The URL can be used to link to this page

Home My WebLink About0058 POPLAR DRIVE - Health (2) 58'POPLAR DRIVE (OSTERVILLE)-3 A= 121 -048 ` 4 0 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION / Property Address:. 58 Poplar Drive Osterville.MA 02655 Owner's Name: Susan Tibbetts Owner's.Address: �% G Date of Inspection: May 24 2007 Name of Inspector:(Please Print)James M.Ford Company Name: James M.Ford Mailing Address: P.O.Box 49 Osterville.MA 02655-0049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the iiiformation reports d below is true,accurate and complete as of the time of the inspection: The inspection was performed basemen m training and experience imthe.proper function and maintenance of on site sewage disposal systems. I amp DEF= approved system inspector pursuant to Section.15.340 of Title 5(310 CMR 15.000). The -tem. Passes Conditionally Passes 4phisoin urther Evaluation by the Local Approving A thority N orInspector's Signature: Date: M 30 2 07 The system inspector shall sub :tection report to the Approving.Authority(Board'of Health or DEP)within 30 days of completeIf the system is a shared system or has a design flow of 10,000 god 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. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 A Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 58 Poplar Drive Osterville.AM Owner: Susan Tibbetts Date of Inspection: May 24 2007 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution.box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe.(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 58 Poplar Drive Osterville.MA Owner: Susan Tibbetts Date of Inspection: May 29 2007 C. Further Evaluation is Required by the Board of Health: R 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 M303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a.surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a,manner.that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surfacemater 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 and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 58 Poplar Drive Osterville,MA Owner: Susan Tibbetts Date of Inspection: May 24 2007 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No _ ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool.is less than 6"below invert or available volume is less than'/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. _ ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. _ ✓ Any portion of a cesspool or privy is.within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system.must serve a facility with a design flow of.10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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.. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 58 Poplar Drive Osterville.MA Owner: Susan Tibbetts Date of Inspection: May 24 2007 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: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 58 Poplar Drive Osterville,MA Owner: Susan Tibbetts Date of Inspection: May 24,2007 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):. n/a Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRL,L Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present.(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped 2 years ago per owner Was system pumped as part of the inspection(yes or no): 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Date of installation unknown . Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 58 Poplar Drive Osterville.MA Owner: Susan Tibbetts Date of Inspection: May 24, 2007 BUILDING SEWER(locate on site plan) Depth below grader Materials of construction: _cast iron 40 PVC -_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) (Cesspool acting as a septic tank) Depth below grade: Material of construction: _concrete _metal ._fiberglass _polyethylene ✓ other(explain) Cesspool block If tank is metal list age: Is age confirmed by a Certificate of Compliance.(yes or no): (attach a copy of certificate)' Dimensions: 6' x 6'leach pit actin ag s a septic tank ` Sludge depth: -- Distance from top of sludge to bottom of outlet tee or baffle: -- Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: -- Distance from bottom of scum to bottom of outlet tee or baffle. -- How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or,baffle condition;structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Liguid was up to the outlet p�e The cover was 4"below grade. GREASE TRAP: None (locate on site plan) Depth below grade: 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 ty Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 58 Poplar Drive Osterville.MA Owner: Susan Tibbetts Date of Inspection: May 24. 2007 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: None (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.): 8 i Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 58 Poplar Drive _ Osterville. MA Owner: Susan Tibbetts Date of Inspection: May 24, 2007 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number.: 2-6'x 6':(1000 aP 1.) leaching chambers,number: leaching galleries,number: leaching trenches,number,length'. leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: . Comments(note condition of soil;signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Overflow nit#1 had 5'ofliauid on the bottom. An outlet tee was present Overflow nit#2 was dry. The scum line was 3',YP from the bottom: There did not appear to be any signs offailure. The cover was 30"below grade CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.)- 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 58 Poplar Drive Osterville, AM Owner: Susan Tibbetts Date of Inspection: May 24,2007 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 33 36 3 a 53 3;L 10 r 4l ' Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 58Poplar Drive Osterville, MA Owner: Susan Tibbetts Date of Inspection: May 24, 2007 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30+/- feet Please indicate(check)all methods used to determine.the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and:water contours maps, the maps were showing aoroximately 30'+1-ground water at this site. This report has been prepared'only for the septic system and components described herein. This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees,either expressed,written or implied, relating to the septic system,the inspection,this report and/or any components of the septic system which have not been located and inspected. 11 TOWN OF BARNSTABLE *.,—ILAGE CATION a 1 OFF/Rr 1)r. SEWAGE# 0snr,"k ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY S GJ LEACHING FACILITY:(type) (size) NO.OF BEDROOMS 3 OWNER PERMIT DATE: 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 BY ��SpaGf iyn -7� FOrG a 33 3oe 3 a 53 3;L 3 -7a q� LO`, AT ION SEWA . E PERMIT NO. �<; ram: VILL, GE IN../SETA LLE/R'S NA E & ADDRESS B=Wr-WPR OR O*N E R DA E PERMIT. ISSUED DATE C:O-MPLIANCE. : ISSUED l ` ; + A � { y ` 1 { \,.-r: r 4\ � 1 �� `� „� `� '�� ._':, r; LO4 AT10 - $ SEW. PERMIT N0. VI L` GE IN.STA LLER'S NAJAE i ADDRESS OR divNER DA E. PERMIT ISSUED , DATE COMPLIANCE. . ISSUED I .. j i f i i 1 TOWN OF BAMSTABLE -CATION 8 1 ojofc ' 1�r, SEWAGE# VIi.T.iv �JSTerv�� ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. EPTIC TANK CAPACITY -s of LEACHII�TG FAILITY:(type) a� (size) NO.OF BEDROOMS 3 OWNER PERMIT DATE: 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 j within 300 feet of leaching facility) Feet FURNISHED BY �i1 Spt�Oh �. FD/� i slick a C3 ! 33 3o6 a a 5.3 3 L 3 i No.... .... Fw3.................... ........ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Appliratinn for lliipusttl Works Tonstrnrtiun amit Application is hereby made for.a Permit to Construct ( ) or Repair (JO� an Individual Sewage Disposal Sys esn at: . 01-OL..................................................... ....•. • 244..--------.._........-----......-- /�oca' Address 1 or Lot No. O Addrii"3�" . . ....... ..... -- a Installer Address a. Type of Building �j Size Lot�e_0.Q------Sq. feet U Dwelling ..................................v _..._.....Expansi ttic ( ) Garbage Grinder No. of Bedrooms Other—Type T e of Building No. of ersons.__ Showers Pa YP g -------••------------------- P --•------------------ (�'�) — Cafeteria Ga Other fixtures --------------- ••-•--•--•---•---•---- . -- _• . W Design Flow.................:.__,�_..................gallons per person per day. Total daily flow---------- .......................gallons. WSeptic Tank—Liquid'ca.pacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.__...._.........,..Total leaching area....................sq. ft. � Seepage Pit No.47------------- Diameter.................... Depth below inlet_/Q___..._..._. Total leaching area....:__..___......sq. ft. Z Other Distribution box ( ) Dosing tank ( )0-4 Percolation Test Results Performed bY... .................................................................. Date � ................ �_...._. ,.� Test Pit No. 1----------------minutes per inch Depth of Test Pit............_....... Depth to ground water................._...... L=, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O Description of Soil.. !'.... . ... x V ....--•-------•------••--•------------------•---......•--------•----•--------------...---------••-•-•••--------•-•-------•----•--•--•--•........... ....... ................................ ----...----•-•------------ W --------•---•-•--•---•-•••-•--------•...........-•••••-••-•-•-•--•-••--•---•--••-•-------------------•------• -------- ------ --------- U Nature of Repairs o ' erations—Answer when applicable ___.._.� Q...... _ J L --- �� . -••-----•---•--------------------------- of t� e Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLI 5-of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate'of Compliance has been i s d by he bS&rd gilgalth. Signed.. . •- ;.;. Date Application Approved By.-----� - lC..........................................•--•----•---•----•--•-- �� Date .,. Application Disapproved for the following reasons:................................................................................................................ •---•-....-•--•..................•-------------.....---•---------•--•-•--------•----•--•---•---------•--------•--•---•-••--••---•------•-----•---------••----•------------•-•---•------•••-------------- `� Date Permit No. `5 .......... Issuedqvvp, ------•. -•..... ................... ,r. Date :iv No......` .... F:zs ...... 5................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �a Applirtttion for Uiipntittl Workfi Tomitrnrtinn "motif A, licition is hereby made for a Permit to Construct ( ) or Repair Y) an Individual Sewage Disposal &J,717.. ..................................... Lo rt-'Add68. l "t S� Y t^ _; or Lot No. :..6t f r I ss W Installer / Address 9 �.. d Type of Building 3 Size Lot.7 r�_d_�_Q....Sq. feet U Dwelling 4eNo. of Bedrooms___________________________________________Expansi Attic ( ) Garbage Grinder Other—Type of Building ____________________________ No, of persons._____.____.__.._. Showers ( ) — Cafeteria ( ) Q' Other fixtures ____________________________ _ W Design Flow...............e..... ...............gallons per person per day. Total daily flow_________ _+ _ ...................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter__-____.._______ Depth................ x Disposal Trench—No_____________________ Width.................... Total Length_______.___._._._._ Total leaching area________.___________sq. ft. Seepage Pit .._- __ . Diameter____________________ Depth below inlet pag p Total leaching area__________________sq. ft. Z Other Distribution box ( ) Dosing tank `"' Percolation Test Results Performed by.......................................................................... Date ...............................'t aTest Pit No. I................minutes per inch ,Depth of Test Pit................... Depth to ground,`Water.....................__. fs, Test Pit No. 2_______________nunutes per mch _, Depth of Test Pit_________._________ Depth-t6 groupd water........................ .t O Description of Soil_ r ----- x W ---••••. ------------------------------------------------------- ----------------------------------------.-=--U Nature of Rep r Alterations—Answer when applicable._ ........ ._ '___._______- -------•----•--•------------------------•-•-•--__-••-------•------•--------- Agreement The undersigned`agrees to install the:aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITS: 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate°of Compliance has been s ued y the Doarj gif health. a� Signe ---------------------= 20 1 Application Approved BY_ __ ` __x ' aFe______________ ;..,..,,.(. r c� Fly > Date Application Disapproved for the following reasons---------------•---•--------------------------------•--- --------------------------------.._........----•-_. �.- ._.._....---•-•-------------------`--------------------•-------•-•----........---••-------•--...._....__....---•------------------------------------------------------------------------------- Date PermitNo........y...................•---.........--------.. Issued_....................................................... Date YY TH E'COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF...... �pr�if�rtt#�e of f�unt�littnrr THIS IS TO.CE4TIFY That the Individual Sewage Disposal Systemconstructed ( ) or Repaired ( ) by.......... at-•••--••--•---•---.--- •-----•-•-•---•---... -•---•. •------ ---•----- ........................ ......... been installed in accordance twith the provisions of TITLE r of The State Sanitary Code as described in the application for Disposal WorkskConst-ruction P � -- ------------- dated- -- � --------------- THE ISSUANCE OF THIS CERTIFICATE SHALL-,'NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM W L FUNCTION SATISFACTORY. DATE !" - --- Inspector _. ...... r a THE COMMONWEALTH OF MASSACHUSETTS f 'Eft.' ♦jkt�� 1��P>L BOARD , Q—.44, EALTH .................................OF........................................... •-••--••---_--_-_.......... No.. ,....... FEE...... Disposal vrk� vnstr ivn amit Permission is hereby granted... '...... ' .:............I=- !........� K* ``.. ".. to Construct ( � ) or Repair ( ) an Individual Sewage Disposal System ' at No........10s!__d 04_.4-A............................._.....�s../� dr...�I►.......................................................i'. ..iy�Y, �atw�� ................. ._... Street ' `' as shown on the application for Disposal Works Constr>ctz'on,�+ 4akit No. `r L T ' Dated. a /�� - t -�_ _-«. - ---------------- __- --- B o Boar of Health • DATE. �j FORM 1255 HOBB WARRE `""Y,1, C PUBLISHERS Town of Barnstable oFt "r Regulatory Services Thomas F. Geiler,Director Public Health Division * tSARNSTASLE Thomas McKean Director A s639 a�0 200 Main Street, Hyannis,MA 02601 °� �., rFGNIF►�l Phone: 508-862-4644 Email: health()town.bamstable ma us Fax: 508-790-6304 Office Hours: M-F 8:00—4:30 February 22,2006 Mr. Paul Tibbetts .58 Poplar Drive OStervi11e,MA 02655 Dear Mr. Tibbetts: Recently a letter has been released to homeowners and commercial business owners regarding the removal of Underground Storage Tanks (UST). When removals, abandonment, and testing of the tanks have occurred, our electronic files are updated. We have found that many files have not been correctly updated and/or the proper notification was not received by our Department. The tank we inquired about is listed on Parcel 048 on Assessor's Map 121 and is registered with the Health Department as tank tag#547. The Town of Barnstable, Health Department,has completed the research on your parcel and concluded that the Underground Storage Tank of Fuel Oil was properly removed in February of 1993. We received a copy of the UST removal application for permit and permit for removal and transportation to approved tank yard form from the Fire Department that was completed by Shoreline Tank Service. This information will be placed in your street file and the electronic files will be updated correctly. We thank you for your cooperation in this matter and if you have any questions about this topic or you need further information, guidance or assistance,please do not hesitate to contact the Public Health Division. Sincerely, .4ardous ha L. Parker Materials pecialist Thomas A. McKean, RS, CHO Director of Public Health FORM F.P. 292 (rev. 9/90) 011r C901tintonwrIM4 of M8.0990nBrffn Department of Public Safety Division of Fire Prevention and Regulation f V y APPLICATION FOR PERMIT, AND PERMIT, FOR REMOVAL AND TRANSPORTATION TO APPROVED TANK YARD FDID# 01920 Permit # Date February 24, 19 93 Osterville � City,Town or District C . 8 2 S . 40 N . G . L . /73 c DIG SAFE t7UMBER Fee Paid:S i o_no 93080947 lam"0 start date 2/24/93 In ad r--danci-4 th the provisions of Chapter 148, Sec. 38A, M.G.L. , 527 CMR 9.00 application is hereby made by: Shoreline Tank Service Street Address & City or Tow 87 Pond Street, Osterville, MA 02655 • Signature of applica . Applicants name printed: r rL �---- For permission to remove and transport one underground storage tank from. Owner: Orsky Residence Street Address: 58 Poplar Drive, Osterville Hitchcock Oil MA-10 Firm transporting waste: State Lic. # Hazardous waste 'manifest # E.P.A.,# Approved tank yard: Mid City Scrap Yard # 12889 Tank yard Address: Westport, MA Type of inert gast UL tank # : Tank capacity: 2,000 Substance last stored: #2 Fuel Oil Date of issue: February 24, 19 93 Date of expiration: March 10, 19 93 Signature/Title of Officer granting permit: " KEEP ORIGINAL AS APPLICATION AND ISSUE DUPLICATE AS PERMIT xTowno#Barns#able a Find Map%Parcel1,'; 121048 Heath Department Heaith System ga _ �� •� ' .fit �� Y €7 ' r m u ,. MaplParcei, �121048 g TankWM- 01 Tamb� 00547 Installed 01�/01/1970 Location' B TestNotificatronD'a#e��-£ W'Stalus Date �tz�, K Rer�toval�NoUficati'on�®ate z� Test ' s a rzs � � �Abantlon Pa c Removal 1 1� 02/24/1993 ` � � � R �fariance ` � x Fuel Stored" 'FO el Storage Reason <' r G paci Cons#ruc ion Leak Uetetro Cathodic Detection �_. � Storage Tank Info 001000 SS i ,,,,•., ', Additional'Detaris Removed obsery MM with COMM dci Chan 9 e r 3 I IR .....�..,,..,,,..,,,,. ,,,_,.,.. ... ..,...w,. ,,,,.. ...,,n...�- ,,.,emu..«..a ..u, ,,..._. ,1,.......,...w....�..a. ........''�,,,d,�..�''....... .x...u1 1i .• � 9 �� ' � •mac \�w.° `� ' " • ♦f/`y,�-� fit!+r r r � - C.A4 Y•�� .r� I'•r. .. ti /, •ice'/. ••' -. �� r/'�• ;' r f. �/�� i of_ r wrf* if i� \ go °�O • �� •; : iilj tt '� ;Ti :1 !t*Silt F� 3 11!Y 111�' e i ri iSii si:`. ii '?' I' :l6 �: ;� i3ei . . ff i i �. r �� i �ti �, �� ... .` � � ' - � '' - -. . t` t . - � ., - � • v :� .... .a Town of Barnstable gyp. Regulatory Services' "k! "17, 0i", B NST,U Thomas F. Geiler.Director �� Public Health Division Thomas McKean, Director 200 Main Street, Hyannis,AMA 02601 Office: 508-862-4644 Fax: 508-790-6304 To: TIBBETTS,PAUL F'&SUSAN M- Date Thursday,January 05,2006 58 POPLAR DRIVE OSTERVILLE: 02655` RE:Underground,Storage Tank at: 58 POPLAR DRIVE ' Map Parcel: 121048 Tank NO: 01 Tag NO: 00547 Our records indicate that your underground fuel(or chemical)storage tank is over 20 years old,and has not been removed as required by section 326-3:subsection 2 of the Town of Barnstable Code regarding fuel and chemical storage systems.. You are directed to remove this tank within sixty(60)days from the date of this notice. After your tank is removed, please furnish this office evidence in the form of a permit from your local Fire Department within ninety(90)days of the receipt of this notice. You may request a hearing provided a written petition requesting same is received by the Board of Health within ten(10),days afterj.h.is order is served. Per Order of the-Board-of Health Thomas A.McKean RS CHO �/ �/�_ ealth Agent _n /�i �-v ca � CY '"`L � p' Qrt��yl0�, r F Find,MParcet 121048 ® \ y F�nd�Qwn r PaFcelid 121048l�el V AccauntNo c 000639r parent '' 0000000 , 29AC � e�gh DeveiLot LOT 51 , L N " Lot Size 0 35 Acres Cunr,7®wn'#TIBBETTS PAUL F&SUSAN M % StateAC lass 101 / € o Bidgs 1 �Area�000022281 »v 58 POPLAR DRIVE Year Added\ 00 t OSTERVILLE MA �02655 � Deed Date 090193Reference 8761 205 a °�°CornpEez U nit : .._ � ;?� � ��d'��y�� ,ter , . ��Ms», cc-z',- ,» 9��`�" � `_. •c av'' Ml January 1st TIBBETTS PAUL F&SUSAN M 0 Ref 8761/205 ffift Ual/ue Land 000055200 Buildings 000128300 extra Features 0000002100 \� 3Loc Rion 58 POPLAR DRIVE Road Inde " 1300 Frntg 0110 y Fire Dist CO'; ,9 Sec Index z. 0000 € Frntg 0000 \\ r \ j�am"' r - � C •',w /(: rx, m K.w , _ -roz✓ E f��z ..\ � \ Mll 'R9 �' PAUL F. TIBBETTS 58 Poplar Drive Osterville, MA 02655 (508) 428-0094 Thomas A. McKean, RS, CHO Town of Barnstable . Board of Health P.O. Box 534 Hyannis, MA 02601 RE: UNDERGROUND STORAGE TANK 58 POPLAR DRIVE, OSTERVILLE, MA MAP PARCEL: 121048 TAG NO. 01 TAG NO. 00547 i Dear Mr. McKean: Pursuant to your correspondence dated March 5, 2001 regarding the above-referenced underground storage tank, I have contacted the Barnstable Health Department and the Fire Department . Chris at the Health Department checked the records which indicate that the outside oil tank was abandoned on June 5 , 1991 and filled with cement . This procedure was inspected and approved by Glen Wilcox. When I purchased this property in August, 1993 , a cellar oil tank (which still exists) was attached to the burner. Please contact me if I must take any further action. Very truly yours, _ . J Paul F . Tibbetts lam` P F ro *qRPAUL F. l ETTS 58 B Poplar Drive Osterville, MA 02655 (508) 428-0094 Thomas A. McKean, RS, CHO Town of Barnstable Board of Health P.O. Box 534 Hyannis, MA 02601 RE : UNDERGROUND STORAGE TANK 58 POPLAR DRIVE, OSTERVILLE, MA MAP PARCEL: 121048 TAG NO. 01 TAG NO. 00547 Dear Mr. McKean: Pursuant to your correspondence dated March 5, 2001 regarding the above-referenced underground storage tank, I have contacted the Barnstable Health Department and the Fire Department . Chris at the Health Department checked the records which indicate that the outside oil tank was abandoned on June 5, 1991 and filled with cement . This procedure was inspected and approved by Glen Wilcox. When I purchased this property in August, 1993 , a cellar oil tank (which still exists) was attached to the burner. Please contact me if I must take any further action. Very truly yours, Paul F. Tibbetts Town of Barnstable Barnstable �'SrMU. ` Board of Health 1659. �''°h�cMe+A P.O. Box 534, Hyannis MA 02601 office: 508-8624644 Susan G.Rask,R.S. FAX: 508-790-6304 fFp Z. li Ralph A.Murphy,M.D. Sumner Kaufman, M.S.P.H. To: TIBBETTS,PAUL F&SUSAN M Date Monday,March 05,2001 58 POPLAR DRIVE OSTERVILLE M 02655 RE:Underground Storage Tank at 58 POPLAR DRIVE Map Parcel: 121048 Tank NO: 01 Tag NO: 00547 Our records indicate that your underground fuel(or chemical)storage tank is over 20 years old,and has not been removed as required by section 03:subsection 2 of the Town of Barnstable Health Regulation regarding fuel and chemical storage systems. You are directed to remove this tank sixty(60)days from the date of this notice. After your tank is removed, please furnish this office evidence in the form of a permit from your local Fire Department within ninety(90)days of the receipt of this notice. You may request a hearing provided a written petition requesting same is received by the Board of Health within ten(10) days after this order is served. Per Order of the Board of Health Thomas A.McKean,RS,CHO Health Agent 'I OWN OF BARNSTABLE - UNDERGROUND F UEL AND UJIEN i ('()I- S FORAGE RFC I SI Rf)-► I ON MAP NO. PARCEL. NO. I'AG NO. ADDRESS OF TANK: VILLAGE: MAILING ADDRESS ( IF DIFFERENT FROM ABOVE) : OWNER NAME: PHONE: INSTALLATION DATE: BY: INSTALLER ADDRESS: 'CERT.IVO. *TANK LOCATION: ABOVE BELOW C D C O Cf0 I O G T A N K L O Q A T I ON W I T H PR Q O P Q C T T O m U Z L D I N 0 CAPACITY TYPE OF TANK AGE YRS. FUEL/CHEMICAL TESTING CERTIFICATION [ ] PASS [ ] FAIL DATE LEAK DETECTION [ ] CHECK IF N/A TYPE/BRAND ZONE OF CONTRIBUTION [ ] YES [ ] NO DATE TO BE REMOVED FIRE DEPT. PERMIT ISSUED [ ] YES [ ] NO DATE CONSERVATION [ ] CHECK IF N/A DATE BOARD OF HEALTH TAG NO. [ ] DATE * PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD r I OWN OF BARNSTABLE - UNDERGHUUND FUEL AND C:FlL:l� : I.;Al. S I OROGE REG I S1 FAA I I ON r MAP NO, PARCEL. NO. TAG NO. . ADDRESS OF TANK: VILLAGE; - MAILING ADDRESS ( IF DIFFERENT FROM ABOVE ) : OWNER NAME: PHONE: INSTALLATION DATE: BY: INSTALLER ADDRESS: 'CERT .NO. *TANK LOCATION: ABOVE BELOW ( DQQCPQ I DG TANK LCCAT I ON WITH RQQPQCT TC -mU I LD I NO )- CAPACITY TYPE OF 'TANK AGE YRS. FUEL/CHEMICAL TESTING CERTIFICATION [ ] PASS . [ ] FAIL DATE LEAK DETECTION [ ] CHECK IF N/A TYPE/BRAND ZONE OF CONTRIBUTION [ ] YES [ ] .NO DATE TO BE REMOVED FIRE DEPT. PERMIT ..ISSUED [ ] YES [ ] NO DATE CONSERVATION [ ] CHECK IF N/A DATE BOARD OF HEALTH TAG NO. [ ] DATE r PLEASE PROVIDE, A SKETCH SHOWING THE _TANK LOCAT I ON, ON:..,THE.,.-BACK,_,OF..THIS CARD MAP NO, PARCEL NU. TAG NO. ADDRESS OF TANK: VILLAGE: .MAILING ADDRESS ( IF DIFFERENT FROM ABOVE) : OWNER NAME: PHONE: INSTALLATION DATE: BY: INSTALLER ADDRESS: -'CERT .140. *TANK LOCATION: ABOVE BELOW (9� < 0W=(=MX=K YANK t-nt=AYXaM WX'T-H PROKOF-MOY YC3 =UXL-nl"CM) CAPACITY TYPE OF -TANK AGE YRS. FUEL/CHEMICAL TESTING CERTiFICATION C I PASS FAIL DATE LEAK DETECTION I CHECK IF N/A TYPE/BRAND ZONE OF CONTRIBUTION YES NO DATE TO BE REMOVED FIRE DEPT. PERMIT ISSUED [ ] YES [ ] NO DATE CONSERVATION CHECK[ ] CHECK IF N/A DATE BOARD OF HEALTH TAG NO. [ `_ ~_* _PROV%DE_A_S oFt� Town of MUMSTMLE, ' Board of Health ArF039. P.O. Box 534, Hyannis MA 02601 Office: 508-862-4644 Susan G.Rask,R.S. FAX: 508-790-6304 Ralph A.Murphy,M.D. Sumner Kaufman, M.S.P.H. To: TIBBETTS,PAUL F&SUSAN M Date Monday,March 05,2001 58 POPLAR DRIVE OSTERVILLE M 02655 RE:Underground Storage Tank at 58 POPLAR DRIVE C95i-`'r e) Map Parcel: 121048 Tank NO: 01 Tag NO: 00547 Our records indicate that your underground fuel(or chemical)storage tank is over 20 years old,and has not been removed as required by section 03: subsection 2 of the Town of Barnstable Health Regulation regarding fuel and chemical storage systems. You are directed to remove this tank sixty(60)days from the date of this notice. After your tank is removed, please furnish this office evidence in the form of a permit from your local Fire Department within ninety(90)days of the receipt of this notice. You may request a hearing provided a written petition requesting same is received by the Board of Health within ten(10) days after this order is served. t Per Order of the Board of Health Thomas A.McKean,RS,CHO Health Agent TOWN OF BARNSTABLE - UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION OWNER AND INSTALLER INFORMATION L'U_Q +A ADDRESS: E5 'R 1'1 R r MAP NO. PARCEL -NO. OWNER NAME: bgat w\ V I LLAGE: 0�i INSTALLATION DATE: t BY: VNI J0. ADDRESS: CERT. NO. 6 TANK INFORMATION. .. „ LOCATION OF TANK: ��,�� ,�"i � ,may�► CAPACITY t PrF 17 TYPE " AGE FUEL/CHEMICAL TESTING .CERT I F I CATION C ] PASS C ] FAIL DATE-- LEAK DETECTION C�] CHECK I N/A TYPE/BRAND ZONE OF CONTRIBUTION V ].._YES. _C: 7 NO EM0yED1 -� FIRE DEPT. PERMIT ISSUED C I YES E I NO DATE L:U1 _ER_VA TION— CX;i CHECK IF N/A DATE BOARD OF HEALTH TAG NO. ]C ]C ]C ] DATE C 1L.✓ 71 a✓ PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD .,� '� S _� I z _�