HomeMy WebLinkAbout0093 PINE LANE - Health (2) �`t93 Pine��Lari�ti .
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Crocker, Sharon
From: AirSafe Inc <airsafeinc@airsafeinc.com>
Sent: /'�Wednes a , November 20, 2019 7:02 PM
To: Health,.--'-
Subject: ANF 93 Pine Ln�
Attachments: ANF 93 Pine Ln.pdf
To Whom It May Concern,
Attached for your records is the Asbestos Notification Form for asbestos abatement at 93 Pine Ln in Osterville.
Please let me know if you have any questions.
Thank you,
Shelley Mattson
Air Safe Inc
978-339-5361
CAUTION:This email originated from outside of the'Town of Barnstable! Do'not click links;;open
attachments or reply, unless you recognize the sender.'s.aemail,address and know the content is safer.
4
1
Massachusetts Department of Environmental Protection
;100320110
BWP AQ 04 (ANF-001) -
Asbestos Project#
Asbestos Notification Form r Project Revision
r' Project Cancellation
A. Asbestos Abatement Description
1.Facility Location:
NUALA QUINN 93 PINE LN
Instructions 1.All a.Name of Facility b.Street Address
sections of this form BARNSTABLE
must be completed in MA 02655 7743618838
order to comply with c.City/Town d.State e.Zip Code f.Telephone
MassDEP notification NUALA QUINN OWNER
requirements of 310
CMR 7.15 and g.Facility Contact Person Name h.Facility Contact Person Title
Department of Labor Worksite Location: ATTIC
Standards(DLS)
notification i.Building Name,Wing,Floor,Room,etc.
requirements of453 2. Is the facility occupied? ria.Yes r.b.No
CMR 6.12
3. Is this a fee exempt notification(city, town, district, municipal housing authority, state facility, or
owner-occupied residential property of four units or less)? ri a.Yes r b.No
MassDEP Use Only
4.Blanket Permit Project Approval,if applicable:
Date Received Approval ID#
5.Non-Traditional Asbestos Abatement Work Practice.Approval,
if applicable: Approval ID#
6.Asbestos Contractor:
AIR SAFE INC 22 WILLOW STREEr
a.Name b.Address
CHELSEA MA 02150 9783395361
c.City/Town d.State e.Zip Code f.Telephone
AC000464 h.Contract Type: rl 1.Written 1712.Verbal
g.DLS License#
JAIME E AMAYA AS060847
7.
a.Name of Contractor's On-Site Supervisor/Foreman b.DLS Certification#
8 KEVIN CLIFFORD AM000092
a.Name of Project Monitor b.DLS Certification#
9 FLI ENVIRONMENTAL INC AA000144
a.Name of Asbestos Analytical Lab b.DLS Certification#
10.
12/4/2019 12/6/2019
a.Project Start Date(MM/DD/YYYY) b.End Date(MM/DD/YYYY)
7AM-5PM NA
c.Work Hours-Monday Through Friday d.Work Hours-,Saturday&Sunday
11.What type of project is this?
r a.Demolition r b.Renovation r c.Repair r d.Other-Please Specify:
Revised: 11/13/2013 Page 1 of 4
i
Massachusetts Department of Environmental Protection - - - -- ---
100320110
BWP AQ 04 (ANF-001) - -
Asbestos Project# '
Asbestos Notification Form r Project revision
rl Project Cancellation
A. Asbestos Abatement Description: (cont.).
12.Abatement procedures(check all that apply):
r� a.Glove Bag r! b.Encapsulation rI c.Enclosure ri d.Disposal Only r e.Cleanup
P f.Full Containment ri g.Other-Please Specify:
13.Job is being conducted: r a.Indoors r1 b. Outdoors
14 a.Total amount of each type of asbestos Containing materials(ACM)to be removed,enclosed,or
encapsulated:
900
1.Linear Feet(Lin.Ft.) 2.Square Feet(Sq.Ft.)
b.Boiler,Breaching,Duct, c.Transite Pipe
Tank Surface Coatings 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft.
d.Pipe Insulation e.Transite Shingles
1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft.
f. Spray-On Fireproofing g.Transite Panels
1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft.
h.Cloths,Woven Fabrics i.Other-Please Specify:
1.Lin.Ft. 2.Sq.Ft.
j.Insulating Cement VERMICULITE 900
1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft.
15.Describe the decontamination system(s)to be used:
THREE CHAMBER DECON
16.Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)
(g):
6 MIL POLY
17.For Emergency Asbestos Operations,the MassDEP and DLS officials who evaluated the emergency:
a.Name of MassDEP Official b.Title of MassDEP Official
c.Date of Authorization(MM/DDNYYY) d.Waiver#
e.Name of DLS Official f.Title of DLS Official
g.Date of Authorization(MM/DDNYYY) h.Waiver#
18. Do prevailing wage rates as per M.G.L.c. 149, § 26,27 or 27A—F apply to this r a.Yes r b.No
project?
Revised: 11/13/2013 Page 2 of 4
Massachusetts Department of Environmental Protection - -- -
BWP AQ 04 (ANF-001) >oo32oilo
Asbestos Project#
L7,,7-
Asbestos Notification Form .
Project Revision
r Project Cancellation
B. Facility Description
1. Current or prior use of facility: RESIDENTIAL
2.Is the facility owner-occupied residential with 4 units or less? ri a.Yes ❑ b.No
3 NUALA QUINN 93 PINE LN
a.Facility Owner Name b.Address
OSTERVILLE MA 02655 7743618838
c.City/Town d.State e.Zip Code f.Telephone
4 NUALA QUINN 93 PINE LN
a.Name of Facility Owner's On-Site Manager b.Address -
OSTERVILLE MA 02655 7743618838
c.City/Town d.State e.Zip Code f.Telephone
5.NA NA
a.Name of General Contractor b.Address
NA MA 11111 1111111111
c.City/Town d.State e.Zip Code f.Telephone
NA
g.Contractor's Worker's Compensation Insurer
NA 12/31/2019
h.Policy# i.Expiration Date(MM/DD/YYYY)
6.What is the size of this facility? 1600 1
a.Square Feet b.#of Floors
Note:Temporary storage of Asbestos C. Asbestos Transportation & Disposal
containing waste 1.Transporter of asbestos-containing waste material from site of generation:
material is only
allowed at the place r a.Directly to Landfill or r b.To Temporary Storage Location/Transfer Station
of business of a DLS
licensed Asbestos
contractor or a transfer AIR SAFE INC. 22 WILLOW ST
station that is c.Name of Transporter d.Address
permitted by
MassDEP and CHELSEA MA 02150 9783395361
operated in e.City/Town f.State g.Zip Code h.Telephone
compliance with Solid
Waste Regulations
310 CMR 19.000 2. If a temporary storage location/transfer station is used,list name of transporter of asbestos containing
waste material from temporary storage location/transfer station to final disposal site:
SERVICE TRANS GROUP 301 OXFORD VALLEY RD SUITE 8036
a.Name of Transporter b.Address
YARDLEY PA 19067 2673999411
c.City/Town d.State e.Zip Code f.Telephone
Revised: 11/13/2013 Page 3 of 4
Massachusetts Department of Environmental Protection 100320110
BWP AQ 04 (ANF-001) -
Asbestos Project#
Asbestos Notification Form ❑ Project Revision
L,ik, [I Project Cancellation
C.Asbestos Transportation & Disposal: (cont.)
3.Name and address of temporary storage location/transfer-station for the asbestos containing waste .
material
AIR SAFE INC. 22 WILLOW ST
a.Temporary Storage Location Name b.Address
CHELSEA MA 02150 9783395361
c.City/Town d.State e.Zip Code f.Telephone
4.Name and location of final disposal site(asbestos landfill):
MINERVA LANDFILL MINERVA ENTERPRISES,INC..
a.Final Disposal Site Name b.Final Disposal Site Owner Name
8995 MINERVA DRIVE
c.Address
WAYNESBURG OH 44688 3308663435
d.City/Town e.State f.Zip Code g.Telephone
Note:Contractor must
sign this form for DLS
notification purposes D. Certification
DFW DFW.
"I certify that I have personally 1.Name. 2.Authorized Signature,
examined the foregoing and am PRESIDENT 11/20/2019
familiar with the information
contained in this document and 3.Position/Title 4.Date(MM/DD/YYYY)
all attachments and that, based 9783395361 AIR SAFE INC.
on my inquiry of those 5.Telephone _ 6.Representing
individuals immediately 22 WILLOW ST CHELSEA
responsible for obtaining the 7.Address 8.Cityrfown
information, I believe that the MA 02150
information is true, accurate, and
complete. I am aware that there 9.State 10.Zip Code
are significant penalties for
submitting false information,
including possible fines and`•.
imprisonment. The undersigned
hereby states that I have read the
Commonwealth of
Massachusetts regulations
governing asbestos abatement
(453 CMR 6:00 promulgated by
the Department of Labor
Standards and 310 CMR 7.15
promulgated by the Department
of Environmental Protection),
and that I am aware that this
permit application or notification
shall not be deemed valid
unless payment of the
applicable fee is made."
Revised: 11/13/2013 Page 4 of 4
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `
^M 93 Pine Ln System B ) Side of house
Property Address
aa•
Jere Doyle
Owner Owner's Name
information is Osterville Ma 02655 3/28/17
required for every - �
page. City/Town State Zip Code Date of Inspection
�s
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 ,S
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Michael DiBuono
use the return Name of Inspector
key.
DiBuono Sewer and Drain _
as Company Name
8 Johns path
Company Address
eryr� S Yarmouth _ MA _ 02664
City/Town State Zip Code
508-364-9587 _ S113522 _
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 ® Conditionally Passes ❑ Fails
i
gall l r ❑ Needs Further Evaluation by the Local Approving Authority
_ _ 3/30/17
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.
t5ins•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 1 of 17
L0 J�a V�
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 93 Pine Ln System ( B ) Side of house
Property Address
M.; Jere Doyle
Owner Owner's Name
information is required for every Osterville Ma 02655 3/28/17
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:
Front system contains a 1,500 Gallon septic tank as well as a concrete distribution box and a 1,000
Gallon leach pit. Leach pit is clean and dry staining indicates levels only within 22" of invert pipe
B) System Conditionally Passes:
® One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
' Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 93 Pine Ln System ( B ) Side of house
Property Address
Jere Doyle
Owner Owner's Name
information is Osterville Ma 02655 3/28/17
required for every — -- ---- -
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms 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 ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below):
Distribution box is rotted and full of roots. Recommend replacement with new H2O Db3
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
93 Pine Ln System B Side of house
Property Address
Jere Doyle
Owner Owner's Name
information is required for every Osterville Ma 02655 3/28/17
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
.more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ z 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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
93 Pine Ln System ( B ) Side of house
Property Address
Jere Doyle
Owner Owner's Name
information is required for every Osterville Ma 02655 3/28/17
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 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 93 Pine Ln System ( B ) Side of house
Property Address
Jere Doyle
Owner Owner's Name
information is required for every Osteryille Ma 02655 3/28/17
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)
N ❑ 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): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 93 Pine Ln System ( B ) Side of house
Property Address
Jere Doyle
Owner Owner's Name
information is required for every Osterville Ma 02655 3/28/17
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: Vacant
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
Seasonaluse? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail
218 Gpd
r
Sump pump? ❑ Yes ® No
Last date of occupancy: 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 5,8ystem? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
z
Commonwealth of Massachusetts
EEENR�w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
93 Pine Ln System ( B ) Side of house
Property Address
Jere Doyle
Owner Owner's Name
information is required for every Osterville Ma 02655 3/28/17
page. CityrFown 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: None provided
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):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
93 Pine Ln System ( B ) Side of house
Property Address
Jere Doyle
Owner Owner's Name
information is Osterville Ma 02655 3/28/17
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
installed approximately 1983
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.5feet
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.):
System is vented at the roof line
Septic Tank (locate on site plan):
Depth below grade: 1feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1,500
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:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
93 Pine Ln System ( B ) Side of house
Property Address
Jere Doyle
Owner Owner's Name
information is required for every Osterville Ma 02655 3/28/17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Cont.Septic Tank
p (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
24"
Scum thickness 3"
Distance from top of scum to top of outlet tee or baffle 42
Distance from bottom of scum to bottom of outlet tee or baffle " Sludge stick
How were dimensions determined? Tape Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
System is functioning properly and as designed
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction: r
❑ 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•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 93 Pine Ln System ( B ) Side of house
Property Address
Jere Doyle
Owner Owner's Name
information is required for every Osterville Ma 02655 3/28/17
page. City/Town State Zip Code Date of-Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: --------- —
Capacity: gallons
Design Flow: --
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
93 Pine Ln System ( B ) Side of house
Property Address
Jere Doyle
Owner Owner's Name
information is required for every Cisterville Ma 02655 3/28/17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Rotted and full of roots
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 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:
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
93 Pine Ln System ( B ) Side of house
Property Address
Jere Doyle
Owner Owner's Name
information is required for every Osteryille Ma 02655 3/28/17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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.):
Pit is dry and clean
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer —
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 93 Pine`Ln System ( B ) Side of house
Property Address
Jere Doyle
Owner Owner's Name
information is required for every Osterville Ma 02655 3/28/17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
' Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
93 Pine Ln System ( B ) Side of house_ _
Property Address
Jere Doyle
Owner Owner's Name
information is required for every Osterville Ma 02655 3/28/17
page. City/Town 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
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
93 Pine Ln System ( B ) Side of house
Property Address
Jere Doyle
Owner Owner's Name
information is required for every Osterville Ma 02655 3/28/17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ .Check cellar
❑
Shallow wells
Estimated depth to high ground water: 15+ ft
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:
USGS maps indicate ground water at app 18'
You must describe how you established the high ground water elevation:
USGS maps indicate ground water at app 15'
III
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
4/7/2017 Assessing As-Built Cards
ASSESSOR'S MAP NO. PARCEL
�
L0°-CATt�N SEW-A E -FERMIT NQ.
VILLAGE
INSTALLER' NAME. ADDRESS _
0 U I L D E R 0R 0 NE,R
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
http://www.townofbarnstabl e.us/Assessi ngi H M di spl ay.asp?m appar=118080&seq=1 1/2
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 93 Pine Ln System ( B ) Side of house
Property Address
Jere Doyle _
Owner Owner's Name
information is Osterville Ma 02655 3/28/17
required for every _
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
❑ Inspection Summary: A, B, C, D, or E checked
❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
❑ System Information — Estimated depth to high groundwater
❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Commonwealth of Massachusetts
W Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 93 Pine Ln System ( A ) Front_of house
Property Address �+
Jere Doyle _
Owner Owner's Name
information is
required for every Osterville _ Ma 02655 3/28/17
page. City/Town State Zip Code Date.of Inspection �
•e
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 �7
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not _Michael DiBuono
use the return Name of Inspector
key.
DiBuono Sewer and Drain
tab Company Name
8 Johns path
Company Address
arw� S Yarmouth _ MA 02664
City/Town State Zip Code
508-364-9587 _ S113522
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:
[5� Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
3/30/17
Ins6ector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
93 Pine Ln System (A ) Front of house
Property Address
Jere Doyle
Owner Owner's Name
information is required for every Osterville Ma 02655 3/28/17
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:
® 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:
Front system contains a 1,500 Gallon septic tank as well as a concrete distribution box and a 1,000
Gallon leach pit. Leach pit is clean and dry with little use. Kitchen only
13 System Conditional) Passes:
y y
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The.septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
l
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
93 Pine Ln System (A ) Front of house
Property Address
Jere Doyle
Owner Owner's Name
information is Osterville Ma 02655 3/28/17
required for every —
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms 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 ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
,,__
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
sms•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
AK�k Title 5 Official Inspection Form -`
o
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
93 Pine Ln System (A ) Front of house
Property Address
Jere Doyle
Owner Owner's Name
information is required for every Osterville Ma 02655 3/28/17
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
_supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
93 Pine Ln System ( A ) Front of house
Property Address
Jere Doyle _
Owner Owner's Name
information is required for every Osterville Ma 02655 3/28/17
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.]
0 ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For,large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area — IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304..The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M °V 93 Pine Ln System ( A ) Front of house
Property Address
Jere Doyle
Owner Owner's Name
information is Osterville Ma 02655 3/28/17
required for 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?
0 ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ 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): 3 — Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
93 Pine Ln System ( A ) Front of house
Property Address
Jere Doyle
Owner Owner's Name
information is Osterville Ma 02655 3/28/17
required for every --- --- —
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: Vacant
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
Seasonaluse? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
218 Gpd
Sump pump? ❑ Yes ® No
Last date of occupancy: 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:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
93 Pine Ln System ( A ) Front of house
Property Address
Jere Doyle
Owner Owner's Name
information is required for every Osteryille Ma 02655 3/28/17
page. - City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
None provided
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):
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System•Page S of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
93 Pine Ln System ( A ) Front of house _
Property Address
Jere Doyle
Owner Owner's Name
information is _Osteryille Ma 02655 3/28/17
required for every —
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
installed approximately 1985
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.5
feet
Material cf 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.):
System is vented at the roof line
Septic Tank (locate on site plan):
Depth below grade: 1
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1,500
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:
15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form -
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
93 Pine Ln System A Front of house
Property Address
Jere Doyle _
Owner Owner's Name
information is required for every Osterville Ma 02655 3/28/17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
24"
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle
42"
Distance from bottom of scum to bottom of outlet tee or baffle Sludge stick
How were dimensions determined?
Tape Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
System is functioning properly and as designed
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 93 Pine Ln System ( A ) Front of house
Property Address
Jere Doyle
Owner Owner's Name
information is required for every Osterville Ma 02655 3/28/17
page. Cityrrown 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.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form -
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 93 Pine Ln System ( A ) Front of house _
Property Address
Jere Doyle
Owner Owner's Name
information is Osterville Ma 02655 3/28/17
required for every _—_
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Level and at normal level
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.):
No 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:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 93 Pine Ln System ( A ) Front of house
Property Address
Jere Doyle
Owner Owner's Name
information is Osterville Ma 02655 3/28/17
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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.):
Pit is dry and clean
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
l5ins•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
u W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
93 Pine Ln System ( A ) Front of house
Property Address
Jere Doyle
Owner Owner's Name
information is required for every Osteryille Ma 02655 3/28/17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 93 Pine Ln System (A ) Front of house
Property Address
Jere Doyle
Owner Owner's Name
information is Osterville Ma 02655 3/28/17
required for every —
page. City/Town 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
t5ins-3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 15 of 17
Co
mmonwealth of Massachusetts
W Title 5 Official Inspection Form 'y
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
93 Pine Ln System ( A ) Front of house
Property Address
Jere Doyle
Owner Owner's Name
information is required for every Osterville Ma 02655 3/28/17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 15+ ft
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:
USGS maps indicate ground water at app 18'
You must describe how you established the high ground water elevation:
USGS maps indicate ground water at app 15'
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 16 of 17
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 93 Pine Ln System ( A ) Front of house
Property Address
Jere Doyle
Owner Owner's Name
information is Osterville Ma 02655 3/28/17
required for every _
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
❑ Inspection Summary: A, B, C, D, or E checked
❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
❑ System Information — Estimated depth to high groundwater
❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Replication for Bisposar 6pstem Construction permit
Application for a Permit to Construct( ) Repair(P Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.4 �^t Owner's Name,Address,and Tel.No. 1
Assessor's Map/Parcel #1K —.1
Installer's Name,Address,and Tel.No.!S . 3 b q 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(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs oryAllteratti x-ions(Answer when applicable) Reflee-
dd
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 o e tion until a Certificate of
Compliance has been issued by this Board of Healt
Signed Date / 7 ��
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. (� '^ V Date Issued
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered incomputer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
4plication for Vsposal ,pstem Construction 3pPrmit
Application for a Permit to Construct( ) Repair(�) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. L� Owner's Name,Address,and Tel.No.
D6fi.� et . � ��
Assessor's Map/Parcel g Q
v1,( �
,r"`
Installer's Name,Address,and Tel.No.50� 3 Designer's Name,Address,and Tel.No.
tj 1161.^orC) Sew o.r\a 4X,,.n
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures ti
Design Flo(mir.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) Rt it j°`C e. P 51� J, A)
Date last inspected: --2 f
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 o eration until a Certificate of
Compliance has been issued by this Board of Healt
S+g� Date
Application Approved by Date (�(D 7-
Application Disapproved by Date
for the following reasons
Permit No. ,�O — y Date Issued 0
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(OCR Upgraded( )
Abandoneed(qZ )by i�+ ki> D 5CJ Ct4i-f— 1//41:h- V-
at / J +� " L�f 0S4-<f has been constructed in accordance
with the r visio s of Title 5 and he for Disposal System s }Construction Permit No�d 1 dated `I —
10
Installerp �, t�A� e—�fp ors t^ Designer
#bedrooms pt/ Approved design flow gpd
The issuance of this//it/shall not be construed as a guarantee that the system willf nctib�n a sign d.
Date 120 Inspector
� _
-------- - ----------------------------------------------------------=-- ------------------------------------ --
-- -- - - --- - - - ------
No. ;?o Fee 7
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal *pstem Construction J)Prmit
Permission is hereby grantedto Construct( ) "Repair(()O Upgrade( ) Abandon( )
System located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
G �
Provided!Co struction must be co ted within three years of the date of this permit.
Date 1 Approved by
AsBuilt - Page 1 of 2
}
ASSESSOR'S-MAP NO. ;PARCEL'..
'•
L0"" TtANil SfWA r E PERMIT NO.
VILLAGE
' INSTALLER' NAME. ADDRESS
- 50-
0193o
U 1 L D'E R OR 0 M ER `
DATE PERMIT, :ISSUED
. .
DA*T.E C.OMPLIA-NCE- ISSIl;E'D
u
-
"
' v
r. r
1
http.Hissgl2/intranet%propdata/prebuilt.aspx?mappar-118080&seq l¢, 3/13/2017
eo
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No....C>..... Fi&B....S....
kvi
THE COMMONWEALTH'OF MASSACHUSETTS
BOARD OF HEALTH
.............OF.... i?r.............................
Allpfiration for Disposal Works Tonstrurtion ramit
3 Application is hereby made for a Permit to Construct or Repair X) an Individual Sewage Disposal
A/6 System at:
............ ......................
57.... ...............................
Location-Address or Lot No.
.............R fz--......... ........ .........w..............................................................
Ow rlu Address
................................................................................................ .................................................................................................
I -rW(!) V'E;P"r)C, 5"l S'Y-f�Address Type of Building Size LodG_15Y3....Sq. feet
U ooms....4Garbage Grinder Dwelling—No. of Bedrooms._.........................................Expansion Attic
4
P4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria
Otherfixtures ...........................................!..................................................
.............. .0 ----------
w Design Flow.......5�57...... gallons per persove,4v,,Total Hip
VW65 _4 Q w........ Lo%v
it'"y... V
1:4 Septic Tank—Liquid*capacity_ allons Length Width.6 - Diameter................ Depth 0
_-V sz�-A tr pr -.6-
Disposal Trench—No. ..............!9�%idtb_' AiAngth I-A Total leaching area....................sq.Tt.
............ ....Seepage Pit No....12----------- Diameter...-jj-Z-/..... Depth below inlet.... Total leaching area.50..7..sq. f t.
ZOther Distribution box osing tank
14 DN Z 97/ �..�.?..._._.
4Percolation Test Results Performed by. .. (_t.ZA,''*k5l.f.......1.14C..... Date...........
4 Test Pit No. I....` -....minutes per inch Depth of Test Pit.................... Depth to ground water........................
0-4
rX4 Test Pit No. 2................minutes per inch Depth of Test Pit................._:. Depth to ground water-___-__._...............
1:4 ........................................................... ..............................?......................S.......L.
0 Description of Soil..... .0.2....
k�'E _;�-----Z..1'_:nJ_6.........qA4���
........ .. . .....:56�-Jt>...............................................................................................................................
............................................... .........................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable..............................................................................................
.........................I.....................................................................................................................................I........................................
Agreement:
The undersigned agrees to install the aforedescrA*bed Individual Sewage Disposal §Istem in accordance with
the provisions of TJITA U 5 of the State Sanitar Cod — The undersigne further agre51jiot to place the system in
ni operation until.a Certificate of Compliance een is ed e boyrt health.
Sig ......... ........ ..... .. . ............... ............D
....._............
/ 7Application Approved By............... ..................... . ------
D te
Application Disapproved for the following r on .............................................................. ...............................................
.........................................................................................................................................................................................................
Date
Permit No...... 7 S> 7. E S. ......... IssuedL.......................................................
Date
ANN&
No ..L..... +� FEZ
THE COMMONWEALTH OF MASSACHUSETTS
yBOARD OF HEALTH
.............OF....:j3q. jj.t......................._..
Appliratinn for Uispnsal Works Tonstrnr#inn Permit
Application is hereby made for a Permit to Construct ( ) or Repair X an Individual Sewage Disposal
System at:
.......3.5.....P......:s�---•--�..... ......... ........ ....... -o`T.-------------•----------.........•-----.............-----
Location-Address ( `` ^ or Lot No.
• -...Q.-.._r P_.9_V..1 1:f......---•--I�-4` -------------• ----------•••---------................---..........---
O Address
a .............................................:a..... ....O T-•---;-K........... �,�.j..............................�-,..e........__........ ......_...
• 1 w T �1 G S�S�AvAddress � .ri
dType of Building Size Lot....... . . . ...Sq. feet
U Dwelling—No. of Bedrooms...4..................................Expansion Attic ( ) Garage Grinder
ALIOther—T e of Building No. of persons............................ Showers — Cafeteria
a' Other fixtures ..........
Design Flow.........5T..............Cgallons per person er d y.,Total 4il fl w.__.... 'O..................... on .
Pd Septic Tank'—Liquid capacity.mc allons Length...RR� ._,,,Width.15 ,�. Diameter................ Depth �y
W Disposal Trench—No. ....._...._•._.-.._. Width.-. ....... T�fal ength..... Total leaching area....................sq. it.
.__.. Diameter.._.. _ .........._. Total leachin area. s ft.
Seepage Pit No....... e.... Depth below inlet.... gQ-• . q.
Other Distribution box ( ) Dosing tank ( ) , 'f'�
z 9 7`'' Percolation Test Results Performed by1 `T. 72 . .�4.T 1- -.._...�1 �.._._ Date....•._..../J..8.•.............
1 Test Pit No. 1....Z....minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P+' •---••----------------- •• ...•-••--......---•••-- -- -------•---------------------------i...._
D Description of Soil----. �r �.�-Q � ?'V�._ ..4�. .fj+ ��. 1 ......... L ..71..................
W ••--•••••••------------------•-•••••-•-••-•-•••••-•----•--------•--••--•--•----•--------•--••-•----------•••---•----------------•••--•-•-•----------••••-••---••-•-••-••------....................•-•---
UNature of Repairs or Alterations—Answer when applicable......................................•..............-_................._......................
-•----------------------------------•---------------•-•-••-----•----•---•--......----....------....---•--......-----------------------•----••--------------------------•---..............•---••••-•-•••.
Agreement:
The undersigned agrees to install the aforedesc 'bed Individual Sewage Disposal stem in accordance with
the provisions of TITI,L 5 of the State Sanitar,Cod —The undersigned further agre of to place the system in
operation until a Certificate of Compliance een is ed a bo health.
Sig _.. ....... -• .............. ................................
Date -
' Y�" -
Application Approved By•••--•---•----••..•... •--•............- ....................•-••-•----......_--•_... -'C 7.....
Date
Application Disapproved for the following r ason :---•--••--------------------•---------------------------------•-^------------...............-•••......---•-----
..............•-----•---•--.......•-•--•--•----•--•-•••--•-•---••---•-•-•-••••--...•••-•-•-•••-•••----•........:---•---••-----••--•••----••-----....•••-•--••-•-•-••••••--•••••-••--•----•--••---._._....
Date
�f
PermitNo...... - .�....._._.. Issued......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
/ G�wpi BOARD OF HEALTH
tj..........................................OF............................................ e. .....p.:........................
Trrtifiratr of Tnmplittnrr
THIS I•;�ERTIFY,.)That the�ndividual Sewage Disposal System constructed ( ) or Repaired ( )
�G? ��c n e. ::.
by----------------•-------------••-: --•---•--•--••----. ........ er
staii
_--
--.
has been installed in accordance with the provisions of TITA __ f The State Sanitary C scribed h� i
1 ......
TIME ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE .?. ......................... Inspector-------J=__—�_
�(� ........... ..... ;i
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
lt i .....................OF....... :�.................................................................... —
No......................... FEE........................
Et
a o%g,Tnn rnnr#inn rrmif
Permission is hereby granted......................_. ......�^ �:._
to Construct .(' ) or Rppair ( ) an Individual ewage osal System
�.M,: - -r r.c L r� s 1 �.
at No.........- ••'-----• ......
Street / •.� _
as shown on the application for Disposal Works Construction Permit No �!-!D ed......... ....`
................................
................. ' :-.-..........:.............•--..._..•---...._
Board of Health
DATE---..........(5 ......................................................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
°y `R
BAXTER & NYE, INC.
Registered Land Surveyors and Civil Engineers
7 Parker Road/Osterville, Massachusetts 02655/Tel. (617)428-9131
WILLIAM C.NYE,R.L.S.-President
RICHARD A.BAXTER,R.L.S.-Vice President PETER SULLIVAN,P.E.-Vice President-Engineering
February 27 , 1987
Town of Barnstable.
Board of Health —�
P .O. Box 534 %J
Hyafifiis , i0iA 026n1
RE: John J. Doyle Property
39 Pine Lane, Osterville
Dear Board:
This is to inform you that we have been engaged by
ifr . Doyle to design a new septic system at the subject
property.
This work will be completed as soon as the weather
permits .
Feel free to contact our office at any should you
have any questions concerning this matter .
Very truly yours,
William C . Nye, Rr. S .
WCN/fm j
MEMBERS OF
CAPE COD SOCIETY OF PROFESSIONAL ENGINEERS AND LAND SURVEYORS I AMERICAN CONGRESS ON SURVEYING AND MAPPING
MASSACHUSETTS ASSOCIATION OF LAND SURVEYORS AND CIVIL ENGINEERS
14,
J•P.MACOMBER & SON INC.
BOX 66
CEN TER VILLE,MA.02632
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