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HomeMy WebLinkAbout0068 POPLAR DRIVE - Health 68 Poplar Drive Osterville P 9 4 4 o c e ° t y5 n r � No. / Fee �✓ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftPlitation t6 t4posal bpstpm Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( ) [Uotfomplete System ❑Individual Components Location Address or Lot No. �AName,Address,and Tel.NoTg v7Q ©� ���`.v�5\41.4 n 42�� Assessor's Map/Parcel ` (5 1A c4k 11;x C., Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.SM'—SCO-3111 Type of Building: Dwelling No.of Bedrooms Lot Size r � ��'� Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided ?j gpd Plan Date _ .$ �) a�� Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. C Description of Soil ��­e_ Nature of Repairs or Alterations(Answer when applicable) ,/ e��.11 5 Q k1\,m"n, �. �ln-,�.,.._P1�,t'-�s � �•.; "fir� "����/ei�., 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. Si e ' " Date (AL,-,, a r Application Approved by Date Application Disapproved by Date for the following reasons Permit N . l C L Date Issued No. ,-,4.! r Fee /d THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 1( PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Y� application.,ft M-49'lDBal *pstem Construction Permit Application for a Permit to Construct( ) Repair('�) gkj\radgr(Abandon( ) W41101mplete System Individual Components Location Address or Lot No. ' (&%ltJ to r+ OO s Name,Address,and Tel. `�, Assessor's Map/Parcel t o Q t- � 1Mi0 r f Installer's Name,Address,and Tel No. Soy? =� v� Designer's Name,Address,and .�32a��Oc.�"C''�''�.7�t,--..ov`i'�i `��" '�+�@��'eJ"•.c Sf c��.S t��r.,C r .9 v , Type of,Building: DwellingNo.of Bedrooms Lot Size�\ �`�: q,-f Garbage Grinder( ) Other Type of Building C, No.of Persons Showers( ) Cafeteria Other Fixtures Design Flow(min.required) Z �] gpd Design flow provided �� � gpd Plan Date Number of sheets Revision Date ~ Title Size of Septic Tank Type of S.A.S. r, Description of Soil,. Nature of Repairs or �l-. � �3 Alterations(Answer when applicable) 75 �.`C \--k- ' 131--1 'A cQ Date last-inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in i 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' ,..-�''�� Date "L_x, s l Application Approved by Date Application Disapproved by Date . for the following reasons Permit No— ! Date Issued ] s.- _ u ----•----- -- ------ ------- ---- -- ----------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS - Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage ` nn Sewa a Disposal system Constructed Repaired Upgraded( ��.. Abandoned( )by e a4CX.�i K�G1�.i�' -1�C A at �Q, �: ,r y.:'� •� -� has been constructed in accordance - with the provisions of Title 5 and the for Disposal System Construction Permit No.c dated �� l Installer�' 4� iS\,CS",^l�� y�•e►L�,,p";iW� Designer 06,0)1e_ - -V #bedrooms Approved design flow gpd s The issuance of this permit sha 1 not be co�snstrued as a guarantee that the system wil�1 fun h es' . ed. Date t� Inspector _ ... . . -- /� --- No. Fee / QV THE COMMONWEALTH OF MASSACHUSETTS `PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS MiStloBal *p8tem Construction i3ermit Permission is hereby granted to Construct( ) Repair( ) Upgrade(1,,1K Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be comp ted within three ears of the date of this ermi t. Y PDateA roved b PP Y l AO TOWN OF BARNSTABLE OCATION ,,a SEWAGE It VILLAGE��--LA\,&e., ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE Ic— .�U SEPTIC TANK CAPACITY `S9Z:> LEACHING FACILITY:(type) (size) NO.OF BEDROOMS OWNERC1 PERMIT DATE: 3 ` $� COMPLIANCE DATE: Separation Distance Between the: � Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility > lCl 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 ,�� , V ` ep 0 3� �i t7 T l V V T1 f Town of Barnstable OF tF1E T "o Regulatory Services Richard V. Scali,Interim Director * snsxsrna[.e. Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 o Installer&Designer Certification Form Date: 1 " Sewage Permit#tag "CI Assessor's Map\Parcel (Z� Designer: I�eye,4- S d n S nL Installer: Address: O Address: @ � AAk 0 L� On ? �� as issued ape to install a (date) (installer) septic system at V ?D QL -' (L 051 based on a design drawn by (address) �('�P�✓\ dated l X (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. r I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(ifrequired) was inspected and the soils were found satisfactory. I certify that the system referenced above was construct c e with the terms of the RA approval letters(if applicable) taller's Signature) a 11 1 it "'--(Designer's Signature) (Affix Designer amp Here)' PLEASE RETURN TO BATITABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Form Rev 8-14-13.doc f Town of Barnstable P4 I S 7 3 7 s Departinent of Regulatoty Services 1 .eaN t4 g Public Health-Division Date 13Ile-MAM r 200Main Streit;H'yannla'MA 02601 ` Date Scheduled_ `� .g .' • , fD�•. . . I� -, w - w,;: Time 6 Fee Pd. " orl Sultan 1 Assessment for e �Yd S e Disposal- - - - Performed-By: AV,Vr A Witnessed By: I LOCATION&.GENERAL INFORM ION, Location Address�jT C �L< Owner's Name`t�o ,�`. ��� Address Assessor's Map/Pareat �_c \ '� Engineer's Name NEW CONSfMUCT ON r- RBPAfit ` Tel'e hone# 5��,�;j6 0 -J (1 Land Use V (�9 1�{/ , Slopes(%) \f Surface Stones N Distances firm: Open Water Body, _ft Possible WetAlrea j`/;1[1_ft Drinking Water Weli�K�ft Dmihage Way�! i�y - ft Property Llne �f G (( Other t SKETCH:(Street name,dimensions of lot,exact locations of test holes&pore testa,locate wetlands inn prnximlty to holes) .S ^ • µ r .. Parent material(gaologlo) Q���' S(I Depth to Bedrock s Depth to Oroundwater. S ending Water in Halo: >[� Weeping from Pit Foca Estimated Seasonal High Groundwater [ 1 17 DETE PATION FOR SE ASONAL•HIOIj'WATExt TABLE Method Use' d: I th Obsory d standing In obs.hole: In, Dapth:to soil Mottles: In, De th to weeping from side of obs.hole: ln, Groundwater Adjustntdnt {r, Index Well-# ReadingDato: Index Well level •AdJkfhotbr,,,,._ Adj.droundwater•Lavel.,,_ PERCOLATION TEST Bgie Timm„_,_, • Observation Hilo# Time at 9" _ Depth of Pew •' ' +, TimO at 6" +a. Start Pro-soak Time l °3 *, _ µ. lmo(9"�6") ^ Had Pro soak /0 d Rate MlhJlnch Site Suitability Assessment: Site Pe said - ` B Slto Palled j s Addidonal'Tesdng Needed(Y/N) i• Original: Public Health Division Observation Hole Data To Be Completed on Back---------" ' ***If percolation test Is to be conducted within 100' of wetland,you must first notify the g Barnstable Conservation Division at least one(1) week prior to beginning. Q:1SEP!'ICU'ERCFORM.DOC - DEEROBSERVATION HOLE LOG Hole# Depth from Sol(Horizon Sall Texture Sdil Color Sall. Other Surface(In.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. • lsletency.96•aritvell • 0 t'- rim' b .42 �l 3eV- 132: G F—o.S 2,5 & , DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soll Texture Soil Color • Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders, �^- 3 to �-�'lsr • 3�= 132 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Sall Color Sall Other Surface(In.) (USDA) (Munsell) Mottling (Structure,Stones,.Boulders, DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soll Color soil thcr Surface(In.) (USDA) (Munsell) Mottling (Structure,Scones;Boulders, Flood Insurance Rate Map: Above 500 year f lood boundary No— Yes 2L Within 500 year boundary No Yes.:_ Within too year flood boundary No.4 Yes pepth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pe v us materlal exist in all areas observed thrpughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? .. Certification / q I certify that on C� L (date)I have passed the soil evaluator examination approved by the Department vlron ental Pro ctlon and that the above analysis was performed by ma consistent with . the required trainl expertise an a erience described in 10 CMR 15.01 . . Datb Signature • ' F Q:15flPTiLVBnCPORM.DOC � Robert T. Morford 9 Bellinghamshire Place New Hope, PA 18938 Office 609-924-4268 Ce11908-208-5259 May 13, 2008 VIA FACIMILE & FedEx Mr. Thomas A. McKean Director Public Health Division Town of Barnstable 200 Main Street Hyannis, MA 02601 ` n- Re: 68 Poplar Drive, Osterville Dear Mr. McKean: I am in receipt of your letter dated May 71h, 2008 to the Trust of Ruth C. lewell,zof which I am Trustee. At the direction of Jaime Cabot, I am writing in regardlo the two violations of the State Sanitary Code cited in your letter; 105 CMR 410.552 and 105 CMR 410.450. Thank you for bringing these to my attention. I am prepared to remedy these violations as follows: 105 CMR 410.552 — When I was last to the house (September '07), I dropped off the screen from the side door to Anderson's Hardware for repair. I will be at the house again on Memorial Day weekend and will install the screen then. 105 CMR 410.450 — The twin beds in the finished basement are intended for use. They were relocated to the basement when we replaced them with a queen bed in one of the upstairs bedrooms. Again, when I am there next weekend, I will dismantle them and store the frames in the unfinished portion of the basement. If it is okay with you, I ask that I continue to store the mattresses in the finished portion of the basement so that they do not pick up any odors or the like in the other area. Please advise as to whether these remedies are acceptable. Thank you. Bob Morfor SENDER: COMPLETE THIS SECTION COMPLETE,THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete nature item 4 if Restricted Delivery is desired. ❑Agent ® Print your name and address on the reverse ❑Addressee so that we can return the card to you. Received by(Printed Nam C. Dat of Delivery ® Attach this card to the back of the mailpiece, ` 2� or on the front if space permits. D. Is delivery address different from item 11 Yes 1. Article Addressedwto: a If YES,enter delivery address below: ❑No r' t-2 5 3. Service Type ❑Certified Mail ❑Express Mail ❑Registered ❑Return Receipt for Merchandise �j ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number (transfer tram service labeq 10 41 13 5 8 PS Form 3811,February 2004 Domestic Return Receipt 102595.02-M-1540 I i i1Y I UNITED STATES POSTAL SERVICE First-Class Mail Postage$Fees Paid USPS Permit No.G-10 I • Sender. Please print your name, address, and ZIP+4 in this box • I _ � I I � Town of Barnstable id Public Health Division I i Og 200 Main Street Hyannis,MA 02601 C tii-11 t 1 ti I1.1 ill I f Il It ttlti 1111111111111 t 11 p lllli,l� Ln CO it r� , T �p Postage $ LI �r210 ru Certified Fee p Return Receipt Fee P® e er O (Endorsement Required) Restricted Delivery Fee O (Endorsement Required) Ln USQ r-I Total Postage&Fees is S , ru Yv Gf -t -C:Le�w e 4 0 ---------------------------------- Street,Apt.No.; . Nor PO Box No. ry state;Z + Certified Mail Provides: o A mailing receipt . c A unique identifier for your mailplece n A record of delivery kept by the Postal Service for two years Important Reminders: o Certified Mail may ONLY be combined with First-Class Mafia or Priority Mail®. a Certified Mail is not available for any class of international mail. o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. e For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Retum Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested°.To receive a fee waiver for a duplicate retum receipt,a USPS®postmark on your Certified Mail receipt is regwred. n For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted-Delivery". a If a postmark on the Certified Mail receipt Is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an Inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 Certified Mail#7006 2150 0002 1041 93 �'WETati Town of Barnstable . Regulatory Services + BARNRrABLE. MAE& -Thomas F. Geiler, Director Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 , Office: .508-862-4644 Fax: 508-790-6304 May 7;2008 Trust of Ruth Clewell 12 Suffolk Lane �to Middletown,NJ 07748 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II — MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE CODE CHAPTER 170. The property owned by you located at 68 Poplar Drive, Osterville, was�inspected on May 5, 2008 by Jaime Cabot, Health Inspector for the Town of Barnstable. This inspection was conducted on'the basis of a complaint., The following violations of the State Sanitary Code were observed: 105 CMR 410.552 —Screens for Doors No screen on storm door. 105 CMR 410.450—Means of Egress No second egress. Three beds to be removed from basement. You are directed to correct the violations listed above within twenty-four (24) hours of your receipt of this notice by removing three bedrooms from the basement and thirty(30) days to place a screen in the storm door. You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. Non-compliance will result in a fine of $100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have an uestions regarding the above violations, please contact the Town Health Division and asW to speak with the inspector who performed the inspection. ER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., CHO QAOrder letters\Housing violations\Rental ordinance\68 Poplar Drive.doc ORM30 C&W Homs&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS ^ �� BOARD OF HEALTH �� CITY/TOWN b DEPARTMENT Z000 9 C//�� - �^ ADDRESS % o �` Z M s•�'� l rD TELEPHONE Address �'� �� LA p��S�Ee�ic.c,�Occupant \/�►Q�- �( Floor - Apartment No. No. of Occupants No.of Habitable Rooms "1 No.Sleeping Rooms_ No.dwelling or rooming units= No.Stories 2 Name and address of owner K ®F 1Zy"(K LbtiG "i 0 i LVL:t&W 1J o- 7 zA 5 Remarks Reg. Vio. YARD Out Bld s.: Fences: / Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: No sc,Rt2--�j pcJ Scup-0-. now-, I� Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: !J 0 � an- ZF1 6— Dampness: a> R>f-o& `Co I>rL Stairs: ,. Ak;e MI.ems Lighting: STRUCTURE INT. Hall,Stairway: Obst'n.: Hallall,, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 . Bedroom 2 Bedroom 3 2 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: S s, Flues,Vents,Safeties: Kitchen Facilities CSink w.�1Cvt, -xor Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted -To bt- Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE Lp OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE S AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES F PERJURY "INSPECTOR TITLE k 2Ad,_ -11 S 0AQ_ A.M. DATE TIME ;O A.M. THE NEXT SCHEDULED REINSPECTION SAr P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter II, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is riot included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such.violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold,to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. E Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) .The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A).(2) and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. �' �I s Town of Barnstable Geographic Information System April 29, 2008 " �P n 017 0 Q a o o d e. o t'�n " , p rn Q a vn p mrj' 0 167 Feet DISCLAIMERS:This map is for planning purposes only. It is not adequate for legal Map:121 Parcel:049 Selected Parcel boundary determination or regulatory interpretation. Enlargements beyond a scale of Owner:MORFORD,ROBERT J ET AL TRS Total Assessed Value:$408000 1"=100'may not meet established map accuracy standards. The parcel lines on this map t;.I +-�E are only graphic representations of Assessor's tax parcels. They are not true property Co-Owner:C/O MORFORD,BRUCE Acreage:0.35 acres Abutters boundaries and do not represent accurate relationships to physical features on the map Location:68 POPLAR DRIVE such as building locations. Buffer ��%.! J Certified Mail#7006 2150 0002 1041 9358 WME lati Town of Barnstable ' Regulatory Services • BARN MBLE. MAf�' g Thomas F. Geiler, Director Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 May 7, 2008 Trust of Ruth Clewell 12 Suffolk Lane Middletown, NJ 07748 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II — MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE CODE CHAPTER 170. The property owned by you located at 68 Poplar Drive, Osterville, was inspected on May 5, 2008 by Jaime Cabot, Health Inspector for the Town of Barnstable. This inspection was conducted on the basis of a complaint. The following violations of the State Sanitary Code were observed: 105 CMR 410.552 —Screens for Doors No screen on storm door. 105 CMR 410.450—Means of Egress No second egress. Three beds to be removed from basement. You are directed to correct the violations listed above within twenty-four (24) hours of your receipt of this notice by removing three bedrooms from the basement and thirty (30) days to place a screen in the storm door. You may request a hearing before the-Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. Non-compliance will result in a fine of $100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have any-questions regarding the above violations, please contact the Town Health Division an(f asW to speak with the inspector who performed the inspection. ER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., CHO QAOrder letters\Housing violations\Rental ordinance\68 Poplar Drive.doc C FORM 30 CHEW HoseSs WARREN'" THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CITY/TOW N = o DEPARTMENT ADDRESS TELEPHONE Address C e o IFeyiLA-K Occupant_i/AQx—A ( Floor - Apartment No. No.of Occupants No.of Habitable Rooms 71 No.Sleeping Rooms_ No. dwelling or rooming units= No.Stories Name and address of owner s t �� a:�ZK CLf+aTu- 2 5� �&-e— � L%t.,c- �`�►i 0 10L E.�() O j 7 i4 b Remarks Reg. Vio. YARD Out Bld s.: Fences.- Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: N 0 SC,(4La 01.1 5'CUP_$--. �zrbP Roof �r�l Gutters; Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: !V0 k af5 ' i efj Dampness: SIL ,iw�v4 Stairs: �t^ Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: ` Hall, Floor,Wall,Ceiling: V Hall Li tin : Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST El P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: 0 110 ❑ 220 Fusing,Grnd.: AMP: Gen. Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den L. Living Room Bedroom 1 . Bedroom 2 Bedroom 3 2 Bedroom 4 sy Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: S s, Flues,Vents,Safeties: Kitchen Facilities Sink Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted `T Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 4.10.750 OF THE CODE OR THE . AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES F PERJURY " INSPECTOR 7W TITLE �- A.M. DATE O TIME S A.M.' THE NEXT SCHEDULED REINSPECTION M&Ar P.M. TOWN OF BARNSTABLE � p. �CATION Po s�`,o r— ��;u� SEWAGE# VILLAGE ���-c fv�.\ice ASSESSOR'S MAP&PARCEL IXtiSTALLERS NAME&PHONE NO. SE W CAPACITY YQJO cf. a-s.p r3 LEACHING FACILITY: (type) (size) j, 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 ,� Po 6 O � � II O � � 1� io TOWN OF BARNSTABLE `'`L.C'AT16 6_ a�/ ,? Tolle SEWAGE#,b7-5,FFC'770A1 `III L'AvE 06 J�rylI a ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ff LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER 2)0A P 0o Z e-'\A- ti n PERMITDATE: 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) Nv1119 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) /y� Feet Furnished by Gc)ZQo,.-3-,,Kgt j 0 � C� t � ! C vv 1 1 r r� f r TOWN OF BARNSTABLE _LOCATION L s—q 1)g SEWAGE # VILLAGE -eR lei& ASSESSOR'S MAP & LOT INSTALLER'S NAME Si PHONE NO. ,T l 1 S C Q L C f SEPTIC TANK CAPACITYf�® LEACHING FACILITY:(type) (size) le 0 1 NO. OF BEDROOMS PRIVATE WELL OR UBL_C_WATER BUILDER OR OWNER t DATE PERMIT ISSUED: ('y. " L DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No e i t r ASSESSORS MAP NO: No ...L PARCEL NO.: 011 - FIm$......................... THE COMMONWEAL '— t BOAR OF A�9 .7,e LTH ...................OF..... ;AtZh. .-----------------------------•--••.....•.... Appliratiou for Uiuvuiitti Murky Toutitriiitiinn Urrmit Application is hereby made for a Permit to Construct ( ) or Repair ( Van Individual Sewage Disposal System at: _ ..... _- ... --------- ---- ................................. ocation- r or Lot No. oN � �� � Own � ddress Installer Address Type Dwelling 3 No. of ...............f B _..........._._.__..._..Expansion Attic ( ) Garbage Grinder(j )e of Buildin Size Lot....! .....0_�......5 feet Other—Type T e of Building No. of ersons......, Showers Pa YP g ---------------------------- P -•----------------- (�.) — Cafeteria ( ) Other fixtures .e'�'WG �/ .Sl `� �' f" Alj9 :<�1t''� �" Sliv i Z;c=Plf.. Design Flow-----------Z .�.......................gallons per person per day. Total daily flow---------- � ........_-:_.gallons. WSeptic Tank Liquid capacity?A:...gallons Length................ Width................ Diameter._--___--_. Depth... Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ,J�------------------------------•-•-----••-----••------._._.._..-----------•-----•-......................................................... 0 Description of Soil--•---Sf1 etJ-•------................................I.............................................................................................................. x V ------------------•--•--••......-----•.........._....------------------------- --------------•------•----------------------------•--•-----•-------------------------•------------------- W _ U Nature of Repairs or Alterations—Answer when applicable......f1 _.__....__. .___. � ....�.................... ��o ------------------------------------•--•--•---•---------•---------•----------------.....---•----•-••---•--...-------------------------------•••••••---------•-•--- f?_r"K�( 9G�1iNp�,Z Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of AI'IU 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issued by a d of h t Signed .. . .---. . -..... ... --- ........................ �v- -------- Da Application Approved By........... ------ -- .............................. ------.....� Date Application Disapproved for the following ea ons:--•--••--•..................................•-••--•-----•---•----•-•-•-----•-•----------------•---......_..... --------------------•---•-•--------..........._..-•----------...-----.........--------.........--•--•----..--•-•--•-------•-------•----------•------------------•--•----------------------------••-----.. Date PermitNo......................................................... Issued........................................................ Date 226 No Fimig THE COMMONWEALTH OF MASSACHUSETTS BOAR OF HE4LTH ----------- ........OF...... �r�.:u.... .. [.... Appliratiun for Disposal Works Tour r rrnti# Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at ......... ` ..... �P L i -• I- �L---•" ...OSTc ZU.. .....------------------•-----.... ..--- --------------. _--------------------- ... . . . ( •ocation:-•-•--- or I.ot No. N --- r' ---------- ------ ......---------------.......... . ---...........•......-. -•-•--.....---- W J,/ Owne �-°� dress + r.. �'e r �,` C✓ L}G X :/J Installer Address d Type of Building, Size Lot .... 1..ff�.a0.0.....Sq. feet U Dwelling—No. of Bedrooms......................... .....Expansion Attic ( ) Garbage Grinder ( / ) Other—Type of Building ............................ No. of persons.......2................. Showers ( /) — Cafeteria ( ) Other fixtures ..a1 .W 4----A-/.f_S�p!jl ......= .:_siiv!......•---- .r .Ji�d91.� W Design Flow............1u A.......................gallons per person per day. Total daily flow............./-1`o..__................gallons. e2 - r WSeptic Tank—Liquid capacltye_._..�._.gallons Length................ Width................ Diameter___......_._. Depth.... x Disposal Trench—No.................,;.. Widths................ Total Length.................... Total,leaching area....................sq. ft. 3 Seepage Pit No-----_-------------IDiameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results 4 Performed by......................................................................... Date........................................ Test Pit No. 1................minutes-per itteh Depth of Test Pit.................._. Depth to ground water........................ ti, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 --••------ ---•-------••-------•................•------.......--•----------•••-------....------•-----......--•-•----......_...----•----- 0 Description of Soil.......9:4 A-D............................... V ---- •------------------------ •----------------------- •------------------------ ••---------------------------------- ••-------- •------ •------ -------------- .... -----------------•---------- •-. - ......_.... VW ••-•-----------------------•-----....--------...-•-----•-------------•-----•-•-----•---.....-•----•------------------•------•------•----------•• ...-----........••••-••-----•-----••-•-•----•-•--- Nature of Repairs or Alterations—Answer when applic ..__..Aj;)!2........... �A�....__�Z ................................ ---------------------------••--••-----------------------------------=------•---•--...----•-• ......:I........................................................................................... Agreement: The undersigned agrees to install the aforedescribed th vidual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issued by b a d of hea Signed...... .: £ .. ....... : ..................... ...1���:�(�..._.... Dater Application Approved By............--�-•--- -- •- .............. .. ----i Date Application Disapproved for the following ns:...........................................................•.............................................. _.._ .....................................................................................................................................................................••••-------------•-•••-......_------ Date PermitNo......................................................... Issued...................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r U..' . ...........................OF... .......................................... (In if iratr of Tomplianr TES IS TO C_Ea FY, That tie Individual Sewage Disposal System constructed ( ) or Repaired ( L� by..... ' ' ....� �.:... '.�S:�ti _.1....... ......................................................... •-•---..._....._....:......-•---•----- . .. = .... QQ ,Q / ,l Installer�y °'�— / has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the -. application for Disposal Works Construction Permit No ' '........ .`�`-"-&?..... dated.-_..__� ;_..I.. ...:.................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...... .I. ?................ Inspector _.. ::.::.... f cl THE COMMONWEALTH OF MASSACHUSETTS �~ BOARD OF HEALTH ' ;� a i2G r NO......................... FEE........................ Maps Murky pnstrWw- n f rruti# 2 r- Cu Permission is hereby granted._.- �'PS .....�.. to Construct ) r air ( a I ividual Sewage • posal Sys at No. _ � .. ....._..... © / _(/l l.a--- ---------- .......... Street as shown on the application for Disposal Works Construction Permit No...b.,.......... Dated.......L�.....................' / �� ' Board of Health DATE.._...... 4 '�—'d FORM 1255 A. M. SULKIN, INC., BOSTON Sid � 123�2 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTS 'kkJ5 -fib'RLE RECEIVED i iJ AUG 2 4 2004 TOWN OFBARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 68 Poplar Drive �C�� , Osterville %-... ' O.-... .____. Owner's Name: Kerri Wick Owner's Address: Date of Inspection: 8/16/2004 Name of Inspector: (please print) Patrick T.Sullivan Company Name: Ready Rooter Mailing Address: P.O.Box 371 Sandwich,MA 02563 Telephone Number: (508)888-6055 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 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 Needs Further Evaluation by the Local Authority Fails Inspector's Signature: _G% Date: d�( 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. Notes and Comments Owe.. J`ou� c'� tn•otc 3 `JwpC...a i�� �c7 �'e�'h uraTC-.Ij`TaA` +.'_ ****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. Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 68 Poplar Drive Osterville Owner: Kerri Wick Date of Inspection: 8/16/2004 Inspection Summary:Check A,B,C,D or E/ALWAYS complete all of Section D C. System Passes: 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: .^� d •1.S t0 " J`s�b./� B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"sectio eed to be replaced or repaired.The system,upon completion of the replacement or repair,as approved b he Board of Health,will pass. i 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 tapk(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failgd 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 soun6,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,.h'igh static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or une4en distribution box.System will pass inspection if(with approval of Board of Health): ' bro �n pipe(s)are replaced o truction is are Stribution box is leveled or replaced ND explain: The system required pumpin more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 68 Poplar Drive Osterville Owner: Kerri Wick Date of Inspection: 8/16/2004 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the B rd 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 det"ines 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 fee6f 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 an'y determines that the system is functioning in a manner that protects the public health,safety and en7iment: _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 Zotre 1 of a public water supply. t S�t _The system has a septic tank and SAS and the SAS is within w feet of a private water supply well. t _The system has a septic tank and SAS and the SAS is les 4han 100 feet but 50 feet or more from a private water supply well**. Method used to determine dis,nce t **This system passes if the well water analysis,perfond at a DEP certified laboratory,for colifonn bacteria and volatile organic compounds indicates that theAvell is free from pollution from that facility and 'the presence of ammonia nitrogen.and nitrate nitrogen i equal to or Tess than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis st be attached to this form. t 3. Other: t Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 68 Poplar Drive Osterville Owner: Kerri Wick Date of Inspection: 8/16/2004 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _,Z Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ _%Z Static liquid level in the distribution box above outlet invert due to and 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. Z Any portion of a cesspool or privy is within a Zone I of a public well. _ Any portion of a cesspool or privy is 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.] &DQ(Yes/No)The system fails. I have determined that one or more of the above 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 sign 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 criter' above) yes no the system is within 400 feet of a surface drinking w er supply the system is within 200 feet of a tributary to a rface drinking water supply the system is located in a nitrogen sensitiv rea(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question' ection E the system is considered a significant threat,or answered "yes"in Section D above the large system failed.The owner or operator of any large system considered a significant threat under Section E or faile under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should con t the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 68 Poplar Drive Osterville Owner: Kerri Wick Date of Inspection: 8/16/2004 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 _ -ZWere any of the system components pumped out in the previous two weeks? -V-/_ 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 septiG4ank 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 than 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)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 68 Poplar Drive Osterville Owner: Kerri Wick Date of Inspection: 8/16/2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_a Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 33O a,-F. Number of current residents: IS— Does residence have a garbage grinder(yes or no):Y<S Is laundry on a separate sewage system(yes or no):j];�[if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):A2c--3 �1= ���• �`F' - Water meter readings,if available(last 2 years usage(gpd)):Z�ad3= L4 a3?U, Sump Pump(yes or no):,dip z�•.,— .i�v,c c r Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft c.): Grease trap present(yes or no):_ Industrial waste holding tank prese (yes or no):_ Non-sanitary waste discharged to a Title 5 system(yes or no):_ Water meter readings,if availa e: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): g If yes,volume pumped: 1 allons--How was quantity pumped determined? Reason for pumping: c, �r 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): Gov.�jr e— C cx� /mil_• Approximate age of all components,date installed(if known)and source of information: 4' 1 Zt` Were sewage odors detected when arriving at the site(yes or no):./�� Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 68 Poplar Drive Osterville Owner: Kerri Wick Date of Inspection: 8/16/2004 BUILDING SEWER(locate on site plan) Depth below grade: 3c5" Materials of construction:_cast iron_40 PVC Ether(explain): p Distance from private water supply well or suction line:�l/tea Comments(on condition of joints,venting,evidence of leakage,etc:): SR4*G4Ai4::: ✓(locate on site plan) Depth below grade: Q q Material of construction: concrete_metal_fiberglass_polyethylene ✓ther(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of ` certificate) Dimensions: 't Sludge depth: cj " Distance from the top of sludge to bottom of outlet tee or baffle: 3 7 Scum thickness: Z�" 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): �Q `d+G�G. S�y-•as rG `�..�.L'G�T i��'C w�'�Sa''Vy.� �ro�n.� r91'v.,�ST.�gc,.r.n, ma C-a;,..� GREASE TRAP:_(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 to/ions, or baffle: Distance from bottom of scum ttlet tee or baffle: Date of last pumping: Comments(on pumping recommlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evide ,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 Poplar Drive Osterville Owner: Kerri Wick Date of Inspection: 8/16/2004 TIGHT or HOLDING TANK: (tank must be pumped at ti of inspection)(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiber ss_polyethylene_other(explain): Dimensions: Capacity: /switches, Design Flow: Alarm present(yes or no): Alarm level: Alarm inno): Date of last pumping: Comments(condition of alarm : DISTRIBUTION BOX: (if presen/utlets e on site plan) Depth of liquid level above outlet invert: Comments(not if box is level and distribu evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: (locate on/plan)Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump cha pumps and appurtenances,etc.): I _ Page 8 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 Poplar Drive Osterville Owner: Kerri Wick Date of Inspection: 8/16/2004 TIGHT or HOLDING TANK: (tank must be pumZof inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiber thylene_other(explain): Dimensions: Capacity: --gallons Design Flow: Alarm present(yes or no): Alarm level: Alarm ino): Date of last pumping: Comments(condition of alarm : DISTRIBUTION BOX: (if presen/utliets e on site plan) Depth of liquid level above outlet invert: Comments(not if box is level and distribu evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no). Comments(note condition of pump cham er,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: 68 Poplar Drive Osterville Owner: Kerri Wick Date of Inspection: 8/16/2004 SOIL ABSORPTION SYSTEM(SAS): Z(locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: '_ ` - x C o..c sc;e: \cx•L "a �x q( -�c ,,s� �T. _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.): cti� iv��.�'�, �� L�•��i�� 1p c—� � ��a �nc�c� � "h �a ram, WG qt^ G 1<1�7 <5Q' G'►�v\�1� `�C...�G �. pJ��,,��� •�. CESSPOOLS: (cesspool must be pumped as part of mspection)(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 hyd ulic 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 hydra c failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 Poplar Drive Osterville Owner: Kerri Wick Date of Inspection: 8/16/2004 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. 3 3 43 Ss 3Sr.6 �r Page 11 of I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 Poplar Drive Osterville Owner: Kerri Wick Date of Inspection: 8/16/2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water ^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:�TB� _Observed site(abutting property/observation hole within 150 feet of SAS) ✓Checked with the local Board of Health-explain: 4 A Clr=_Or' _Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how yo established the high ground water elevation: I t•: 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 /'2 l.. a /CERTIFICATION Property Address: 68 Poplar Drive L� Osterville Owner's Name: Robert J. Lynn Owner's Address: 322 Olmstead Hill Road Wilton,CT 06897 Date of Inspection: 8/16/2006 Name of Inspector: (please print) Patrick T.Sullivan Company Name: Ready Rooter Mailing Address: P.O.Box.371 Sandwich,MA 02563 Telephone Number: (508)888-6055 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 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: —ZPasses Conditionally Passes T Needs Further Evaluation by the Local'Authority Fails Inspector's Signature: �i-- 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. Notes and Comments (� Sys-�_,./-J�, c�i./`�.1 ��i `JVV�..J Q•T' 'tV1S'1/\J�+' `��y � ****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. Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 68 Poplar Drive Osterville Owner: Robert J. Lynn Date of Inspection: 8/16/2006 Inspection Summary:Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: 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 P s section need to be replaced or repaired.The system,upon completion of the replacemen/ptic roved by the Board of Health,will pass. Answer yes,no or not determined (Y,N,ND)in the ing statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or (whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration orimminent. System will pass inspection if the existing tank is replaced with a complying septic tank as ae Board of Health. *A metal septic tank will pass inspection if it is structuraY sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is avail ble. ND explain: Observation of sewage backup or break o or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or even distribution box.System will pass inspection if(with approval of Board of Health): br:ken pipe(s)are replaced :::Juction is removed istribution box is leveled or replaced ND explain: The system required pumpin ore than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of a Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: i Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 68 Poplar Drive Osterville Owner: Robert J. Lynn Date of Inspection: 8/16/2006 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by oard of Health in order to determine if the system is failing to protect public health,safety or the environmen 1. System will pass unless Board of Health de rmines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner w ' h will protect public health,safety and the environment: _Cesspool or privy is within 50 fee f a surface water Cesspool or privy is within 50 f t of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Wat Supplier,if any)determines that the system is functioning in a manner that "protects the public healt safety and environment: ` The system has a septic tank and soil absorption syste (SAS)and the SAS is within 106 feet of a surface water supply or tributary to a surface water suppl . The system has a septic tank and SAS and the S is within a Zone 1 of a public water supply. —The system has aseptic tank and SAS and the AS is within 50 feet of a private water supply well. The system has a septic tank and SAS an e SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used t determine distance **This system passes if the well water an ysis,performed at a DEP.certified laboratory,for coliform bacteria and volatile organic compounds in cates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitr to nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 68 Poplar Drive Osterville Owner: Robert J. Lynn Date of Inspection: 8/16/2006 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 and overloaded or clogged SAS or cesspool _ Liquid depth in cesspool is less than 6"below invert or available volume is less than%a 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 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.[This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above 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 sign 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 criteri above) yes no the system is within 400 feet of a surface drinking wate supply the system is within 200 feet of a tributary to a surf a drinking water supply the system is located in a nitrogen sensitive are�(Interim Wellhead Protection Area IWPA)or a mapped Zone 11 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 faiyd.The owner or operator of any large system considered a significant threat under Section E or failed unde'Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the ppropriate regional office of the Department. i Page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 68 Poplar Drive Osterville Owner: Robert J. Lynn Date of Inspection: 8/16/2006 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? _ __j_/ 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? Conuv.�`cr�, Cass�a�� _ Were the.sepao4wlc 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 than 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 15302(3)(b)] i Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 68 Poplar Drive Osterville Owner: Robert J. Lynn Date of Inspection: 8/16/2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: O Does residence have a garbage grinder(yes or no): Yr- S Is laundry on a separate sewage system(yes or no):x-,tz-[if yes separate inspection required] Laundry system inspected(yes or no):T Seasonal use:(yes or no): Y�$ Water meter readings,if available(last 2 years usage(gpd)): 44L( cra..P.0 Sump Pump(yes or no):.,.i� Last date of occupancy: ., ' • COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.20 : gpd Basis of design flow(seats/persons/s etc.): Grease trap present(yes or no): Industrial waste holding tank pres t(yes or no):_ Non-sanitary waste discharged t the Title 5 system(yes or no): Water meter readings,if avail e: Last date of occupancy/use- OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: ::Z: ,��a a� _ ��,.r P Was system pumped as part of the inspection(yes or no):— — 5�� ,�,. -A V N1 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): Cx,,�,tz,.i�cP G��< � o�� to..� G ess�o� ;4 �r� cos• Approximate age of all components date installed(if known)and source of information: �C5s�coC war.-.Q �c�r -lcc.� - � vro ri 0c. d r�r�c -Sr �:�- ;�. .d ��� a f�l F��_ moo-«. Q ca.�, <;�.,z-c 3,o. k+ Were sewage odors detected when arriving at the site(yes or no):,,kD<:�s + Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM • PART C SYSTEM INFORMATION (continued) Property Address: 68 Poplar Drive Osterville Owner: Robert J. Lynn Date of Inspection: 8/16/2006 BUILDING SEWER(locate on site plan) Depth below grade: 30" Materials of construction: cast iron 40 PVC Zther(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leaka e,etc.): SFpT..,,r�—ANK: (locate on site plan) Depth below grade: .0 y" Material of construction:_concrete_metal_fiberglass_polyethylene _f ther(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: �C Sludge depth: Distance from the top of sludge to bottom of outlet tee or baffle: Scum thickness: O' 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: U,�", Comments(on pumping recommendations,inlet an outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): '�h�a�`,b�... ��.a:v��..� a'���..s 'sv"'�L... �m ��i�t'� '"cy`u�T• GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:_concrete me _fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of Joet eorbaffle: Distance from bottom of scum to booutlet 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,evide ce of leakage,etc.): I Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 Poplar Drive Osterville Owner: Robert J. Lynn Date of Inspection: 8/16/2006 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction:_concrete_me _fiberglass Tpolyethylene_other(explain): Dimensions: Capacity: gallon Design Flow: gall s/day Alarm present(yes or no): Alarm level: Alarm in wo ing order(yes or no):_ Date of last pumping: Comments(condition of alarm d float switches,etc.): DISTRIBUTION BOX: (if present must opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(not if box is level and distribu on to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: (locate on s/condition Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamof pumps and appurtenances,etc.): a Page 9 of.I 1 OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 Poplar Drive Osterville Owner: Robert J. Lynn Date of Inspection: 8/16/2006 SOIL ABSORPTION SYSTEM(SAS): locate on site plan,excavation not required) If SAS not located explain why: Type J leaching pits,number:� ,� x C( p�-ec n..s� �`�-. '�72 _leaching chambers,number: _leaching galleries,number: _leaching trenches,number,length: _leaching fields,number,dimensions: V overflow cesspool,number: I C x C _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.): cam + �� 1nCkovJ CESSPOOL: (cesspool must be pumped 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 infl (yes or no): 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 soi,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 Poplar Drive Osterville Owner: Robert J. Lynn Date of Inspection: 8/16/2006 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. 43 A `i 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property 4(� /0opla r owner' s name of) Terms n Date of Inspection AY S) Lq� PART A CHECKLIST Check if the following have been done: ✓ Pumping information was requested of the owner, occupant, and 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. M/_ As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The site was inspected for signs of breakout. .- All system components, excluding the SAS, have been located on the site. N 11 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 SAS on the site has been determined based on existing information or approximated by non-intrusive methods. ✓ The facility .owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. 12 b®e 1 ao e g l t 8 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential _3 number of bedrooms number of current residents e5 garbage grinder, yes or no `O laundry connected to system, yes or no !y0 seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: 00 15o18 Last date of occupancy GENERAL INFORMATION Pumping recgrrds and source of information: V85 System pumped as part of inspection, yes or no if yes, volume pumped 1500 qG�. Reason for ,pumping; - I�ef (/)sn-ech(-n )-f s as5420o 1 4 ours ''law 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) ✓ Other (explain) eaCh 02a Approximate age of,,all components. Date installed, if known. Source of informatio : �esseools ea chP2 - ar,5 ND Sewage odors detected when arriving at the site, yes or no !4- I Y 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: (locate on site plan) depth below grade: material of construction: V" concrete metal FRP other(explain) dimensions• & , X sludge depth distance from top of sludge to bottom of outlet tee or baffle a„ scum thickness to " distance from top of scum to top of outlet tee or baffle i(a" distance from bottom of scum to bottom of outlet tee or baffle 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, recommendations for repairs, etc. ) Sys�rn � DISTRIBUTION BOX:Loo � 't3ox (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, recommendation for repairs, etc. ) PUMP CHAMBER: (locate on site plan) pumps in working order, yes or no Comments: (note. condition of pump chamber, condition of pumps and" appurtenances, recommendations for maintenance or repairs, etc: ) 10` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : (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 l - /000 9�. leaching pits and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool , number / Comments: A (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc. ) CESSPOOLS (locate on site plan) : number and configuration . 6arr -P 4&Zr depth-top of liquid to inlet invert '5 '� depth of solids layer depth of scum layer dimensions of cesspool x�� materials of construction Cow blac,- indication of groundwater n �t-7f,0 Ueserve inflow (cesspool must be pumped, as aj- -f)r,;e part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) SUS n �crs,c fi m ed.-C-/ a,4- )7r7e 0-F CrKl�-e e fi 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, recommendations for maintenance or repairs,etc. ) y 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' t Ci;ss�o l C,,�,,SSf 1 4�,ac. i d6 ' CLssPao 1 � 3� w6 ' c�ss�oo Ja 3 " 8 ' DEPTH TO GROUNDWATER oZ G. 2 depth to groundwater RO��' a G�;ssp00o method of determination or approximation: (4!56-5 s G hsen t� t�eC� date- — T I. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector Go rd c'-) B 0-4 oOt s Company Name O Cu-n Gen, fin 5 Company Address Certification Statement I certify that I have personally inspected the sewage disposal system at this adress and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regrading upgrade, maintainance and repair are consistent with my training and experience in the proper function and maintainance of on-site sewage disposal systems. Check one: I have not found any information which indicates that the system fails to adequetly protect public health or the environment as defined in 310 CMR 15.303. Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15.303. The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector's Signature Date Original to system owner Copies to: Buyer (if applicable) Approving authority OSTERMLLE �o d l\ l O �TF' ROUTE 28 TP-2 Q0% 110,61 �, 3 LOCUS 0-�� � INES� \ O\ e�M R W Rp'LOT 53 LOCUS MAP LOCUS INFORMATION PLAN REF: 199/31 TITLE REF: 21357/179 N /G i i i" i \ PARCEL ID: MAP 121 PAR. 49 BENH.O CORC BtLHDK FLOOD ZONE:ZONING: "RC" "X' / 4E II G 'i ; EL=49.50 COMMUNITY PANEL' 25001C0544J DATED:07/16/14 Of 68 SEPTIC SYSTEM G TOF 50.16 0 �O REPAIR PLAN • '� •, ���' 'o LOCATED AT: 68 POPLAR DRIVE OSTER VI LLE, MA. PREPARED FOR a� so ROBERT J: MORFORD/ O AY �, READY ROOTER EXC. pR� W t^ AUGUST 2, 2018 �'P LOT 52 O 0F k4.J9 O LOT 54 D M �yo O \\ �25.6Ar N . 1� N � 7 gp - N� LOT 51 t MEYER & SONS INC. LEGEND P.O. BOX 981 PROPOSED CONTOUR GRAPHIC SCALE EAST SANDWICH, MA. 02.537 ® PROPOSED SPOT GRADE so o ,o so t+o so �. PH: (508)360-3311 -- g$ -- EXISTING CONTOUR � FAX: (774)413-9468 + 96.52 EXISTING SPOT GRADE meyerandsonsincOgmaii.com W— EXISTING WATER SERVICE IN FEET TEST PIT 1 inch = 20 pt. SHEET 1 OF 2 J 2026 i - ELEV. TOP FOUNDATION NOTE: PLACE MAGNETIC MARKING TAPE OVER ALL COVERS (Existing) BRING ALL COVERS TO WITHIN 3" OF FINISH GRADE FINISHED GRADE (47.5-46.5) = 50.16 �F.G.EL- 48.0 � F.G.EL• 47.20 F.G. EL- 47.0 � - " MAINTAIN 2% MIN SLOPE' OVER LEACHING AREA ~' 2` OF 3/8- DOUBLE WASHED r F.G. 4 46A � 3/4" - 1-1/2" STONE OR FILTER FABRIC DOUBLE WASHED STONE 6 " 4" SCH 40 PVC : 10"I 6 ®aaa• ®al®E3 TEE'S ARE TO BE 14' INV. 44.30 ® S= 1 (MIN. aaaaa�a®aaa W. ®aa®ease®®a 4 SCH 40 PVC INV: 45.0 2 E F. DEPTH sasses®aaaa R INV. 44.05 4' 2 X 8.5' 4' EXIST. OUTLET gqAS PROPOSED DB-3 DISTRIBUTION BOX EFFECTIVE LENGTH = 25, 46.83 INV: 45.25 (1-120) INV. ELEV.= 43.80 PROPOSED 1,500 .GALLON SEPTIC TANK GAS BAFFLE TO BE INSTALLED ON ��1�` OF ' sJ9 BREAKOUT NOTES: OUTLET TEE AS MANUFACTURED BY o D R ELEV.= 44.80 TUF-TITE, ZABEL, OR EQUAL TOP CONC. ELEV.= 44.80 1) CONTRACTOR SHALL VERIFY ALL EXISTING N A0 PIPE INVERTS PRIOR TO CONSTRUCTION INV. ELEV.= 43.80 a®a aaaaaaa 2) TANK'AND D=BOX SHALL BE SET LEVEL AND '�G�STE Il3aaaaaa TRUE TO GRADE ON A MECHANICALLY COMPACTED - •4#ITAV - BOTTOM EL.=- 41 .80 aaaaaaa SIX INCH CRUSHED STONE BASE, AS SPECIFIED IN �(/ 3.75' 5 FT. 3.75' 310 CMR 15.221(2) EFFECTIVE WIDTH = 12.5' 3) INSTALL INLET & OUTLET TEES W/GAS BAFFLE AS REQ'D SEPARATION 6.10. FT. 4) PLUMBING TO BE MODIFIED TO MEET PROPOSED SEPTIC SYSTEM PROFILE BOTTOM of TESTHOLE EL: 35.70 _ S I ABSORPTION YST T N OUTLET LOCATION AND ELEVATION (PLUMBING PERMIT REQ'D) (500 GALLON LEACH CHAMBER) GENERAL NOTES: , I. - SOIL : 15737 DESIGN CRITERIA P ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL LOGS # BOARD OF HEALTH AN N ENGINEER. D THE DESIGN 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS DATE: JULY 18, 2018 NUMBER OF BEDROOMS. 3 BEDROOM DESIGN OF THE STATE ENVIRONMENTAL.CODE, TITLE V. AND ANY APPLICABLE SOIL TEXTURAL CLASS: CLASS 1 (6.74 GPD/SF) LOCAL RULES AND REGutAT10Ns. SOIL EVALUATOR: DARKEN MEYER, R.S., CSE #1614 DESIGN PERCOLATION RATE: <2 MIN/IN 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR WITNESS: DON DESMARAIS, BARNSTABLE HEALTH DEPT. TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE DAILY FLOW: 110. G.P.D. X 3 BR DESIGN FLOW: 330 G.P.D. DESIGN ENGINEER. TP-1 Depth Elev. TP-2 De GARBAGE GRINDER: NO (not designed for garbage grinder) 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING Elev. 0" " SEPTIC TANK: 550 gpd x 200% = 1,100 gpd USE PROP. 1,50OG SEPTIC TANK FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN 46.70 ENGINEER BEFORE CONSTRUCTION CONTINUES. A LOAMY SAND 47.20 A LOAMY SAND 0 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. 03 IOYR 3/2 8- 10YR 3/2 8" LEACHING AREA REQUIRED: (330)/0.74 = 445.94 S.F. 46.53 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF B LOAMY SAND B THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL WARD OF LOAMY SAND USE TWO (2) 500 GALLON PRECAST LEACH CHAMBERS W/ 4' (At HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 43.88 10YR 5/8 34" 4420 1OYR 5/8 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. C . C 36" STONE ON ENDS & 3.75' STONE ON SIDES: 25' L x 12.5' W x 2'D S.ALL AREAS DISTURBED DURING CONSTRUCTION SWILL BE RESTORED BOTTOM AREA 25 x 12.5 312.5 SF TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE MEDIUM MEDIUM, SIDE AREA: (25 + 12.5) X 2 X 2 = 150 SF THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING SAND CONSTRUCTION. PERC TES 2.5Y 6/4 2.5Y s/4 TOTAL SQUARE FEET PROVIDED = 462 vs. 445.94 REQ'D 10. EXISTING LEACHING TO BE PUMPED, CRUSHED AND FILLED PER TITLE 5. 0 EL 42M DESIGN FLOW PROVIDED:, 0J4(462 S.F.) = 342.25 G.P.D. vs. 330 G.P.D. req'd 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY 35.70 132 36.20 132" PROPOSED SEPTIC SYSTEM UPGRADE PLAN 13. NO PRIVATE WELLS WITHIN 150' OF PROPOSED LEACHING. 14. NO WETLANDS WITHIN 100' OF PROPOSED LEACHING. PERC RATE <2 MIN/IN. ("C1' HORIZON) 68 POPLAR DRIVE, OSTERVILLE, MA ' 15. ALL PIPING TO BE 4" SCH 40 O 1/8-/FT (UNLESS SPECIFIED) NO GROUNDWATER OBSERVED Prepared for: Morford R ady Rooter IExc. Design and Site Plan by: SCALE DRAWN DATE • 1, Darren M. that I am cu MADEP MEYER&SONS,INC. to conduct ss evaluations P-s....E. tiwt above ana rrenty app►�d by pursuant to 310 CMR 15.017 PO BOX N.T.S. DMM 08/02/18 yeie tide been performed by me consistent with the REV DATE te requin-w of 310 CMR 15.017. 1 further certify that I have poeasd the Sall Evol. Exam In October, 1999. E4STSANDWICH,MA02537 CHECKED SHEET NO. 506.962-2s22 DMM 2 of 2