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Home My WebLink About0060 PINE LANE - Health 1 f f 601PJne°Larie i � d �s i { I L CL�TION O ,EW&C,E PERMIT MO. o IWS-TaLLE-R 5 W&ME ADDRESS BUILDER 5 Q ANTE P, ADDRESS — DATE PERMIT 15SUED .'.— D ATE COMPLI &MCE IS—SUED: • 1 - I I ep, ,5 AL f Commonwealth of Massachusetts • Title 5 Official Inspection Form rij Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments 60 Pine Lane Property Address a"y Kevin Shea Owner information is Owner'shame / AAA 02655 9-5-17 required for every Osterville V page, citylrown 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 A. General Information �� ,,�� filling out forms JT'�b �aauu OF,mutn� on the computer, ��`��tH.. sL?-Vo use only the tab 1. Inspector: key to move your y r °:' JAMESjp cursor-do not James D.Sears a use the return Name of Inspector key. a Capewide Enterprises sT�i�'c moo• R Company Name •r N SPS 0%N 153 Commercial Street "��:�frn,t„�,►„n��``�� Company Address Mashpee AAA 02649 Citylrown State Zip Code 508-477-8877 S1623. Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuantto Section 15.340 of Title 5(310 CMR 15.000).The system:, ® Passes ❑ Conditionally Passes ❑ Fails . ❑ Needs Further.Evaluation by the Local Approving Authority 9-5-17 pector'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 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. ff¢ial Inspection form:Subsurface Sewage Disposal S stem-Page 1 of 17 tSins.doc•rev.8I19 Title 5 0 p S at0 ge sD Y B a6ed xeJ dH 9U2 L 60Z 90 daS r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 60 Pine Lane Property Address Kevin Shea Owner Owner's Name information is psterville MA 02655 9-5-17 required for every /town Page Ci N State Zip Code Date oflnspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E J 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: The system is a 1500 Gal Tank 0 Box and pit. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Check the box for"yes","no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection ff 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 2D years old is available. ❑ Y ❑ N ❑ ND (Explain below): tSlns.doc,rev.6116 Title 5 Official Inspection Form:Subsurface sewage Disposal System-Page 2 of 17 Z abed xed dH S£ZZ L602 SO daS Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 60 Pine Lane Property Address Kevin Shea Owner Owner's Name Information required for every Osterville MA 02655 9-5-17 page, City/Town State tip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired, B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ NO (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (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 ❑ NO (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO (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 Mns.doc•rev.6116 Title S Offidel Inspectioi Form:Skosurface Sewage Disposal System-Page 3 of 17 £ abed xed dH SEZZ L i0Z SO daS Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 60 Pine Lane Property Address Kevin Shea Owner Owner's Name Information is required For every Osterville MA 02655 9-5-17 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply, ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is Less than 100 feet but 50 feet or more from a private water supply well"•. Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in glillillillililill is less than 6° below invert or available volume is less than 1/Z day flow Pt"r MnsAoc•rev.811E Td$a 5 Official Inspection Form:Subsurfate Sewage Disposal System-Page 4 of 17 a6ed red dH SUZ LI.OZ '90 daS Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 60 Pine Lane Property Address Kevin Shea Owner Owner's Name information is required for every Osterville MA 02655 9-5-17 page. City[Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria Indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 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. 15ins.doc•rev.6116 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Pape 5 of 17 S a5ed xeJ dH S£:ZZ L60Z g0 daS r i Commonwealth of Massachusetts f Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 60 Pine Lane Property Address Kevin Shea Owner Owner's Name information is required for eve ry Osterville MA 02655 9-5-17 �Y page. d C /Town State Zip Code Date of Inspection n 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 NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner) provided with ❑ ® information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on, ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): NA Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 t5ins.doc-rev.W 6 Title 5 Official inspect on Form Subsurface Sewage Disposal System-Page 6 of 57 9 a6ed xed dH S£ZZ L 60Z 90 d8S 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 60 Pine Lane Property Address Kevin Shea Owner Owner's Name information is required for every Osterville MA 02655 9-5-17 page. CityrTown State Zip Code Date of Inspection D. System Information Description: 1500 Gal Tank D Box and pit 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2015-32,000Gals g ( y g (gp )) 2016-41,000Gal's Detail: Sump Pum ? ❑ Yes ® No P Last date of occupancy: Da eesent ComrnerciaUlndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(9Pd) Basis of design flow(seats/personslsq,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: 15ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 or 17 L a5ed xe� dH KZZ L I,0Z 50 claS C Commonwealth of Massachusetts EMPSEMIM Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 60 Pine Lane Property Address Kevin Shea Owner Owners Name information Is required for every Osterville MA 02655 9-5-17 page Cityfrown 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: NA 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): 15ins.doc-rev.&is Title 5 Official Inspection Form:Subsurface Sewage Disposal Systom-Page 8 of 17 g a5ed xe� dH 9E:22 L 60Z 90 daS Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 60 Pine Lane Property Address Kevin Shea Owner Owner's Name Information is required for every Osterville MA 02655 9-5-17 page. cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Pit NA Tank and D Box 2007 permit #2007 - 115 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan)-. 28" 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.): Pipeing is 4" PVC SCH -40 Septic Tank (locate on site plan): 16" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 1500 Gal, Precast H-10 Dimensions: Sludge depth: 311 t5ine.doc•rev.Bit Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page got 17 6 a5ed wed dH LEZZ L60Z 90 daS Commonwealth of Massachusetts Title 5 Official Inspection Form lu - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 60 Pine Lane Property Address Kevin Shea Owner Crooner's Nance information is required for every Osterville MA 02655 9-5-17 page. Cityfrown State Zip Code Date of Inspection D. System Information (cunt.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 27" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle -8 - Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-TapeSludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level.Tank and cover's at 16" below grade.Two inlet tee's wloutlet tee. No sign of leakage or over loading. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc•rev.6116 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System-Fags 10 of 17 06 abed xez! dH LE:ZZ L60Z 5o daS r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Pine Lane Property Address Kevin Shea Owner Owner's Name information is Osterville MA 02655 9-5-17 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 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 El metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches: etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t6ins.doc rev.6M6 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 o1 17 6 a5ed xe� dH L£ZZ L60Z S0 daS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Pine Lane Property Address Kevin Shea Owner Owner's Name information is required for every Osterville MA 02655 S-5-17 page. Cityrrown State Zip Code Date of lnspWion 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.): D Box is 16N16"-T below grade wlone line out. Box is clean and solid. No sign of over loading or solid carry over. Pump Chamber(locate on site plan): Pumps in working order, ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why. Sns.doc-rev.6H 6 Title 5 Ofridal inspection form:Subsurface Sewage Disposal system-Page 12 0117 Z6 a5ed xez dH 8£22 LiOZ 90 cbS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 60 Pine Lane Property Address Kevin Shea Owner Owners Name information is required for every Osterville MA 02655 9-5-17 page. City/Town State Zip Code Date of Inspection D. System Information (cons) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: - ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Typetname of technology: Comments(note condition of soil, signs of hydraulic failure, level of pondirg, damp soil,condition of vegetation, etc.): Leaching is a 1000 Gal. precast pit w/3' stone. Pit at 32"below grade w/cover at 1'. T water w/stain line at 2'. No sign of over loading or solid carry over. 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 `I Indication of groundwater inflow ❑ Yes No 151ns.doc rev.6/16 Title 5 Official I�pedion Form:Subsurface Sewage Disposal System-Page 13 of 17 £6 a6ed Xed dH K22 L 602 90 d@S i Commonwealth of Massachusetts Title 5 official Inspection Form io Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 60 Pine Lane Property Address Kevin Shea Owner owner's Name information is required for every Osterville MA 02665 9-5-17 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) 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.): Oins.doc•rev.Gil Title 5 Official Inspection Form:Subsurfsos Sewage Disposal System-pase 14 of 17 6 a6ed xe:1 dH 8£ZZ L60Z SO d@S Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 Pine Lane Property Address Kevin Shea Owner Owner's Name information is required for every Osterville MA 02655 9-5-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System; Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately A B � 3 � Y A-r /3 -) = ate 13 q• /1-3= 3 4,'s' 13-3. 3 V� t5ins.cloe•rev.6H6 Tilla 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 S6 abed xez dH 8£:ZZ L60Z SO daS r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 Pine Lane Property Address Kevin Shea Owner Owners Name information Is required for every Osterville MA 02655 9-5-17 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 12'+ Estimated depth toFigh ground water: 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: Hate ® 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: Auger T.H. 124 no G.W.. Bottom of pit at 6'-8" below grade. Bottom of pit at 3'-4"+ above T H Depth Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•iev.6115 TM 5 Official Inspection Form:Subsurface Sewage Disposal System•page 16 of 17 gt abed key dH 6£:ZZ L60Z 50 daS f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Pine Lane Property Address Kevin Shea Owner Owner's Name information is required for every Osteryille MA 02655 9-5-17 page. City[Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, 8, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached In separate file t5ins.doe-rev.6116 Title 5 official Inspection Form:Subsurface Sawege Disposal System•Pape 17 of 17 L a5ed xej dH 6£ZZ L 60Z 90 CIGIS Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 60 Pine Lane Property Address' Ken Ridley Owner Owner's Name information is required for Osterville Ma 02655 1/16/07 every page. City/Town State Zip Code Date of Inspection //S�- a 57/ Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling out A. General Information forms on the - computer,use 1. Inspector: only the tab key - to move your Robert Paolini cursor-do not Name of Inspector use'the return key. Capewide Enterprises Company Name r� P.O.Box 763 Company Address Centerville Ma 02632 rem City/Town State Zip Code (508)428-4028 Telephone Number License Number B. Certification . I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section ,15.340 of Title 5 (310 CMR 15.000).The system: ® Passes f ❑ Conditionally Passes ❑ Fail's < ❑ Needs Further Evaluatio y the Local Approving Authority r..r:"CD ' 1/16/07 Inspector's Signature Date CP7 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. 60 pine lane•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 2 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M °V 60 Pine Lane Property Address Ken Ridley Owner Owner's Name information is required for Osterville Ma 02655 1/16/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not determined," please explain. ❑ 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. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed 60 pine lane-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M t 60 Pine Lane Property Address Ken Ridley Owner Owner's Name information is required for Osterville Ma 02655 1/16/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) l B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ 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: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and.the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a.private water supply well. 60 pine lane-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 3 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System-Form - Not for Voluntary Assessments ,M 60 Pine Lane Property Address Ken Ridley Owner Owner's Name information is required for Osterville Ma 02655 1/16/07 every page. 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: 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 '/2 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. 60 pine lane•11106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 4 Commonwealth of Massachusetts W Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Pine Lane M SV 6 e Property Address Ken Ridley Owner Owner's Name information is required for Osterville Ma 02655 1/16/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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 El ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 60 pine lane•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 60 Pine Lane Property Address Ken Ridley Owner Owner's Name information is required for Osterville Ma 02655 1/16/07 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information'was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ❑ E 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)] t 60 pine lane•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 Pine Lane Property Address Ken Ridley Owner Owner's Name information is required for Osterville Ma 02655 1/16/07 every page. City/Town State Zip Code Date'of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (a tual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: 2 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 ears usage 2006:3000 g ( y g (gpd))' 2006:3000 Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 60 pine lane-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I wM 60 Pine Lane Property Address Ken Ridley Owner Owner's Name information is required for Osterville Ma 02655 1/16/07 - every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: _ Source of information: Was system pumped as part of the inspection? ❑ Yes ® No, t 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) ❑ Tight tank. Attach a copy of the DEP approval. ® Other(describe):, 6x8 cesspool with 1000 gallon LP overflow Approximate age of all components, date installed(if known)and source of information: 1951 Were sewage odors detected when arriving at the site? ❑ Yes ® No 60 pine lane-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8 i Commonwealth of Massachusetts W Title 5 Official Inspection Form IA o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 60 Pine Lane M Property Address Ken Ridley Owner Owner's Name information is required for Osterville Ma 02655 1/16/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 14" 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.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No ------------------------------------------------------------------------------------------------------------------------- Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? 60 pine lane•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 9 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 60 Pine Lane Property Address Ken Ridley Owner Owner's Name information is required for Osterville Ma 02655 1/16/07 every page. City/Town State Zip Code Date of Inspection • I D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): f 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 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): 60 pine lane•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 60 Pine Lane Property Address Ken Ridley Owner Owner's Name information is required for Osterville Ma 02655 1/16/07 every page. City/Town 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.): *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 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.): Pump Chamber(locate on sate plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 60 pine lane•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 11 I Commonwealth of Massachusetts _ r Title 5 Official Inspection Form r _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G'M 60 Pine Lane Property Address Ken Ridley Owner Owner's Name information is required for Osterville Ma 02655 1/16/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: Type: ® leaching pits number: 1 ❑ 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.): Sandt soil,no evidence of hydraulic failure.Vegetation appears normal. S 60 pine lane-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 12 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 60 Pine Lane Property Address' Ken Ridley Owner Owner's Name information is required for Osterville Ma 02655 1/16/07 every page. 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 1-6'x8' 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.): Sandy soil No signs of hydraulic fail u re.Vegetation appears normal. 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.): 60 pine lane•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 13 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 60 Pine Lane Property Address Ken Ridley Owner Owner's Name information is required for 'Osteryille Ma 02655 1/16/07, every page. City/Town 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. c , r, 60 pine lane•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 14 i Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 60 Pine Lane Property Address Ken Ridley Owner Owner's Name information is required for Osterville Ma 02655 1/16/07 r 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 ground water: 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: http;//Town.Barnstable.ma.us You must describe how you established the high ground water elevation: Used:Gaherty& Miller Model 12/16/94 Ground Wayer Elevations above Sea Level.Used:Observation well data June 1992.Used: Annual ranges of ground water elevations for Cape Cod 92-000-01 Plate#2 60 pine lane-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6/15/2000. Inspection forms may not be altered in any way. A. Certification 1. Property Information: 60 Pine Ln. Property Address Peter Bilodeau Owner's Name 83 Bunker Hill Rd. Osterville MA 02655 Owner's Address Osterville MA 02655 City/Town State Zip Code Date of Inspection: 8/27/11 Date 2. Inspector: Matthew L. Childs Name of Inspector same Company Name 4 Orchid Ln. Company Address _ W. Yarmouth MA 0267 City/Town State. X Zip Co e 508-989-1479 Telephone Number ' .;a Certification Statement: 1 certify that I have personally inspected the sewage disposal system at this address and-f,at tt e 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 ❑l Needs Further Evaluation by the Local Approving Authority 8/27/11 Inspector'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. Bilodeau.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 Y` Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 60 Pine Ln. 1 Property Address Osterville MA 02655 CitylTown State Zip Code Peter Bilodeau 8/27/11 Owner's Name Date of Inspection 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: passes • I B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health, will pass. . Answer yes, no or not determined (Y,.N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ 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. ND Explain: N/A Bilodeau.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ec^M Subsurface Sewage Disposal System Form A. Certification (cont.) 60 Pine Ln. Property Address Osterville MA 02655 City/Town State Zip Code Peter Bilodeau 8/27/11 Owner's Name Date of Inspection 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 ❑ obstruction is removed ❑ 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 Bilodeau.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 60 Pine Ln. Property Address Osterville MA 02655 City/Town State Zip Code Peter Bilodeau 8/27/11 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health(cont.): 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: N/A **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: N/A Bilodeau.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 60 Pine Ln. Property Address . Osterville MA 02655 City/Town State ZipCode Peter Bilodeau 8/27/11 Owner's Name 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 El ® 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. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] 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. Bilodeau.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 r Commonwealth of Massachusetts Title 5 Official Inspection Form } Not for Voluntary Assessments ,M Subsurface Sewage Disposal System Form A. Certification (cont.) 60 Pine Ln. Property Address Osterville MA - 02655 . City/Town State Zip Code Peter Bilodeau 8/27/11 Owner's Name Date of Inspection 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. Bilodeau.doc• 11;2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M B. Checklist 60 Pine Ln. Property Address Osterville MA 02655 City/Town State Zip Code Peter Bilodeau 8/27/11 Owner's Name Date of Inspection 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(3)(b)J Bilodeau.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System.Form C. System Information 60 Pine Ln. Property Address Osterville MA 02655 Cityrrown State Zip Code Peter Bilodeau 8/27/11 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 gpd. 0 Number of current residents: 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: N/ADate Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/A Gallons per day(gpd) Basis of design flow(seats/persons/sq:ft., etc.): N/A 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: N/A Last date of occupancy/use` N/A Date Other(describe): N/A Bilodeau.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16. Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 60 Pine Ln. Property Address Osterville MA 02655 CityFrown State Zip Code Peter Bilodeau 8/27/11 Owner's Name Date of Inspection General Information Pumping Records: Source of information: owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: N/A gallons How was quantity pumped determined? N/A Reason for pumping: N/A Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): , Approximate age of all components, date installed (if known) and source of information: Add 1500 gal. tank and d-box to existing pit on 4-18-07 per disposal permit. Were sewage odors detected when arriving at the site? ❑ Yes ® No Bilodeau.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 r Commonwealth of Massachusetts Title 5 Official Inspection Form } Not for Voluntary Assessments Subsurface Sewage Disposal System form 'LAM C. System Information (cont.) 60 Pine Ln. Property Address Osterville MA 02655 City/Town State Zip Code Peter Bilodeau 8/27/11 Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 1.5'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.): All in good working order at time of inspection. Septic Tank (locate on site plan): 2' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ❑ No certificate) Dimensions: 9'x6'x5' outside 1500 gal. Sludge depth: 3 Distance from top of sludge to bottom of outlet tee or baffle 2.8 Scum thickness Distance from top of scum to top of outlet tee or baffle 4 Distance from bottom of scum to bottom of outlet tee or baffle .91 How were dimensions determined? sludge judge Bilodeau.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•. Page 10 of 16 Commonwealth of Massachusetts u Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form I C. System Information (cont.) 60 Pine Ln. Property Address Osterville MA 02655 City/Town State Zip Code Peter Bilodeau 8/27/11 Owner's Name Date of Inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank shows no signs of leakage and appears to have been maintained properly at time of inspection. Grease Trap (locate on site plan): Depth below grade: N/Afeet 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 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: N/A Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): N/A Bilodeau.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 r Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form ' M C. System Information (cont.) 60 Pine Ln. Property Address Osterville MA 02655 City/Town State Zip Code Peter Bilodeau 8/27/11 Owner's Name Date of Inspection Tight or Holding Tank(cont.) Dimensions: : N/A Capacity: N/A gallons Design Flow: N/A gallons per day Alarm present: ❑ Yes ❑ No Alarm level: N/A Alarm in working order: ❑ Yes❑ No Date of last pumping: N/A Date Comments (condition of alarm and float switches, etc.): N/A Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0.0' 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.): D-box is level with no leakage at time of inspection. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Bilodeau.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 I , Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form .,H u C. System Information (cont.) 60 Pine Ln. Property Address Osterville MA 02655 City/Town State Zip Code Peter Bilodeau 8/27/11 Owner's Name Date of Inspection 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: 1 ❑ 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.): 1 6'x6' pit with 3' of stone was dry at time of inspection. Stain lines at 1.5'. Not in failure. Bilodeau.doc•11/2004 Title 5 Official Inspection Form-Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form Giy Sey`e C. System Information (cont.) 60 Pine Ln. Property Address Osterville MA- 02655 City/Town State Zip Code Peter Bilodeau 8/27/11 Owner's Name Date of Inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth —top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding; condition of vegetation, etc.): N/A 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 Bilodeau.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M Spey`• C. System Information (cont.) 60 Pine Ln. Property Address Osterville MA 02655 Cityrrown State Zip Code Peter Bilodeau 8/27/11 Owner's Name Date of Inspection 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. Fline Ln. /S #60 A 1-393 B-1-22' A 2423 B-2-Y A-3.36.5' A+2T B- T Bilodeau.doc•11i2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 60 Pine Ln. Property Address Osterville MA 02655 City/Town State Zip Code Peter Bilodeau 8/27/11 Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: 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: Hand auger 8' in bottom of dry leach pit and did not encounter groundwater. Bilodeau.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 k LOC&.TkON1. EWLI,C,E• PERMIT UO. VILLAGE • 4ad� — - -�- -- — — — IN5TQLLE IS ► &ME 4,• ADDRESS BUILDERS t &"F— ADDRESS DATE PER"IT 155UED DATE COMPLI &KICE ISSUED ; A I 7 / t i TOWN OF BARNSTABLE L'�CkTION / yr1i:,� / SEWAGE # V'?I.!AGE 40KrI0.0,V.w- ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY A<fe> LEACHING FACILITY: (type) (size)NO.OF BEDROOMS .. BUILDER OR OWNER / ,d rtC4 ez �L PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within.100 feet of leaching facility) Feet r Furnished by -? �� `� _ - a,e_r 11 9"� ,_� �-, � � �� .��a: � � f �:�� . , � � ��r ��,�`° Y i.,,l !tl� ��. /boo �� /� w � � , � � � w _ � �. 't r> .. -�-J LOCATION A ,EWO,(�E PERMIT k10. VILLAGE OZ - - - - - - IhlSTL1LLE 5 IJ�NIE � ADDRESS BUILDERS- iJl VAF- ADDRESS DIN,TE PERMIT ISSUED L-1- ID ATE COMPLI &MCE ISSUED ; sj> Wy^ f, , r � i F f • f THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ----- -- OF....ie. 1:✓�.. .. .`................................................. I Appliration -fur R_qpuual Works Tomitrurtiutt Vrrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) a�n Individual Sewage Disposal System a : �- Loc dr s or Lot No. ........ •- ......... .................. ....... P... .. . ............. .........---•-•-•-----•--•....-••••-••.................----- -•--••......-••-------------••-- ONiv Address... Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width.----------..... Diameter---------------- Depth---------------- x Disposal Trench—No..................... Width-------------------- Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No_____________________ Diameter.................... Depth below inlet_-______._•--__.---- Total leaching area-------.----------sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY.......................................................................... Date----•---------------------------------- Test Pit No. 1----------------minutes per inch Depth of "Pest Pit_..----.____--_____- Depth to ground water...---__.__--_.----..... (14 Test Pit No. 2................minutes per inch Depth of Test Pit..____--______--__•- Depth to ground water...-..-.._--.---_---.--- a -•------------------------------•••------------•-----•-•------------------------•----•••------------......................................................... 0 Description of Soil.....................................................................------------------------------------------------------------...------------------------------..... x U ------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ W ------------------------- ----------------------------------------------------------------------------------- U N/aef P.epairs or Alt rations answer when applicable_.- .-- ---- . --- �_nt: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article \I of the State.Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b issued by 1he board of✓h 1 Si _ Date / Application Approved BY Cy2`--•--•-----•---------------------------------- r. w Date Application Disapproved for the following reasons--------------------------------------------------------------=-------------------------------•----------••--••-. •-------•------------------•-------•------------------------------_._....-------•-•••---•-•------•.......••••••--•-•---••-•-----------------........-----------•----------•-------------•------•-•------ Date PermitNo......................................................... Issued...................... ................................. Date P. ^ ( ' 94 y No...••••--•---....�':'.. .................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1. �"�._.........OF.... .C-/11..>-�...... ....................................... Applirtttion -for Di.ipoiittl Workii Tonitrurtion PPrntit Application is hereby made for a Permit to Construct ( ) or Repair ( )�an Individual Sewage Disposal System /a,7 i ,/ �Loc --Address or Lot No. er Address /J '� .. .. .... Installer Address Q Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) adOther fixtures --•----------------------------------------• ......... .............................................................................................. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width................ Diameter................ Depth................. x Disposal Trench—No. .................... Width.................... Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area-------...........sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed bY-------------------------------------------------------------------------- Date---------------------------------------- a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.,................... �14 Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water--.-..---_-----.--_-___. 9 -•----------------- ----------------------------------------•------------------------------••--------------------------•-------•----------------------------- GDescription of Soil------------------------------------------------------------------------------------------------------------------------------------------------------------------------ x - U --------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- W -----------------------------------------------------------------------------------------•-_--------____-----.. _____r___. --------- __---_.--_-_-.-.--____-_---_-___ �Jy U Natur of Repairs or Al ation —Ans er when applicable._._____ _ __/---r�_�__ __ ..... ---------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has e issued by the board of 7he�alSig =�-' � .ate'-"`'„•.! � ��- -- r Date Application Approved BY------------------------ ...... ..%� - �1 G Date Application Disapproved for the following reasons:---•---•----------------••------•-••----------...........--•-••-•----------------.._....----•--••••--•--•------- ....-•...............................••------------------------•--•----------------•--------•-----.._.... .....-------•----- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH IIJ..�..1'!.. ...........OF_...... . . ..... ............................................ %;�.ertifirtttr of f-10mli ittnrr THIrJS TO EAThat the I (livid al Sewage Dais osal System constructed ( ) or Repaired by (�f' �� . . ---------- - _r� . -, _/,�C Installer �:...� •`-- /j``r J (p L/. r at...- -- .----- --- •------- -- ------------------------•-----.....----- has been installed in accordance with the provisions of : rr l XI of The State Sanitary Code as describe in the 71 application for Disposal Works Construction Permit No.. ........... _.___________ dated_--------------------!��-. ._.__..._._._ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT TIME SYSTEM WILL FUNCTIONS TISFACTORY. R DATE---------- .....� `_'7 ... --•----- Inspector........C-•-•--- =- ---•----- ----------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 0_0 ................ 1/ OF---- .........X2....^............................................................. No......................... FEE....t ............... �i� Permission is hereby gra to .___ �__._ -�- ( --------- g ------------ .................. to Construct Indi ideal S a c�Dis osal m at No..___._ Street as shown on the application for Disposal Works Construction Permit/ o_ ___________________ Dated__...._ _-- __!____r-- ._.... -••------- ---------------•-- --- Board of Health DATE-------------------------------------------------------------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS DOD 7 --11 - No. � �' Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: .—� Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for iow6al *pztem Con!gtrurtion Permit Application for a Permit to Construct(gRepair(VI rUpgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. G 0 P, Owner's Name,Address and Tel.No. Assessor'sMap/Parcel 11 5l ��tX C��C QC V e lcX e,r� �cl,+ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. (off �,�w �. �, sbF- �3a.0s3� 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 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ma"— 5Ob U--tPe. f T �� 0 X Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. nn Signed �'.1. N cQs ram..,. 1� l�.�. .l:a . Date Application Approved by WW. • Date 14Z Vd T Application Disapproved for the following reasons Permit No.s Uo 2`�1 S Date Issued :�% 0 I Now; r � y• a c Fee 06 THE COMMONWEALTH OF MASS CHUSETTS Enteredincomputer: Ye� y PUBLIC HEALTH DIVISION: TOWN OF BARNSTABLES MASSACHUSETTS ` } �ptplication for Migp'ogar *pztem Congtructiori Permit Application for a Permif to ConstTct( -j Repair(V4pgrade( )Abandon( ) ❑Complete System ❑Individual Components {,U ` f Location Address or Lot No. �� Owner's Name,Address and Tel.No .` ��,..e, �, cL�.. , Assessor's Map/Parcel 118 5-1 8 J 0 1-C 17 c,v l� V I 1 cY•e T 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 f Type of Building No.of Persons Showers( ) Cafeteria( Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Dafe Title Size of Septic Tank Type of S.A.S. Description of Soil, Natur-Aoi Repairs or Alterations(Answer when applicable) �1,z�u- -506 `�t<-tf 4= 7— (� y °� �O X Date last inspected: Agreement: .r The undersign4agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. n" , Signed Z u j I l`.1,;N s. ro , ��, •�� l:e .<.(�r . Date 'V)4' Application Approved by F C'I Av e I' Date 3 2 110 -% Application Disapproved for the following reasons Permit No. c`�l�o 7��j Date Issued : � a—7 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABL'E,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( ) Abandoned( )by 0 ur at fl G �P.'n P, ' �_ 4,4 -e . 0s4pr"107 has been constructe in ccordance with the provisions of Title 5 and the for Disposal System Construction Permit No..000-7-11-S dated 3 9 d 7 Installer V Designer The issuance of this permit shall not beZconst ue`41 a guarantee that the system will fu cti n as designed. Date G1 if �� / Inspector _._.. No. �� / �� ----------Fee U) _ 4HE COM1Mv6'9`r"dEPA LTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Miopozar *pg;tem Construction Permit Permission is hereby granted{to Construct( )Repair( )Upgrade(K.)Abandon( ) System located at 00 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:Cons ctio must be completed within three years of the date of this p'p a 0tv-, Date: !V� l Approved by As 6« �� r (�.. 6 FEE:—O F—2 1_ 0 7 0 4 :0 3 PM PETER B I L O D E A U 5084282978 P. 01 149 RF.M91[IMS BR LOCUS INFORMATION W. DATE DELC. CURRENT ORNERt RIOL[T'R[ALTr TRyyf OHRtA{. (4TRtC,T: Mw — NANCr A ROLEY 1I0l91112 PIAaT:La;Tz+�'7nK r RAPS VIV ik Opp WW tlts%PAGE 74 }� :k'7ryEi If?IE II g� /qdC A4N RP ERRKC: PIMA am B9.PAOE t7 nMA 600 -W LN A ALIC04""P.. IIR LONC pSTpIGt; PAWLA#25000Irm1 1992 1Rn P' PAROIL.• 31 q I0— YRIAYAM WittVK: 87,I,TR.t S.F. IONVIO pR11RCt A1[FRDaT t [q-R 0 LOT SIZE: 11,4492 Lt. 7 E[7�AORa ar N•4tN AP[T:r an I cwsf'O BIA.COWAAGE; I.TIEk%F.(9.7X3 4E TRM� LOEUS NNP ACxSC FRONT le• i�* TO Fl;rt.l! CERTIFI TO THE O[:T of Mr I PROFESSAONAI KNO-LeMC. INFORMATION AND BEL10' TAM THE LOT CORNERS. DIMENSIONS ANO 5UBACRS TO. rllE STAVCIURR AS DETERMINED AY INiTRUNHNr c4RVEr AND AS SHOWN ON [NN:PLAN ARE CORRECT. M BANISTABLE VAUD I OOUMn IN Orim _ I foutiD AND NEWPNOFCS41ONAL LAND SURVEYOR-r OATf I I IDd II I I 1 Inc--T , '. 1 ' CERTIFIED �, I I PLOT PLAN II I LOr 92 I AT #60 PINE LANE IN QSTERVILLE MASSACHUSETTS (BARNSTABLE COUNTY) I /00 T NohO DIIE1Ld/0 9t� 1 , LJ..I I I I LOCAVIOMN 3 Z I I 4(Ij• APPRDrNA/TE I Q �. I j11 2T LOT 31 I r [)ItI IIC. I DTBrETItA► i OARAr4 I .. t' -_-_----- -�_ _ —"- •'- — THE HOUSE COMPAAfr I' Mr. J1;FFRLY OOLOSTEIN 1 I 30 PERSEVERANCE wAY I HYANNIS. MA C2901 771-0303 BSC GROUP W Mlda 9DN[.Rnlmt 29 ` Mk7R VIBtrdt. MmyetNun[e w 7R.oy 0?b73 -oP�eD�lstlf 30BT/Ba419 —_--__--- i 1COA Ilr Y�0 6uw Inc 8 1 E CEDAR LANE s PRO,L LRTR.t cwrc vIELo � � o. or:an i�. LIACARTIN . LAIC. IQNt DRAWN. HEALY CNQCkt mo nm mr, 6YtT-cpP'5I0- NOI mB2-01 - ,t0a NOI 1-Bp17,00 9MEET I OF I