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HomeMy WebLinkAbout0206 PINE LANE EXTENSION - Health 206 PINE LANE OSTERVILLE A = 117 073 003 I k Y 1 r f C� c1 IN Ci G�Dar .f s— � .. g., f27- P. a Commonwealth,&Massachusetts op Title 5 Official. Inspection Form iI, Subsurface Sewage Disposal System form -Not for Voluntary.Assessments ...........<, 205-215 Pine Lane Ext. r Property Address • 9 p Y 1 Osterville Com ns Owner Owner's.Name ; information is Osteryille MA . 02655 10-28-20' required for every page. City/Town State Zip Code 'Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. JN oFfMq Important:When A. Inspector Informationy- fillingoutforms DAMES on the computer, R' use only the tab James D Sears =o: SFQ S key to move your Name of Inspector cursor-do not � Robert B.Our Co:INC. � •.F � - use the return ( ` . n Name F' G �� key. Company iy�� 5 INSp�\`����` 363 Whites Path �k�H+euwul�� rab Company Address South Yarmouth MA 02664 City/Town ' State Zip Code rehnn 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that: I am a DEP'approved system inspector in full compliance with Section 15.340 of Title 5 1310 CMR.15.000); I have personally inspected.the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete-as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function acid maintenance of on-site sewage'disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes , 2. ❑'Conditionally Passes' 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 10-20-20 pector's Signature - Date The system inspectors'hall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)withi 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 DE_P. The original--form should be sent to the system owner and copies sent to the-buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 L f } Commonwealth of Massachusetts p Title 5 Official Inspection Form ii- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V � 205 -215 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is Osterville MA 02655 10-28-20 required for every page. City/Town State Zip Code Date of Inspection C. Inspection,Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: The systemis two 1500 Gal Tank's D Box and 18 Chamber's. 2) 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): C t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts �v Title 5 Official Inspection Form �1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `F V 205 -215 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is required for every Osterville MA 02655 10-28-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont:) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection form �n Fig Subsurface Sewage Disposal System Form Not for Voluntary Assessments ............. 205-215 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is required for every Osterville MA 02655 10-28-20 page. CltylTown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier, if any) mines that the system is functioning in a manner that protects the public health, • deter 9 Y safety and environment: The system has a septic tank and soil absorption system (SAS) and the.SAS is within supply:100 feet of a surface water supply pl or tributary to a surface water pp y : - []'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. c. Other. 4) System Failure Criteria Applicable to All Systems: You must.indicate"Yes" or"No"to each of the4ollowing 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts 9n Title 5 Official Inspection Form �_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 205-215 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is required for eve ry Osterville MA 02655 10-28-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria.Applicable to All Systems: (cont.) Yes No El ® 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 'h day flow El ® 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. El ® 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 water supply 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 r 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 2000 gpd 10,000 gpd. El ® The system fails.] 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. 5) Large Systems: To be considered a large system the system must serve a.facility with a design flow of 16,000 gpd to 1.5,000 gpd. For-large systems, you must indicate.either"yes" or"no"to each of the following, in addition to the questions in Section CA. 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 Page 5 of 18 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System• Commonwealth of Massachusetts Title 5 Official Inspection form �I Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments 205-215 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is MA 02655 10-28-20 required for every Osterville page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes%'to any question in Section C.5 the system is considered a significant threat, or answered yes'to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ h Pumping information was.provided by the owner, occupant, or Board of Health ❑. Z 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 volumesof 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 Z. ❑ available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site,inspected for signs of breakout? Z - ❑ 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 0 ® , 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. El Determined in the field (if any of the failure criteria related to Part C is at issue ® approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection- Form �1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 205-215 Pine Lane Ext. a, u Property Address Osterville Commons Owner Owner's Name information is MA 02655 10-28-20 required for every Osterville page. City/Town State Zip Code °Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 12 Number of bedrooms (actual): 12 DESIGN flow based on 310 CMR 15.203 (for example: .110 gpd x#of bedrooms): 1320 Description:, Two 1500 Gala Tanks; D Box, and 18 chambers. NA Number of current residents: Does residence have a garbage grinder? w ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: r Is'laundry on auseparate sewage system_? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? '❑ Yes ® No Seasonal use? ❑ -Yes ® ,No NA water meter readings, if available (last 2 years usage (gpd)): Detail: . Sump pump? ❑ Yes ® - No Present Last date of occupancy: Date I t5insp.doc•iev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 C Commonwealth of Massachusetts Title 5 Official Inspection Form - y1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I, V � 205-215 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is required for every Osterville MA 02655 10-28-20 page City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑. No If yes, discharges to: 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,below): 3. Pumping Records: 6-2020 Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts W Title 5 Official Inspection Form � I5 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments « � 205 -215 Pine Lane Ext. u Property Address Osterville Commons Owner Owner's Name information is required for every Osterville MA . 02655 10-28-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: 1996 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 46 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts w Title 5 Official Inspection- FormTy �I Subsurface Sewage Disposal System Form - Not for Vol untary-Assessments 205 -215 Pine Lane Ext. u� Property Address Osterville Commons Owner Owner's Name information is MA 02655 10-28-20 required for every. Osterville page. City/Town State Zip Code Date of Inspection D. System Information (cont.) r 1 6. Septic Tank(locate on site plan): Front Rear Depth below grade: 46" 18 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: ` 4500 Gal. 1500 Gal Sludge depth: ' 2,,.: 0" Distance from top of sludge to'bottom of outlet tee or-baffle 28 -•30" ' Scum thickness 2„ 0 . Distance from top of scum to'top of outlet tee or baffle 81' ,8„ Distance from bottom of scum to ybottom of outlet tee or baffle 16,' 18" How were dimensions determined? Asbuilt-Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or,baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage; etc.): 4 Tank at working level.-Front tank and outlet cover,at 46" below grade . W/inlet cover at 6". Rear tank and outlet cover at 18". W/inlet cover at grade:In and outlet tee's. No sign in tanks of leakage or over loading a F ' t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form - F1� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 205 -215 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is required for every Osterville MA 02655 10-28-20 page. Citygown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): L 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.): 8. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 it _ r • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t, 205-215 Pine Lane Ext. Property Address P Y ,. Osterville Commons Owner Owner's Name f information is Osteryille MA 02655 10-28-20' required for every page. City/Town State =Zip Code. Date of Inspection D. System Information (cont.) v 8..- Tight or Holding Tank(cont..) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑,Yes ❑ No Date of lastpumping: Date Comments (condition of alarmand,float switches, etc.):` ' Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. 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 o`rout of box,etc.): D:Box is H-20 55" Below grade w/cover at 1'. Box is clean and solid w/no signof over loading or solid carry over. + t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage.Disposal,System•Page 12 of 18 Commonwealth of Massachusetts Title .5 Official Inspection Form 1 }In Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 205-215 Pine Lane Ext. u� Property Address Osterville Commons Owner Owner's Name information is Osterville MA. 02655 10-28-20 required for every Zip Code Date of Inspection page. City/Town State D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* I 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. 11. Soil Absorption System (SAS) (locate on site,plan, excavation not required): If SAS not located, explain why: Type: .. . ❑ leaching pits`. number: . 18 ® leaching chambers, number: El `leaching galleries number: } ❑ leaching trenches number, length: ❑ Teaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 t Commonwealth of Massachusetts �n ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V � 205-215 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is Osterville MA 02655 10-28-20 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is 18 chamber's Wet on Bottom No sign of over loading. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �1; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments - 205 -215 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is Osterville MA 02655 10-28-20 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): .s t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 i Commonwealth. of Massachusetts - _- Title 5 Official Inspection Form �= — ti; Subsurface.Sewage Disposal System Form - Not for Voluntary Assessments 1205 -215 Pine Lane Ext. L Property Address Osterville Commons Owner Owner's Name information is required for every Osterville MA 02655 10-28-20 page. City/Town State Zip Code Date`of Inspection D. System Information (cont.) 14. 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: 1 ® hand-sketch in the area below ❑ drawing attached separately C � _ i 1h 6 is O a it J- a I � t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspecti-on Form L Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 205-215 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is Osterville MA 02655 10-28-20 required for every q page. City/Town p State Zip Code Date of Inspection D _ D. System Informatio.n,(cont.) 15. Site Exam: ❑ Check Slope Surface water. ❑ Check cellar. ❑ Shallow wells 12'+ Estimated depth to high groundwater: 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 pla reviewed: 12-12-95 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: T H on Design Plan 12-12-95 12' no G W.. Before filing,this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 r Commonwealth of Massachusetts �v Title 5 Official Inspection- Form I. �1 Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments 205 -215 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is ;required for every Osterville MA 02655 10-28-20 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed &.Dated and 1, 2,3, or 4 checked ®- C. Inspection Summary: 1,-2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping.contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included GRAD E : . Orr a va t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts W Title 5 Official .Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 205+215 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is required for Osterville Ma. 02655 10/30/2009 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out 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,LLC. Company Name raa P.O.Box 763 Company Address Centerville Ma. 02632 City/Town._ State Zip Code .r (5080428-4028 S14454 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 ❑ eds Furth r Eval 'on by the Local Approving Authority V� 10/30/2009 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 4 the same or different conditions of use. II t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Dis sal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 205+215 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is required for Osterville Ma. 02655 10/30/2009 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: 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•09/08 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 205+215 Pine Lane Ext. Property Address Ostervllle Commons Owner Owner's Name information is required for Osterville Ma. 02655 10/30/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): D-Box is piped from inlet of septic tank.Building invert is halfway under water when tank is full.Box needs to be repiped to outlet end of septic tank. ❑ 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): it ❑ 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 t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 205+215 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is required for Osterville Ma. 02655 10/30/2009 ever,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 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 1/2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 205+215 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is required for Osterville Ma. 02655 10/30/2009 every 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 I 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 205+215 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is required for Osterville Ma. 02655 10/30/2009 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? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 12 Number of bedrooms (actual): 12 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 1320 � t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 205+215 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is required for Osterville Ma. 02655 10/30/2009 every page. City/Town State Zip Code Date of Inspection D. System Information Description: The septic system consists of two 1500•gallon tanks,B-Box and 18 drywells. 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 ears usage d NA 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 10/30/2009 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 205+215 Pine Lane Ext. Property Address Ostervllle Commons Owner Owner's Name information is required for Osterville Ma. 02655 10/30/2009 every 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: 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M ,•y''� 205+215 Pine Lane Ext. Property Address Ostervllle Commons Owner Owner's Name information is required for Osterville Ma. 02655 10/30/2009 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: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 16" 20"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 leakage.System vented through the building vents. Septic Tank(locate on site plan): ' 18" Depth below grade: 1 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: 2/1500 gallon Sludge depth: 5" 3" t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �^M 205+215 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is required for Osterville Ma. 02655 10/30/2009 every 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 27" 29" Scum thickness 0" 4" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 14" 10" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump septic tank every two years.inlet tee is missing one one tank.Outlet tees are in place.No evidence of Ieakage.Tanks appear structurally sound. 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•09/08 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 °wM 205+215 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is required for Osterville Ma. 02655 10/30/2009 every 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-09/08 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 205+215 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is required for Osterville Ma. 02655 10/30/2009 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 No 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.): Box is level.Distribution is equal.No evidence of solids carryover.No evidence of leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 205+215 Pine Lane Ext. Property Address k Osterville Commons Owner Owner's Name information is required for Osterville Ma. 02655 10/30/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 18 ❑ 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.): Sandy soil.No signs of hydraulic failure.Drywells had 6"of water at time of inspection.No stain lines observed. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 205+215 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is required for Osterville Ma. 02655 10/30/2009 every 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Map , Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size Zoom Out 9 In ,. A .... ,,, ......:.. ........tea...,. .r. 511 lmf YJ �} f F t 1 fl $�n3• f.f fij�. t.- i�' tin f s y ?a ® ^ 5C S ® © 'm to _ p 9 r�0F1e) F ' MM ' t!tL'lcflfw=� 1 1 . >fi t t. _ f Set Scale 1" = 20 I Aerial Photos I MAP DISCLAIMER f nn„rinhf)nr)r-,)nnO Tn,un of Rornefnhlo NAA All rinhfe rnecnn http://66.203.95.236/arcims/appgeoapp/map.aspx?propertyID=11706404A&mapparback= 11/13/2009 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 205+215 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is required for Osterville Ma. 02655 10/30/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Botton of leaching 19' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: pate ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 Plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 y! / Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 205+215 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is required for Osteryille Ma. 02655 10/30/2009 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 = e Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 210+216 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name ! information is Osterville Ma. 02655 11/01/2009 required for every page. City/Town State Zip Code Date of Inspection t 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: A. General Information When filling out ,I forms the � }— t5 computeto r,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name � P.O.Box 763 Company Address Centerville Ma. 02632 reran City/Town State Zip Code (508)428-4028 S14454 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 ❑ Needs Further Evaluation by the Local Approving Authority 11/01/2009 Ins ctMiaturee 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 flows,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•09/08 Title 5 Official Inspection Form:Subsurface Sewage i posal Syste •Pa 1 1-f, Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 210+216 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is required for Osterville Ma. 02655 11/01/2009 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. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 210+216 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is required for Osterville Ma. 02655 11/01/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 210+216 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is required for Osterville Ma. 02655 11/01/2009 every 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 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 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 210+216 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is required for Osterville Ma. 02655 11/01/2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 210+216 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is required for Osterville Ma. 02655 11/01/2009 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. ❑ ® 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): 12 Number of bedrooms (actual): 12 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 1320 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M ,•''v 210+216 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is required for Osterville Ma. 02655 11/01/2009 every page. City/Town State Zip Code Date of Inspection D. System Information Description: The septic system consist of two 1500 gallon septic tanks,distribution box and 18 drywells. Number of current residents: Unknown 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d NA 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 8/21/2009Date 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 210+216 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is required for Osterville Ma. 02655 11/01/2009 every 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: 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 210+216 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is required for Osterville Ma. 02655 11/01/2009 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: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3' 14"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.): Joints appear tight.No evidence of Ieakage.System vented through the building vents. Septic Tank (locate on site plan): Depth below grade: 16 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: 2/1500 gallon Sludge depth: 4" 2" t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 210+216 Pine Lane Ext. Property Address Ostervllle Commons Owner Owner's Name information is required for Osteryille Ma. 02655 11/01/2009 every 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 28" 30" Scum thickness 2" 1" Distance from top of scum to top of outlet tee or baffle 6" 7" Distance from bottom of scum to bottom of outlet tee or baffle 12" 13" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump septic tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tanks appear to be structurally sound. 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•09/08 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 210+216 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is required for Osterville Ma. 02655 11/01/2009 every page.a e. 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•09/08 Title 5 Official Inspection Forth: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 210+216 Pine Lane Ext. Property Address s Osterville Commons Owner Owner's Name information is required for Osterville Ma. 02655 11/01/2009 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 No 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.): Box is level.Distribution is equal.No evidence of solids carrover.No evidence of leakage into or out of box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order:. ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 210+216 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is Osterville Ma. 02655 11/01/2009 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 18 ❑ 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.): Sandy dry soil.No signs of hydraulic failure.Drywells had 4"of water on bottom at time of inspection.No visible stain line observed. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 210+216 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is required for Osterville Ma. 02655 11/01/2009 every page. Cityrrown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Map Page I of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map-Size . Zoom Out J s 11,11„In rR ry \ t 1 \' 1 .,�. / 1 ;. 1 / S P 4 4• 6 c o. Q O 4 �. 1, Set Scale 1" = 20 ' I Aerial Photos I MAP DISCLAIMER (`nn,frinhf?nnr%_?nnO Tn in of Ramefahla RAA all rinhfc racanfl lat+ra•//aananar 4naam 1��rraetol�la mo aae/ornime/orrartonarara/mars aarav7rarrarasav+%rTTl=1 1 7071qn1 ART S2/�e/�nno i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 210+216 Pine Lane Ext. Property Address Ostervllle Commons Owner Owner's Name information is required for Osterville Ma. 02655 11/01/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: Bottom of Leaching 22' 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: As-Built ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 210+216 Pine Lane Ext. Property Address Ostervllle Commons Owner Owner's Name information is required for Osteryille Ma. 02655 11/01/2009 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 rr �/ t � a �� �s�•\�-A-c�..3�-tit 9/l,\` 4 No. Fee t THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Migaar 6potem Construction Permit Application for a Permit to Construct)Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 006 1pffJ c LAAjLr [05, > Owner's Name Address and Tel.No. A lQi<S- ,Cgbcl�k le p Assessor's Map/Parcel Nt . j fQ L u ,lam A `-fa Installer's Name,Address,and Tel.No. Designer' Name,Address and Tel.No. 'L�- t��Gt��cd �-�r�►'R1"� (&cll� Type of Building: Dwelling No.of Bedrooms I-Q' 4-z Lot Size SC4 t777 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) DES1rhHNG ENGINEER MUST SUPERVISE INSTALLATION AND CERTI IN WRITING THE SY Date last inspected: �' YJ Agreement: 0 ti The undersigned agrees to ensure the construe ' nd mainten e of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Envir nmental Code a ono place the system in operation until a Certifi- cate of Compliance has been iss 'd by t 's of alth. Si Date Application Approved by Date �� G Application Disapproved for e ollowing reasons ' Permit No. Date Issued y I THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( `-�'I e aired( )Upgraded( ) Abandoned( )by at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Consiruction Permit No. dated Installer Designer The issuance of this-permit shall not be construed as a guarantee that the system will function as designed. Date Inspector .7. _ r y } No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Y PUBLIC HEALTH DIVISION -TOWN OF BARNVS- BLE; MASSACHUSETTS es Zlpprication for Migaal *patent Co.w5truction 30ermit Application for aPermit to Construct )Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components - Location Address or Lot No. 006, U pa c LAxj '©Cy Owner's Name,Address and Tel.No.—SAltq cts Assessor's Map/Parcel . Installer's Name,Address,and Tel.No. Designer' Name,Address and Tel.No. �t: Type 4 Building: Dwelling No.of Bedrooms e/� / /� Lot Size'-,SW 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 1 Size df Septic Tank. --Type-of S.A.S. Description of Soil L Nature of Repairs or Alterations(Answer when applicable)' a Date last inspected: :SlqAal'jo S;t, 7" i Mu S 7 1_-4' f PUS f EC7"' Agreement: AN N u M Lp"� - - The undersigned agrees to ensure the construe 'on'and maintena'n e of the afore described on$site sewage disposal system in accordance.with-the provisions of Title 5,of the�Environmental Code a of place the system in operation until a Certifi- ;- Cate of Compliance has been iss d by t 's "afd'of calth. ' Signe �� l r Date Application Approved by �. Date -Application Disapproved for the following-reasons Permit No. Date Issued .t - ---------------------- ' --t k-----------.-- +I THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS g� r 'Certificate of Compliance _ THIS IS TO'CERTIFY,that the Oh-site Sewage Disposal System Constructed( )"Repaired (. )Upgraded O - Abandoned( )by at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer } Designer The issuance of this'permit shall not be=construed as a guarantee that system will function as dest}ned:` P g Y g Date Inspector --------------------------------------- No. / DESIGNING ENGINE f�ESIG EFL RVISE THE COMMONWEALTH OF MASSACHUSEMALLATION AND CERTIFY IN WRITING PUBLIC HEALTH DIVISION BARNSTABLES MA INSTALLED I STRICT lfgogal *p5tem Construction Vermit Permission is hereby granted to.Construct( . )Repair( )Upgrade{ }Abandon I:)-(7 ( ) System located at '' %t442 E 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. • . i- Provided:Construction must be completed within three years of the date of this permit. Date: I/1 9() Approvei�-bi�> C N -�f. No. r Fee —00-110 THE COMMONWEALTH OF MASSACHUS*g§6GNING ENGINEER MUST SUPERVISE PUBLIC HEALTH DIVISION - BARNSTABLES M CERTIFY IN WRITING AS INSTALLED IN STRICT ]Dt2;po9;a1 *pgtem Cou5tructton ONSITGETOPLAN. Permission is herebyranted to Construct( )Repair( )Upgrade andon �if�) g P Pg ( ) ( System located at 'Z o i>E ��� %,__8SL 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:Constr. ction must be completed within three years of the date of this permit. Date: Approvesfliy_- � � 'VN�AA1 1/all � r S 1 -- -2. c.• � h,�{eoy� �y, 2- !i� 1 j� i - ILK-• �"()��-j - = � 9 , _ r o u,os� IV if O. o — 'f �M A a . I ° �!P look g. w i Fid, ur 1zr fl mil?I ori 14 10 i0 \ FOIgT6P Q�d / I Mt �(i2:2a19 Li la ^ 2'. -o q'.� - 1=Tot T vr+ I TT 1� - ��` U L- -ro •m pt,usra• w.lr4 n� �I rLsr � - - 1-4, SCALE: 0 APPROVED BY: DRAWN BT�`L . DATE'Oy�,�'_. REVISED l!l'� DRAWING NUMBER 5 It I i I + 1-771 r o m Leto _9 �I�Ci Ica 1 � I.J \. �' �1 Iit 1� 2:.0 �i-MdCEM1IE oI—C AIAL a tI,4,6 m lz�b Mom+-+tom, M P. 02cp �1 P4. �;o5 , 274- 11 Co Co SGALBA/ 11 APPRpVED BT: DRAWN BY DATE:I O.-.4• � REVISED DRAWING NVMBER -- -----------= t- -Hi ; Jul I !2 Zl�4: i r L-1 _. y II �'-'I-Ik-I�( �j•%�yp�x�r-1 tz.cY.�l-�{�btu i"rl v rJ\—��r..� ��-�"�_� '�D -N-7- 0,4 — PILL v-7.� 1eI�-1 6p-- N ._ � \- 1 \ 'ter f-A,:�rj�f� _2N�r-Lp- -`'3 ----- -- J I '�08 274-L Jil i ____�' �'I� j -�SI;"�.4��/I L.L . C,�I'�►"�`o r.�, SCALE:1/ 11-I1,01 APPROVEOBY: DRAW N BY OATE:I0-214-I REVi5E0 DNS NUMBER v-4 • 2 1 TE� f P5'1 I "� - Fes_ ex,I FE ,Ej r LM I�jl Gr j Cp1-a LLG �}, r og• 2�� -i I c�� SGALE:,/ �� I��O�� APPROVED9Y: DRAWN BY L� DATE:,O.2 I aEV�SED NOTES: - < TYPr'ROOF CONST. 1 3/4'x 11 7/8"LVL RIDGEBEAM ASPHALT IN TO MATCH EXIISTING GEES 1.) CONTRACTOR IS TO VERIFY ALL EXISTING CONDITIONS -2 x 8 ROOF RAFTERS@ 16'0.c. &DIMENSIONS IN THE FIELD 5/8"CDX PLYWOOD ROOF SHEATHING 1212 5/8'CDY.PLYWOOD SHEATHING -ASPHALT ROOF SHINGLES 4 2 x 6'E 16.D.C. 15#FELT PAPER 2.) CONTRACTOR TO VERIFY ALL INTERIOR&EXTERIOR MATERIALS, -15LB.FELT PAPER (5)10d�AILS EACH END 2 z 8 RAFTERS -SIMPSON H 2.5 HURRICANE CLIPS P,ATE SIMPSON H 2.5 HURRICANE CLIPS DETAILS,&FINISHES IN THE FIELD WITH OWNER AT ALL RAFTER ENDS 1 6T&GBEAD VERIFY WALL HT.IN WIND WASH 3.) ROUGH OPENING HEAD HEIGHT OF WINDOWS AT -ICE/WATER SHIELD AT BOTTOM BOARD CEILING THE FIELD TD HAVE BARRIER ` �� 3'0"WIDE ICEIWATER SHIELD 3'0"OF ROOF THE NEW FASCIA ALUMINUM DRIP EDGE FIRST FLOOR TO BE U-8"ABOVE SUBFLOOR -WIND WASH BARRIERS 3.1 3/4'x B 12"LVL HDR. LINE UP W/EXIST. o -ALUMINUM DRIP EDGE FASCIA NEW AZEK FASCIA,FRIEZE, 4.) ALL CONSTRUCTION TO CONFORM TO 780 CMR MASSACHUSETT NEW 1 x6T&GBEAD &SOFFIT BOARDS TO STATE BUILDING CODE,STH EDITION AMENDEMENT&IRC2009 TYP.WALL CONST. SUNROOM ALL PLYWOOD TO HAVE F BOARD CEILING MATCH EXISTING 1.2x6STUDS(a316"D.c. (UNHEATED) 3°o.c.EDGE NAILING& Z 5.) 110 MPH EXPOSURE B WIND ZONE 2.12'PLYWOOD SHEATHING 12"D.c.FIELD NAILING I W.C.SHINGLE SIDING iz TYP.2xsWALLS i 6.) ALL SHEETS OF PLYWOOD WALL SHEATHING TO BE INSTALLED VERTICALLY, 3. 4.W.C. VAPOR BARRIER Z OR HORIZONTALLY W/BLOCKING AT EDGES,WEDGE/12"FIELD NAILING VERIFY DECKING 7.) ALL LVL LUMBER/BEAMS TO BE 1.9e L/360 LOAD MATERIAL W/OWNERS SUNROOM DETAIL AT CORNICE - 8.) SEE CERTIFIED PLOT PLAN DEVELOPED BY RICK HOOD FOR ALL SUBFl.AOR PROPOSED&EXISTING DETAILS P.T.2 x 105®16'D.c. 3-.P.T.2 x 12 BEAM 9.) FOLLOW ALL MANUFACTURER'S SPECIFICATIONS FOR INSTALLATION O ALL SIMPSON COMPONENTS NEW 10"DIA.CONCRETE SONOTUSE ON 24"DIA. 10.) ALL CONCRETE USED FOR FOUNDATION WALLS,FOOTINGS&SLAB BIGFOOT FOOTING TO TO BE 3000 PSI 4 47 BELOW GRADE.USE SIMPSON ABU66 POST 11.)VERIFY ALL PLUMBING&ELECTRICAL DETAILS W/OWNERS ON THE SITE BASE DURING FRAMING CONSTRUCTION A SECTION a SUNROOM 12.)TIMBER FRAMING TO BE SPRUCE/PINE/FIR NO.2 GRADE 13.)FOLLOW ALL REQUIREMENTS OF THE 110 MPH CHECKLIST SUPPLIED A5 14.)THIS SITE IS IN THE 110 MPH WIND BORNE DEBRIS AREA,EXPOSURE"B" 2x4's @ 16'o.E CONT.RIDGE VENT &WITHIN ONE MILE OF NANTUCKET SOUND PER STATE OF 12 MASSACHUSETTS WIND SPEED MAPS 3� 15.)GLAZING PROTECTION PER 780 CMR 5301.2.1.2 TO BE IMPACT GLAZING CONT.SOFFIT VERIFY ALL WIND BORNE DEBRIS PROTECTION REQUIREMENTS VENTS z 10's�@ 18'Des \ TOP OF PLATE TOP OF PLATE W/OWNERS PRIOR TO START OF CONSTRUCTION 3.2x8H / i \ \ TYP.WALL CONST. 16.)FOLLOW ALL REQUIREMENTS OF THE IECC2012 RESIDENTIAL ENERGY 212'PLYWOOD SHEATHING _ EFFICIENCY REQUIREMENTS&VERIFY ALL DETAILS WITH THE INSULATION \ \ 3.6'(R=20)BATT INSULATION $ INSTALLER/CONTRACTOR. NEW '\ ` 4.12 GYPSUM BOARD S� \ \ m N 17.)ALL HEADERS TO BE 3-2 x 8's UNLESS OTHERWISE NOTED STUDIO \ .9.W.C.SHINGLE SIDING � 12 � \ 6.TYPAR VAPOR BARRIER 12� INVERIFYTHE IELDF]EXISTING FRAMING IECC2012 RESIDENTIAL ENERGY EFFICIENCY DETAILS IN THE FIELD FOR ADDED LOADS DUE TO NEW DORMERS SECOND FLOOR SECO14DFLOOR 2x10's ARE OK BUT EXIST. SUBFLOOR CLIMATE ZONE 5A(USE EITHER PRESCRIPTIVE VALUES OR RESCHECK CALCULATION SUBFLOOR BEAM IS UNKNOWN zx to•s�t6"o.a. zxtaE@16•o.c TABLE 402.1.1 (MINIMUM PRESCRIPTIVE INSULATION&FENESTRATION REQUIREMENT FENESTRATION SKYLIGHT CEILING WOOD FRAMED WALL I FLOOR BASEMENT WALL BASEMENT SLAB CRAWL SPACE WALL U-FACTOR U-FACTOR R-VALUE R-VALUE R-VALUE R-VALUE R-VALUE R VALUE e SECTION @ STUDIO --- - 0.35 1 0.60 1 49 1 20 30 10113 1D(2 FT.DEEP) 1013 A NOTES: NEW 10°DIA CONCRETE A5 A5 1.R-VALUES ARE MINIMUMS&U-FACTORS ARE MAXIMUMS. NEW 10"BE ON 24"DIA p.T.2 x 10 LEDGER BOARD LAG BOLTED TO 4K,2J 3-1 3l4'x 9 12"LVL H DER 4K,21 2.10113 MEANS R=15 CONTINUOUS INSULATED SHEATHING ON THE INTERIOR OR EXTERIOR BIGFOOT FOOTING TO s66D BLOCKING Wl(2)LEDGERLOK BOLTS - OF THE HOME OR R=13 CAVITY INSULATION AT THE INTERIOR OF THE BASEMENT WALL Oro'BELOW GRADE.USE 12'-e" 16 o.c.STAGGERED W/JOISTS HANGERS 3.REFER TO IECC 2012 CHAPTER 4 FOR ALL INSULATION&ENERGY REQUIREMENTS SIMPSON ABU66 POST - 4K,2J BASE A A5 VERIFY EXISTING HEADER SIZE I 3-P.T.2 x 12 BEAM a INSTALL NE W 2-1 314'x 11 7/8'LVL I HEADER IF NO JACK STUDS ARE 4 x 6 POST FR RIDGE BETWEEN DOOR PANELS I DOWN TO HE ER = INSTALL FLASHING UNDER 1 314"x 11 718 LVL RID E_BEAM I HOUSEWRAP&DECKING I DECKING O 1 (4 = m I cS ¢ c O rF POST FROM RIDG EXIST. DOWN TO HEAD FLOOR JOISTS BASEMENT P.T.2x B'E@16"0.a r g 4K,2J INSTALL PEEL&STICK a - RUBBER MEMBRANE 3-1 3/4'x9 12"EVER ER BETWEEN LEDGER& '4 FASTEN HEADERS SHEATHING TOGETHER&TO p` NOTES: CORNER WI SIMPSON AS P.T.2 x 10 LEDGER BOARD LAG BOLTED TO LCE4 POST CAP WI 1.) ALL ROOF RAFTERS TO BE 2 x 8's SOLID BLOCKING W/(2)LEDGERLOK BOLTS ( CORNER CONNECTION ROOF F RA I N G PLAN UNLESS OTHERWISE NOTED 16•o.c.STAGGERED W/JOISTS HANGERS DETAILS(SEE SIMPSON � 3-P.T.2x12 BEAM CATALOG 2.) USE SIMPSON H2.5 HURRICANE CLIPS DECK DETAIL ' FASTEN JOIsT9 TO A AT ALL RAFTERS ENDS BEAM WI SIMPSON HS TIES A5 FLOOR FRAMING PLAN 3.)VERIFY GU,-T _ .-.-, LAYO� W!OWNS IHEOESIGNERSHALLBENOTWEOFANY SCALE DRAWING NO. �%i ERRORS OR OMISSIONS ARE FOUND ON THESE DRAWINGS PRIORTO STARTOF COTUIT BAY DESIGN, LLC IVEVOI A®®OTO®NfREM®®SLING ®R: �-"`{ "onARK A INHES Res F R 1/4" =. 1'-0l' -KE ZIE C MMEE ES WI HO IF COTIMNG CONSTRUCTION Iu\ 43 BREWS-1 ROAD �� �' COMMENCES WRHOUTORS OR OMISSIONS. r P6EL'• f. 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