGEO PALL CELLLICCI DA\ID B S T RL
Lt Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Com.mm'o
PART A
CERTIFICATION
Property Address: 53 Pine Lane Osterville Mass Address of Owner:
Date of Inspection: 9/8/97 I (if different)
Name of Inspector: i O s eph P. Macomber Jr .
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: Joseph P. Macomber & Son , T 1C .
Mailing Address: B-0-X-5b, Centerville , Ma . 02632-0066
Telephone Number: — —
CERTIFICATION STATEMENT
I cenify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper (unction and
maintenance of on-site se agg dispo systems. The system:
' r
Passes
Conditionally Passes
si—Ac F, nhar Fv2I,,;ainn Rv tha I oral Annrovine Authnriry
i'41Ls
Inspector's Signature: _
The System Inspector shall submit a.copy of this inspection report to the Approving Authoriry within thirty (30) days of completing inis
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 suomo
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the syvem owne
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
A) SYSTEM PASSES:
4,'V have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR is 303
>ny fail re criteria nqt evaluated are indicated
COMMENTS: .�°>;
I S Ev^o'
BI SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upo,
/ — completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain wny not
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection, o
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tdnk
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10 '
DEP on the World Wide Web: hnp:1twww.magnet.state.ma.usrdep
Printed on Recycied Paper
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 53 Pine Lane Osterville Ma
Owner: Wianno Real Estate
Date of Inspection: 9/8/9 7
BJ SYSTEM CONDITIONALLY PASSES (continued)
,f�6tili Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
,�_ID The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
CJ 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 the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance ti (approximation not valid).
3) OTHER
Z zm4 ady.-4/s `T d L1& s
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(revised 04/25/97) Page 2 of 10
f
V
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
I
Property Address:53 Pine Lane Osterville Ma
Owner: Wiano Real Estate
Date of Inspection: 9/8/9 7
D] SYSTEM FAILS:
You must indicate ewer "Yes" or "No" as to each of the following:
1 have determined that the system violates one or more of the following failure criteria as defined in 310 CN1R 15.303. The bans
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No /
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe($).
Number of times pumped _.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
_ Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
J/ Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
�. The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
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
Q� 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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 53 Pine Lane Osterville Ma
Owner: Wianno Real Estate
Date of Inspection: 9/8/9 7
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
74-1' None of the system components have been pumped for at least two weeks and the system has been receiving normal
now rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
A
_ All system components, alluding the Soil Absorption System, have been located on the site.
k manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
�C,IJ(j The septic tan
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum
—The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner land occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b))
(revised 04/25/97) P&g• 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 53 Pine Lane Osterville Ma
Owner: Wianno Real Estate
Date of Inspection: 9/8/9 7
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 41?L.p�d./bedroom for S.A.S.
Number of bedrooms: �j!
Number of current residents: 13
Garbage grinder (yes or no):AIC)
Laundry connected to system (yes or no):$4
Seasonal use (yes or no):3 f nn
Water meter readings, if available (last two (2) year usage (gpd): ll%/y'5� �
J�fi6_
Sump Pump (yes or no):
�(1 �,j�j� � 111e�f e lai�S/✓Y 6�J>l�f
Last date of occupanc),:�
COMMERCIAL/INDUSTRIAL:
Type of establishment: A'1#
Design flow:A_gallons/day
Grease trap present: (yes or no)Ah
Industrial Waste Holding Tank present: (yes or no)JA
Non-sanitary waste discharged to the Title S system: (yes or no)A
Water meter readings, if available:A,//+
A)A
Last date of occupancy:
OTHER: (Describe) .4)h
Last date of occupancy: $
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Aari
System pumped as pan of inspection: (yes or no)
If yes, volume pumped: gallons
Reason for pumping; —
TYPE OF SYSTEM
- Septic tank/distribution box/soil absorption system
Single cesspool-�,
A)D Overflow cesspool
_,926_ Privy
UD Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)Ald
(revised 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 53 Pine Lane Osterville Ma
Owner` Wianno Real Estate
Date of Inspection: 9/8/9 7
BUILDING SEWER:
(Locate on site plan)
If
Depth below grade:_
.Material of construction: cast iron _ 40 PVC _ other (explain)
Distance fromfprivate wat r supply well or suction line
Diameter hl
Comments: (condition of joints, venting, evidence,of leakage, etc.) T 1
!Z S rr3 A1lu�4t^ ��' T,./Jn P�/i�J,Q�r� 6 .�A�d , r�V S%2.ifl
ThaaYf,
SEPTIC TANK:
(locate on site plan)
Depth below grade:_AO
Material of construction ALdconcrete,(Ametal4?AF Polyethylene,(,_il9other(explain)
t If tank is metal, list age _4& Is age confirmed by Certificate of Compliance(Yes/No)
Dimensions: /4
Sludge depth: Nly
Distance from top of sludge to bosom of outlet tee or baffle:.41//Y
Scum thickness:�i lW
Distance from top of scum to top of outlet tee or baffle:
Distance from bonom of scum to bonom of outlet tee or baffle: A.)/
How dimensions were determined: IV 4
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
O-,oTia 7-Ay /S Ab7 f�S�vT
GREASE TRAP:A�e_vty.
(locate on site plan)
Depth below grade: 4)W
f n aion:VAconcrete.U4metal Aiber lass o of eth len Cher ex lain)
material o c o s truc — � g � Y Y �o P
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffletiI;P
Distance from bottom of scum to bottom of outlet tee or baffle: .V'�'
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
a re'95 6� /71 is AiDT l'e 4iy
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Properly Address: 53 Pine Lane Osterville Ma
Owner: Wianno Real Estate
Date of Inspection: 9/8/9 7
TIGHT OR HOLDING TANK�Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:AW
Material of construct ion,./Xconcretes!/hmetak/4iberglass4L, PolyethyleneA�other(explain)
NA
A,W
Dimensions:
Capaciry: .fJ gallons
Design flow:— A,�!j — gallons/day'
Alarm level:_ )& Alarm in working order// Yes;4�j No
Date of previous pumping: AA19 _
Comments.
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:_
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
Y
PUMP CHAMBER:&wL°-
(locate on site plan)
Pumps in working order: (Yes or No)/CIW
Alarms in working order (Yes or No)_,djj�l
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 04/25/97) Pag• 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:53 Pine Lane Osterville Ma
Owner: Wianno Real Estate
Date of Inspection: 9/8/9 7
SOIL ABSORPTION SYSTEM (SAS):,
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:
leaching chambers, number:
leaching galleries, number:_a
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system: /I)6
Name of Technology: .Uli
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
CESSPOOLS:
(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: 4"A /P_ _J
inflow (cesspool must be pumped as part of inspection) c ye-
Comments:
(note condition f soil, signs of hydraulic failure, level of pondingy,condition of ve etation, etc.)
t J 4 !'�
/ t 1
PRIVY: �iti
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids: IV14
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
--
y v Ao
(revised 04/25/97) Page 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:53 Pine Lane Osterville Ma
Owner: Wianno Real Estate
Date of inspection: 9/8/97
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
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(r"18•e 01/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Properly Address:53 Pine Lane Osterville Ma
Owner: Wianno Real Estate
Date of Inspection: 9/,8/97
Depth to Groundwater�Q� Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obta,ned from Design Plans on record
_Observation of Site (Abuning property, observation _hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check F E MA Maps
,. Check pumping records
-heck local excavato s, installers
Use USCS Data
Describe n Your o"^ words how you P�rablished the High Groundwater Elevation. (Must be comol--4'
Installed systems_ a1 Pine Lane osterviille. -Permi. # 92-367
79 Pine Lane `'`
-_ .. # 77-52
124 Pine Lane # 92-400
160 Pine Lane # 95-896
No water encountered at 121
Ir.vi..d 04/25/97) Pag• 10 of 10
Y -
(- �.•,..—.. .r+r r.rr nr.•n-..v—.•,-*.+..m.:•.�.-.,+�.:+..-�.+n+,..mi++..�..ar r..+ �r-v r,._,--�.•� -. ._
TOWN OF Barnstable BOARD OF 11EALT11
SU11SURFACF SEWAGE DISPOSAL SYSTFM INSI'FCTION FORM - PART D CF.IcrlFICATI()�r
�- � , t ... .-� i.. .t:TTT.sC1fTT1'. �•.•1^tllTtRT1R�-1"..ITR'•O�I.i�O.�I'T1�T1
-TYPE OR PRINT CI.EARLY-
PROPERTY INSPECTED
STREET ADDRESS 53 Pine Lane Osterville,Mass .
ASSESSORS MAP , BLOCK AND PARCEL #
OWNER ' s NAME Wianno Redl Estate
PART D - CEI?TIFICATION 1
NAME OF INSPECTOR Joseph P. Macomber Jr .
COMPANY NAME Joseph P . Macomber & 'Son , Inc .
COMPANY ADDRESS Box 66 Centerville , Ma . 02632-0066
Street Town or City St•t ;Ip
COMPANY TELCPIIONC (508 775 -3338 FAX ( 508 ) 790 -1 578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage dispose-1 system n �,
this address and that the information reported is true , accurate , and
complete as of the time of .inspection . The inspection Was performed and anv
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance oi,
site sewage disposal systems .
Check one :
CXXXXXXXXXXXXysteiri PASSED CONDITIONALLY
The inspection i�hich I have conducted has not found any information
which indicates that the system fails to adequately protect public
healLh or Lhe. environment as defined in 310 CMR 15 , 303 , Any fai ) U7e
criteria not evaluated are as stated in the FAILURE CRITERIA secti0:1 of
this form .
System FAILED \
The inspection which I hAve conducted has found that the system fn _ ls .o
protect the public health and the environment in accordance with i le
5 , 3tO CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
.Inspector Signature Date 9/9/97
One copy of this rt.ification must be provided to the OWNER , the BUYER
( uhera appIIcable ) and the BOARD OF II EAL'TII .
I ( the inspection FAILED , the owner or Operator shall upgrade the ayste7
one year or the date of the inspection , unless allowed or requlrec:
otherwise as provided in 310 CPfn 15 . 305 .
W
U) �7
7 �
ti
- SbyV 3��1
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVERONMENTAL PROTECTION
BE IT KNOWN THAT
Jose h P. Macomber Jr.
P
Has satisfied the q Department's ualificati4
ns as required and is hereby
Y
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Environmental Protection_
)unc s. 1995
Acting Dircctor of the ton of Watcr Pollution Control