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HomeMy WebLinkAbout0137 POND STREET - Health Ilf Ti -Pond-Street V IA Osterville F/R e o a e " n , ° a , , e 4 a n a G , w ° n o 1 • a ° � 9 � ! S0 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2ppliLation for Misposal *pstrm Construction i3Prmit Application for a Permit to Construct(,4epair( ) Upgrade( ) Abandon( ) ❑Complete System ndividual Components Location Address or Lot No. j; "� Qe�:ryes, �� +��lY Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 0 / z i a r�i�,� J.•_ ✓�,'Y✓i:e.� Installer's Name,Address,and Tel. o. 'q y ai C .3 t J,,fL Ciz� Designer's Name,Address,and Tel.No. Type of Building: 5 - '0 -nZ Dwelling No.of Bedrooms IV Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures 4A Design Flow(min.required) gpd Design flow provided /y gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soily Nature of Repairs or Alterations(Answer when ap licable) i?n) 6 .i I ��n t _S Cn� z�rl �-c,ti '� Sb•e,t,� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed k Date 1 a Application Approved by Date 1-t Application Disapproved by Date for the following reasons Permit No.__a�o -( � bate . . Date Issued U _.,., .:t ,�,yr. w,y,7.i-.. - �r...w r-^ .. '�». .,�r,.,r•. ..�,....,.., x�'xy— .,:-yrnti=�- ev'•.q;M'`•'�,�k+rdo�'tr:,•'�e�,4•ii;.r='k✓,`:k. 1;.. h .: -*��•-r� ,� q �q No. �t :.. Fee. ... THE COMMONWEALTH & MASSACHUSETTS Entered in computer. PUBLIC HEALTH DIVISION`- TOWN OF BARNSTABLE, MASSACHUSETTS ` Yes NpliLation for Misposal *pstrm Construction Permit {� E A licationffor a Permit to Construct Re air Upgrade Abandon Complete System , n/dividual Components PP P ( ) PSr ( ') ( ) ❑ P y LJ� P Location Address or Lot No ('3"r C��n� gT. OSftv.�CIY Owner's Name,Address,and Tel.No. Assessor's Map/Parcel V t C,Tu Z Q l on.rvKa Installer's Name,Address,and Tel Desi '. o. Designer's'Name,Address,and Tel.Noi ' � pi g •° 3 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 ` Design Flow(min.required) gpd Design flow provided Al gpd Plan Date �' ^'Number of sheets Revision Date 1 t Titleter Size of Septic Tank Type of S.A.S. =pescription of Soil a , 6 "4A x Nature of Repairs or Alterations(Answer when applicable) b °l 1 ��� A G& Tiv r ;S tom . 'Date last inspected:. Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in _ W accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signgd Date Application Approved by Date ) ! Application Disapproved by Date 1 for the following reasons _ Permit No. "' 0 fillkw,ate Issued __-----------------------------------------------------------------------------------------------------------------_____________________ THE COMMONWEALTH OF MASSACHUSETTS N W X,; BARNSTABLE,MASSACHUSETTS Nr-A Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )by cc0 at has been constructed in accordance witH the provisions of Title 5-and the for Disposal System Construction Permit No.9017- y 9 dated Installer b T t3 b y 2 Lo . Z� � Designer #bedrooms /J Approved design flow A gpd The issuance of this permit shahnot be construed as a guarantee that the system will fttnctio designed. Date I t © Inspector t A/ No. �OI 1 C( Fee r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS MispoBal *pBtrm (Construction Permit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) System located at 1371 f?o n Ca S AA 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. Provided:Construction must be completed within three years of the date of this permit. C Date 2 " "/ Approved by 5vdj /J l TOV-YN OF BARNSTABLE ` LOCATION. /'57 Tooel Sr SEWAGE # 2, ) VILLAGE n 57-45 1 WI- ' / ASSESSOR'S MAP & LOT//S -033 INSTALLER'S NAME&PHONE NO. Y*y'`'ds s48- 4'2a- y7i SEPTIC TANK CAPACITY 20%ts LEACHING FACILITY: (type) 2-fOo 441 aW (size) NO. OF BEDROOMS 3 BUILDER OR OWNER llc-'k ro ' PERMITDATE: 2Odo COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished byn �y s `7 N 12, �� // 'No. ��� v1u s Fee "� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0Lpprication for Migool bpotem Cotvaruction Permit Application for a Permit to Construct( z Mepair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. pae YT Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Ill / D 0 X_�E ` -SOO6A, , Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this B and o Health. Signed Date Application Approved by Date Application Disapproved for the following reaso Permit No. 7-fv?1'' 17,6 Date Issued 31 3 Z4V.V . No. o —IZ,� �.,orr, .�• Fee THE.COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes y PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Application for Ofgpoof 6wem. Cottgtruction Permit Application for a Permit to Construct( !'Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 37 Po`1 sT, "Owner's Name,Address and Tel.No. Assessor's Map/Parcel O,�r�r�,%/� I/c.Tdr� pFrk�ruskas Installer's Name,Address,and Tel.No. Designer's Names,Address and Tel.No. ,QG 13N^-VS 49140NU5 ,#. l , W /S .� Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) i Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title t Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) of / D a �2 - Oo , Date last inspected: Agreement: ~�!''�-�_...._.,. . `• The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this B and o Health. Signed Date Application Approved by Date 3 Application Disapproved for the following reasoid Permit No. 2-4yU" 17,6 Date Issued 3 3 &VAV --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed(tom-Repaired( )Upgraded( ) Abandoned( )by ,/,as 48Li ae- yae'HOS at - ./.'f7 hcz 5r, has been constructe4 in accordance with the previsions of Title 5 and the for Disposal System Construction Permit No.24w-I z6 dated Installer✓A5-C,04 ,Z)-,-1w"r©5 Designer The issuance of thip perfnit shall not be construed as a guarantee that the system ' a fined. Date 7 Inspector --------------------------------------- No. / /ZP Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS r ioozaf *pgtem Construction Permit Permission is hereby granted to Construct( epair( )Upgrade( )Abandon( ) System located at ST. and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of t ' p it. t Q Date: 3 I3Iadzry Approved 1/6/" NOTICE: This Form Is To Be Used For the Repair Of Failed .Septic Systems Only. CERTMCATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, ,.4 �ea�f , hereby certify that the application for disposal works construction permit signed by the dated t ^ ©® concerning the property located at s . . , I meets all of the following criteria: or-*"—The failed system is connected to a residential dwelling only. There are no commercial or business pus-e�-s-associated with the dwelling. � The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system /,--?here are no private wells within 150 feet of the proposed septic system /- There is no increase.in flow and/or change in use proposed There are no variances requested or needed • The bottom of the proposed leaching facility will not located less than five feet above the Ma)dmum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S. Mll be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will nW be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top 017 Ground Surface EIevation(using GIS information) H) G.W. Elevation y/ . _+the,1LgX "igh G.W. Adjustment D&FFEREPICE BETWEEN A and B SIGNED : (Sketch proposoc'plan of DATE. q:h.iu folder cen sYszem on back]. � o P Legend JCANN OF PROPERTY R1` ' � ►°P � . Road � A►RN, T ,BLE . ; ...A� •;;. _...� ,.._,- '*�^�^'— r*.'� -.'Z�r;, •..yk-u-�,a-'�" :;-^�+.rr.,".'�"��'.9;�:".�. .,ws4.a..ras�. �.�" �- .a...........�.�,�.��,.�,.a„ ,s` �.z r �� . 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Rf s�sWaan,�� �¢_�,I; s4¢f�ebr�mc�Pa4mdlcam ►, tPJEL{,EVEYAa'SONS 1 10/12/2018 AsBuilt ` TOWN OF BARNSTABLE LOCATION 137 Tor?c:i/ SEWAGE# 20DD -124 VILLAGE 6Szj,: ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. ,JosC1'14 1,2s l.��Y�os 54 Y?d- f71� SEPTIC TANK CAPACITY 2aas LEACHING FACILITY: (type) ?-!p0 4,21 /�*4y-/t�(size) ILK 2,5' NO.OF BEDROOMS 3 BUILDER OR OWNER ll 1krOr PERMITDATE: 3-3 24P00 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet 0 Furnished by 1Ca� �r5rr/�Lrr� / a C rori w v' - 1,Mn•I/iccnl7/infronn}/nrnnrl�}�/nrohiiilt�env7mannar=11 Rf1�3Rcan=1 1/2 I _ i k 1 yi I I � 1 I � , `• t C 1 L. I - 10, i a - (A Jab: tJa4e , M� �v .n<m�. Stefan Rich FD I �. •• PPAPOSEC ADOI'il4N@ ao�ma.ow-wan�`p ea e.saq+nen.m+oaa awe�wr�r. a�awi.:«r+.�e I f $ I37 POND 5T. 05MALLE,AA Sv�ee,r.e.w+.w .wa.ebmm.n,�d. rs�pen.maay� waMw...v Ti4?et FOUNbAnOMMOM RAN °"'°�': "�""`."'' t@-ti�adt: s�ef�eric6smcm 6ro4maeLeo.nl. f f i a-cis-zzi :*4vq cv�noAwAwws.eAmexa a qib GYImPMw � o, Aa>mAem!Ynnrmm anumwanvoev.ea:Yrsnea _ .� � Abl�vaM�YruOr�� .IOnVpMiYtl�lf.iAYY it 041E rouHRmvom M]V�QAHIH •• av11W _-__.._� fOif4W MtHee fiU+OkA9 nb�Y6�r M k- - - oAa.+olvmamY 4 I, mowum u+YA.cu - wnm�...iow I � , as --- oo �,�����m�w � °-•_�,� ' .71- Hal (YYlL YwLi�Y1YlAYOO1AK6- MWwv4WmOMMOCu/ � .� Q �� �Mq�A� � CYYl�nlY'P wtl9XAClIFMI� iii} i M' _ lC)A .mDRMv6'1 ���� Y.F� 8I,�.YYY7 + MUU1wYAuw YCuo.Yom IIAW p�. i j a i4�101M1� RAH m t.lttl�e- Q� '� i AfLYLO�mmYYtLLY ®ID1n MnAimYAHA(gMm _ 5 FF g' rUEfAK AOK.� YncigAnYixar P, N t i t t . TOWN OF BAFNSTABLE LOCATION / -7 j SEWAGE# zm a ">::2 4 VILLAGEStirli 1/i�la ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 20� LEACHING FACILITY: (type)2-rao /,r/, "/ . �s/�S (size) NO. OF BEDROOMS_3 BUILDER OR OWNER kro✓' PERMITDATE: — 3 — 2Ooa COMPLIANCE DATE:-3— IT-o 3 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 4 v� ro i r- • v a a� `� pah� .fir, t. 1 � ,. Town of Barnstable �►Rxsresi.$, Department of Health, Safety, and Environmental Services �A Public Health Division 367 Main Street, Hyannis MA 02601 Office: 508-862-4644 Thomas A McKean,RS,CHO FAX: 508-790.6304 Director of Public Health TO: VICTOR A PETKAUKOS, TRUST. DATE: JAN. 209 2000 1A SEAGULL BEACH RD. WEST YARMOUTH,MA. 02673 ORDER TO COMPLY WITH 310 CMR 15.00,.THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at 137 POND STREET, OSTERVILLE was inspected on 06/07/97 by JOSEPH P. MACOMBER JR. a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: THE CESSPOOLS ARE STARTING TO CAVE IN. THEY HAVE SOIL INTRUSION AND ARE CLOSE TO PROPERTY LINE. THE SYSTEM MUST BE UPGRADED TO A TITLE V SEPTIC SYSTEM. THE 95 CODE. The above system, according to our records has been in a failed state for more than two years. Therefore, you are directed to hire a licensed Town of Barnstable septic system installer to sketch a proposed system that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within(14)fourteen days of receipt of this notice. The septic system must be brought into compliance within (30) thirty days of your receipt of this directive. You are also directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into buildings, onto the surface of the ground, or into surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health Town of Barnstable q1.W t&fiieltWr32y.doc - W-�` 21 I � Y A • J 1 G. Y' 118033 •DUMMY PARCEL FOR TESTING :S 118033 V 0006N� 0000000 s 30ppAC PETKAUSKOS,VICTOR A TR 101 1 00001738 1A SEAGULL BEACH RD 00p W YARMOUTH MA 02673 00-0�0-000^M� 000000 10916 00 „ PETKAUSKOS,VICTOR A TR 0000 1053/163 01 3al 1RE J OOpp5020p OOpppp0000 POND STREET 1295 0090 `.• CO Unassigned Road Name 0000 I 0000 b I 1 e f i 1 i , { FAR Real Estate System - General Property Inquiry Help Parcel Id: 118 033- - Account 'No: 60052 Parent: Location: 137 FOND ST OSl" Neighborhood: 30AG Fire Dist: bevel Lot: Lot Size: .28 Acres Current Own: ODONNELL, MARY JO State Class: 101 137 FOND ST t4 P D No. Bldgs: 1 Area: 1736 Year Added: OSTERV I LLE MA 2/,55, Deed Date: Reference: 1c:f53/163 January 1st: ODONNELL, MARY JO Deed MMDD: 0000 Deed Ref: 145:=:/16 Comments: Values: Land: 41700 Buildings: 5000 Extra Features: Road System: 137 Index: 1295 (POND STREET ) Frntgs ( Inde.�:: ( ) Frntg: Control Info: Last Auto Upd: 050695 Status: C Last TACS Update: Land Reviewed By: Date: 0600 Bldgs Reviewed By: Date: 0000 �¢ Tax: Title: Account: Taken: Account Status: Hold Status Cancel Press XMT for more data Nest screen FAR Action Owners Name Road Index: Road Naive Parcel Number�' 118 0-354 DATE: _6/10/97 PROPERTY ADDRESS: -137-?(5hd Street - �jl.lJ Osterville ,Mass . 02655 On the above date, I Inspected the septic system at the above address. This system consists of the following: 1 . 2-6lx6l •block cesspools . Based bn my Insoection, I certify the following conditions: 1 . This is - not a title five septi'd`&ystem 2. This is. a sewage- systems, . ' •3 . Thecesspool's are starting toicave -in. They have soil Vj intrusion-,a.nd arse_ clo;set.to property 7.ine 4. +-System is Of, ailure. Must„ be upgraded to, a title five septic system. Tlie .95-Code . - 51GNATURr`: ' Name:_J P_M_acomber Company: J. P_MacoMber & Son—Inc. • ' , ; Address: -•.die-u-bb-----=1---,-- Centerville jigpLs ' 0.2b32 ' Phone:__ ------- -- I THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY • JOSEPH P. MACOMBER- & SON, INC. Tanks-Ceupools-Leschflelds Pumped L Installed Town Sewer Connections P.O. Box 66' Centerville, MA 02632-0066 775-3338 776-6412 r 3 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS 2 DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON, MA 02108 617-292-5500 WILLIANi F.VELD TRUDY COa Governor Sccretar ARGEO PAUL CELLUCCI DAVID B.STRUH Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commission PART A CERTIFICATION Property Address'. 137 Pond Street Osterville I MasThddress of Owner: Date of Inspection:6/7/97 '(If different) Name of lnspector.Joseph P.Macomber Jr. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: J.P.Macomber & Son Inc'. Mailing Address: Box 66 CPntPrVi 1 1 P ,Ma GG _ 02h32 Telephone Number: T(S_�7�_33 38 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes Conditionally Passes ' Beds Further Evaluation By the Local Approving Authority - Inspector's Signature: "/, Date: The System Inspecto shall submit a copy of this inspection`report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: It)Q I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated'are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: Z 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. Indicate yes„no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:/twww:magnet.state.ma.us/dep Pmted on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:137 Pond Street Osterville ,Mass . 02655 Owner: Mary Jo O ' Donnell Date of Inspection:6/7/97 B) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: All) Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the pre nce of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance .(approximation not valid). 3) OTHER The sewage System consists of two 6tx6l A 1 Not for paragraph 0 SPr't; on 2 (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 137 Pond Street Osterville ,Mass . Owner: 0 ' Donnell Date of Inspection:6/7/9 7 DJ SYSTEM FAILS: Yo must indicate ei;-.er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes y _ Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. a. " Static liquid level in the distnbuion 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. i r than 4 time in the last year NOT due to clogged or obstructed i e(s). Required pumping more t a s y gg p p Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. n f I r privy is within 50 feet of a private water supply well. Any portion • a cesspool • p vy p �'y Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia-nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No _ x,4 _ the system is within 400 feet of a surface drinking water supply _ k�A _ the system is within 200 feet of a tributary to a surface drinking water supply _ t)4 _ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of.a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. 1 Cesspool are' caving ns > 2 Ser, ous soil intrizsio:n 3 3 ..`Cesspools to close to': praperty liri'e (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM J PART B CHECKLIST Property Address: 137 Pond Street Osterville ,Mass . Owner: Mary Jo O ' Donnell Date of Inspection: 6/7/97 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks'and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they.are not available with N/A. X _ The facility or dwelling was inspected for signs of sewage back-up. _ X1 The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components,�Kcluding the Soil Absorption System, have been located on the site. _/(0 _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any cFf the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] (rwlaad 04/25/97) Pago 4 of 10 `i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 137 Pond Street Osterville ,Mass . Owner: Mary Jo O ' Donnell Date of Inspection6/7/97 FLOW CONDITIONS RESIDENTIAL: Design flow: XIO p.d./bedroom for S.A.S. Number of bedrooms: Number of current residents: Garbage grinder (yes or no): Laundry connected to system (yes or no): Seasonal use (yes or no): A-D Water meter readings, if available (last two (2) year usage (gpd): Sump Pump (yes or no):,-�& Last date of occupancy: COMMERCIAUINDUSTRIAL: Type of establishment: V14 Design flow: ,Uf;? aallons/day Grease trap present: (yes or no)A/ Industrial Waste Holding Tank present:•(yes or no),& Non-sanitary waste discharged to.the Title 5 system: (yes or no)AY Water meter readings, if available:V14 Last date of occupancy: OTHER: (Describe) 104. Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS an so ce of information: System pumped'as pan of inspection: (yes or no)10 If yes, volume pumped: _WX • gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool _L Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) &A I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 137 Pond Street Osterville ,Mass . ` Owner: Mary Jo O ' Donnell Date of Inspection: 6/7/97 BUILDING SEWER: (Locate on site plan) rr Depth below grade: /y Material of c n�truction: cast iron 40 PVC other (explai r _ Distance from private water supply well or suction line Diameter ' l Comments: (condition of joints, venting, evidence of leakage, etc.) No signs of leakage at the joints : SYstem vented through the house vent. _ SEPTIC TANK:&Irve- (locate on site plan) Depth below grade:&1 Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age is age confirmed by Certificate of Compliance f,� (Yes/No) Dimensions: Sludge depth: N Distance from top of sludge to bottom of outlet tee or baffle 24— Scum thickness:V_ Distance from top of scum to top of outlet tee or baffle: VA Distance from bottom of scum to bottom of outlet tee or baffler How dimensions were determined: e] Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) ! ep is tanX is not present. GREASE TRAP:A (locate.-on site plan) Depth below grade: 4,14 Material of construction:4concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle:tAo�l Distance from bottom of scum to bottom of outlet tee or baffler Date of last pumping: -AZ-4 Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Grease trap is not present. (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 137 Pond Street Osterville ,Mass . Owner: Mary Jo O ' Donnell Date of Inspectionb/7/97 TIGHT OR HOLDING TANK:Yjg�L, (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: concrete _metal Fiberglass _Polyethylene _other(explain) Dimensions: AIN Capacity: gallons. Design flow: gallons/day Alarm level: ,4/,4 Alarm in working ordero( Yes; No Date of previous pumping: _ Comments: (condition of inlet tee, condition of alarm and float switches, etc.) iligtit or hoiding tanks are not present. DISTRIBUTION BOX:-Idwr (locate on site plan) Depth of liquid level above outlet invert:_ Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out-of box, etc.) Distribution box is .not present PUMP CHAMBER:/v (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) ump chamber is not present. (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 137 Pond Street Osterville,Mass . Owner: Mary Jo O ' Donnell Date of Inspection:/7/97 SOIL ABSORPTION SYSTEM (SAS):z (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type. leaching pits, number: leaching chambers, number: leaching galleries, number: leaching trenches, number,length: —� leaching fields, number, dime sions: (J overflow cesspool, number. Alternative system: Name of Technology: VAI Comments: I�note cpndition of of((,, si s of h draulic failur level of ponding, condition of vegetation, etc.) o signs of hy�rauTic faiure :No signs of ondin :All vegetation is normai. F-3-5I is caving:°: as` soi intrusion. System must' be' >upgraded to , a title fi.ve: sentic system: ( 9 Code � CESSPOOLS: (locate on site plan) Number and configuration: 4 Depth-top of liquid to inlet in rt: Vy' ' Depth of solids layer: _ Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: ZO inflow (cesspool must be pumped as part of inspection)A!4 16w 4z ga) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Boney sanilo me alum sand.No signs of Hydrauilc raliure, or on in : Ail vegetation is norma :: ,oroi is caving as' 'soil-'intrusion,.Must be upgraded to ale five septic system. ( 95 Code ) PRIVY: (locate on site plan) Materials of construction: i/)/9 Dimensions: Depth of solids:�Jf� Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Privy is not present (revised 0{/2S/97) Page 8 of 10 L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 137 Pond Street Osterville ,Mass . Owner: Mary Jo O' Donnell Date of Inspection-.6/7/97 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) n c r` P Y� c 3� i� s � M 37 O•vice sT (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISC L SYSTEM INSPECTION FORM . . C SYSTEM INFO. :ION (continued) Property Address: 137 Pond Street Osterville,Mass . Owner: Mary Jo O ' Donnell Date of Inspection6/7/97 Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwa; ,vation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, ba: .t sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps " Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groun;. r Elevation. (Must be completed) We have put in several systems on Pond Street in Osterville . No water was encountered at` 12 ' 194 Pond Street Permit # 75-424 219 Pond Street Permit # 92-248 299 Pond Street Permit # 82-384 (revised 04/25/97) Ps; of 10 C' � * G W THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT 1 Joseph P. Macomber, Jr. Has satisfied the Department's qualificatigns as required and is hereby authorized to use the title ' CER'I`IF ED TITLE 5 SYSTEM-INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter, 2 1 A of the. General Laws. Issued by The Department of Environmental Protection. June 8. 1995 ` Acung Director of the ' ton of Water Pollution Control TOWN OF BARNSTABLE • n� SEWAGE #� LOCATION /�� /�I� �! VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet . Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ��-� �. W �Q ,� � � k y � , e � 3 � "� � '�� �. � �►w � , r a Z 203 499 142 US Postal Service {' Receipt for Certified Maif` No Insurance Coverage Provided. Do not use for International Mai See reverse Sent to vcjl�- SJr t&NumbeL Postage $ Certified Fee Special Delivery Fee Restricted Delivery Fee LO I Return Receipt Showing to Whom&Date Delivered n Return Receipt Stowing to Whom, Q Date,&Addressee's Address 0 TOTAL Postage&Fees Is z;-'M Postmark or Date 0 u_ Stick postage stamps to article to cover First-Class postage,certified mail fee,and charges for any selected optional services(See front). 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attached, and present the article at a post office service window or hand it to your rural carrier(no extra charge). 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the a') return address of the article,date,detach,and retain the receipt,and mail the article. Ln 3. If you want a return receipt,write the certified mail number and your name and address °) rn on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article a RETURN RECEIPT REQUESTED adjacent to the number. Q 4. If you want delivery restricted to the addressee, or to an authorized agent of the addressee,endorse RESTRICTED DELIVERY on the front of the article. oho M 5. Enter fees for the services requested in the appropriate spaces on the front of this E receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. LL`5 6. Save this receipt and present it if you make an inquiry. 102595-97-e-0145 a ai SENDER:. I also wish to receive the ,v_ ■Complete items 1 and/or 2 for additional services. rn ■Complete items 3,4a,and 4b. following services(for an 0 ■Print your name and address on the reverse of this form so that we can retum this extra fee): card to you. ka ■Attach this forth to the front of the mallpieoe,or on the back if space does not 1. ❑ Addressee's Address 9 permit. ky ■Write'Refum Receipt Requested'on the mailpiece below the article number. 2. ❑ Restricted Delivery N .5 ■The Return Receipt will show to whom the article was delivered and the date delivered. Consult postmaster for fee. 0 v 3.Article Addressed to: 4a.Article NumberCL d E (/�G/�� 14b.Service Type 0 d i❑ Regstere Certified lZ ✓ yy�� ❑ Express Mail ❑ Insured c ❑ Return Receipt for March ndise ❑ COD °c 7.Date of Deliv ° Z 02 v 5.Received By:(Print Name) Addressee's A dress(Only if requested W and fee is paid) t + g 6. to e: Add ssee or Agent) 0 �' � t,` itt i i Atli f t i4I i iit w -- Ps o 81.1, egetrOw 1994'. "` ' ' 102595-97=e-0179 Domestic Return Receipt P E UNITED STATES POSTAL SERVIC O p s��t�las�At1�3k1-- P�1 -„�® .� s `aF®esaPaid I 'A A R c Print your na ; ss, and ZIP-C de°in o-� �`# Pcblic Health Dlalsloo Town of Bamstable 1 P.O.Box 534 Hyannis,Massachusetts 02601 I I 5r Town of Barnstable Department of Health, Safety, and Environmental Services 5 9. Public Health Division 367 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX 508-790-6304 Thomas A.McKean,RS,CHO Director of Public Health TO: VICTOR A PETKAUKOS, TRUST DATE: JAN. 20, 2000 1A SEAGULL BEACH RD. WEST YARMOUTH,MA. 02673 ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at 137 POND STREET, OSTERVILLE was inspected on 06/07/97 by JOSEPH P. MACOMBER JR. a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: CESSPOOLS ARE STARTING TO CAVE IN. THEY HAVE SOIL INTRUSION AND ARE CLOSE TO PROPERTY LINE. THE SYSTEM MUST BE UPGRADED TO A TITLE V SEPTIC SYSTEM. THE 95 CODE. The above system, according to our records has been in a failed state for more than uuo-y z. Therefore, you are directed to hire a licensed Town of Barnstable septic system installer to sketch a proposed system that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within(14) fourteen days of receipt of this notice. The septic system must be brought into compliance within (30) thirty days of your receipt of this directive. You are also directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into buildings, onto the surface of the ground, or into surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. P ER OF BOARD OF HEALTH omas A. McKean, R.S., C.H.O. Agent of the Board of Health Town of Barnstable q-1xW f0W"e52y.dm 1