HomeMy WebLinkAbout0128 REBECCA LANE - Health 12&h , ecca Lane
Osferville P
- �. A 146033
4a� Do = 1 F 247 F 760 06-1 1-2014 2_4 a
BARNSTABLE LAND COURT REGISTRY
DEED RESTRICTION
WHEREAS, Jonathan Fish and Jason Evan Fish, of 128 Rebecca Lane, Osterville,
Massachusetts 02655, are the owners of the property known and numbered 128 Rebecca Lane,
Osterville, Barnstable County, Massachusetts 02655and described in a deed registered with.the
Barnstable County Land Court Registry District against Certificate of Title No..175555;
WHEREAS, Jonathan Fish and Jason Evan Fish, as the owners of said property, have
agreed with the Town of Barnstable Board of Health to a restriction as to the number of
bedrooms which can be included in any principal dwelling located on said property as a pre-
condition to obtaining a disposal works construction permit in compliance with 310 CMR 15.000
State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of
Sanitary Sewage; and
WHEREAS, the Town of Barnstable Board of Health, as a pre-condition to granting a
disposal works construction permit for a septic system in compliance with 310 CMR 15.000,
State Environmental Code, Title V, Minimum Requirements for Subsurface Disposal of Sanitary
Sewage, are requiring the restriction on the number of bedrooms in the principal dwelling
constructed on the property be put on record with the Barnstable County Registry of Deeds by
recording this document;
NOW THEREFORE, Jonathan Fish and Jason Evan Fish do hereby place the following
restriction on said property in accordance with their agreement with the Town of Barnstable
Board of Health and Town of Barnstable Building Department, which restriction shall run with -
the land and be binding upon all successors in title:
128 Rebecca Lane, Osterville, MA may construct upon the lot a principal dwelling that
contains two (2) bedrooms. Jonathan Fish and Jason Evan Fish agree that this shall be a
permanent deed restriction affecting the property located at 128 Rebecca Lane,
Osterville, MA, more particularly described in a deed recorded as Document No.
990,388 and registered against Certificate of Title No. 175555.
)The foregoing restriction shall remain in force only so long as the property is serviced by a
private septic system, and said restriction shall terminate and be of no force and effect upon
connection of the property to a public sewer system.
I
Executed under seal this day of June, 2014.
Jonathan Fish Jason Evan Fish
COMMONWEALTH OF MASSACHUSETTS
Barnstable County
On this /® day of January 2014, before me, the undersigned notary public, personally
appeared Jonathan Fish and Jason Evan Fish and proved to me through satisfactory evidence of
identification, which was .CPS- e1*,K1 i6 to be the persons whose names are
signed on the preceding or attached document, and acknowledged to me that they signed it
voluntarily for its stated purpose.
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•`• P' ••••"" �`r Notary Public
V;40 1 fs'��yG My commission expires: 01/15/2021
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AGHUS�;►►�,,,
TOWN OF BARNSTABLE �
LOCATION �� _,�.����� SEWAGE # _
VILLAGE �5 �1�� ASSESSOR'S MAP & LOT .
iNSTW LLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 0 0
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
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) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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LOQTION ' SES, PEI 1J0.
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WST& LER 5 ► &M 6, DDRESS
BUILDER 5 Q &A/l ll,,Dl RE S
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DATE COMPLI A 4CE ISSUED ; .� ^
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
Appliratiutt -fur UWVviiat Workii Tomitrurtiutt Vaniit
Application i hereby made for Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System�atWO ',
----------------------- --•••-•-----•--...------
__ .........................
Imca' n•Addre or Lot No. 1
K Owner Address
--
Installer Address
Q Type of Building Size Lot..Ig`. .Y.•Sq. feet
U Dwelling—No. of Bedrooms----vZ---------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons--.......................... Showers ( ) — Cafeteria ( )
Other fixtures __
--- - ----- ----
W Design Flow...............�._.__�......_..._.____ allons per person per day. Total daily flow...........-....._. .-.-_.------------gallons.
Septic Tank—Liquid capacit 'C ____allons Length-----------_-- Width................ Diameter................ Depth................
Disposal Trench—No....... ............. W -.___.._.. Tot -ength-_-_______ T�,011eaacl g area-._.--._____---____-sq. ft.
Seepage Pit No..-•- - -i1 n- tren.... sq. it.
z Other Distribution box ( ) Dosing tank ( )��C� 40 /y"
aPercolation Test Results Performed by..................................................................... ---- Pate..................................
Test Pit No. 1----------------minutes per inch . Depth of "Pest Pit.................... Depth to ground water._..____.__-__-__._--..-
1:14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--.._-_-___--_-.--__-. -
-
i
--------- ------------- -- _
Descri2 io o .SL f ---•-- "i .... .._-._
c.� = �_ � = ---------------------------------------
W
UNature of Repairs or Alterations—Answer when applicable................................................................................................
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Agreement:
YThe undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I of the State Sanitary Code— The undersigned further agrees not,to place the system in
operation until a Certificate of Compliance has been issued by the boajd of health.
Sign e --- ----•-. --- ------------ --1� 7c ..
r
to
Application Approved By - /�L't�l L---- . -• ........ ---•hf---- .. ....
Date
Application Disapproved for the following reasons--------------------------------------------------------------------------------------------•-•------------_..._. .
---------------------------------------- ..-------------------------------------------•-------•--•-------•----•-----•------•---•---•------•••------•••-•-•---------------•-••-•---••---------.....
Date
PermitNo......................................................... Issued.......................................................
Date
..r...................... ---.------- ------------------------
. i
No... f / FEs...'f ...................
THE COMMONWEALTH OF MASSACHUSETTS
_ _BOARD OF HEALTH
of.....�...., .- t/L.�t
Apphratioo -for 430paiittl Works ('�"> nstrurtion Prruid
Application is hereby made for a.Permit to Construct (--) o" r,,�Repair ( ) an Individual Sewage Disposal
System
-vC
Location-Address / or Lot No.
j --T Owner .r Address 7
Installer Address
Type of Building Size Lot__. .+ .--1____ ...Sq. feet
U Dwelling—No. of Bedrooms._-_�..................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ______________________---- No. of persons..-____-._._____-_-_-_--.._- Showers ( ) — Cafeteria ( )
dOther fixtures ... '% ' `-='c.►........--•-••--•------------------•----...--••--------------------•---:--•--....-•-•-•-----•--...------•--•-•-•-------
W Design Flow...................': ---_______-__-_gallons per person per day. Total daily flow--_________-�.F-'1__.� _._._._.._.._..gallons.
9 Septic Tank—Liquid capacitv�(-__�'__ggallons Length---------------- Width................ Diameter---------------- Depth---._____-----
Disposal Trench—No_____________________ Width-_--______-----_--. Total'Length.................... Total"leaching area--------------------sq. ft.
. .
Seepage Pit No--------- __R-_ --_ Diameter-------------------- Depthtbelowl inlet_-;__`:= `"Total leaching area-------______-----sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) — 0 /b— PC-�hL Id- /y- 74
aPercolation Test Results Performed by........................................................... .... Date-----.----..------------._.---_--------.
a Test Pit No. I................minutes per inch Depth of "Pest Pit.................... Depth to ground water...___.-.__-_-.-_. ---.
f� Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
.......................................?._...•....=� =`- i "I..... ...... '.
O Description off SOIL-- l -----�����iC-C , ✓-�� ---•'--- 'f `J fir_.d,;a.'. ��1�
x - Z - ----------- -�```Z r-.�S 1 y��-p= G,-
U -------------------------------
w
VNature of Repairs or Alterations—Answer when applicable..---------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-----------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed'-...-----=-----------...-.................................... ",Z,
----------------- -- - -
/ �j� Date
Application Approved By------- � i>- _-_.._!_._ �' l<c�Lt_ �__.._
- _
:1 - ..
V Date
Application Disapproved for the following reasons:................................................................................................................
..-•--••••----------------------•--•----------------------------------••----••---•-----------•••--------•---•-•••-••-----•------•----••-••-•---••-•----•--•••--•------------•-----------------•---------
Date
PermitNo......................................................... Issued........................................................
Date
r
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Qrrtifiratr of 01,outpliaurr �..-
THIS IS TO CERTIFYJhat the Individual•Sewage Disposal System constructed,(�),�or Repaired ( )
by •-•-•-•-•-•-......••--
�r-_,,, Installer
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
r�ai _�
application for Disposal Works Construction Permit No. 5_:_..�.�___.___.__. dated------- 74..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
I �, (.-�
� �
DATE = /'i / `� Inspector = -�----------------------------•------------
1 ................ �= =
THE COMMONWEALTH OF MASSACHUSETTS
t f BOARD OF HEALTH
y(e� ..........................................OF..............:........................--- ----------...-----•-•--..............
No. ••--.1.._... FEE........................
�i��o�tt� ork,� (�oo�tr�trtioit� �rrotit
Permission iiher be y granted_______-------. -' - � �-
to Construct ( ') or Repair ( ) an Individual Sewage Disposal System, ,
at No
' Street_ / --,
as shown on the application for Disposal Works Construction Pew o...... �f...... .� ed..... ....................................
� Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
` e i DEPARTMENT OF ENVIRONMENTAL P
RECE
OCT .. 2 2002
STABLE
TOWN GBH pEP T.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: �g 4—fCGi 441 M .� o� -,.....
r v; ou eX 4 PARCEL
Owner's Name: .7"a P"e G
Owner's Address:
e v / � 42,4 0,26J5
Date of Inspection:
Name of Inspector. (please print)
Company Name: !//,-7 fC/�
Mailing Address• Po /�;'G?X
Telephone Number. (Sc�) �5��j—tclf
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.1he 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:
V Passes
Conditionally Passes
Needs Further Evaluation tn-the Local Approving Authority
Fails
i
Inspector's Signature: G„ Date: A
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
""*"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.
i
Page 2 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: /d a6,4 e CCU L41
Owner. 5b ^ .)
Date of Inspection: U
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Sy71ve
Passes: '
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:
k 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 exfltration 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 i
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:
f
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 4�J tr'CCc, L/j, `
Owner. Coes ^c
Date of Inspection: 9z c;,l_
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
— Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. Svstem will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
r
The system has a septic tank and SAS and the SAS is within a Zone.l 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 laboraton•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 tnggered. A copy of the analysis must be.attached to this form.
3. Other.
s
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: cc ti
Owner. G� "
Date of Inspection: r ��
D. System Failure Criteria applicable to all systems: _
You must indicate`yes"or"no"to each of the following for all inspections:
Yes No/
V,acimp 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
V Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than ''/:6"below invert or available volume is less than day flow
Regwred pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
/of times pumped .
_ V 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.
_ portion of a cesspool or privy is within 50 feet of a private water supply well.
A _ 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. f 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 failure criteria exist as
described in 310 CMR 15.303.therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
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.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: /) 7� `�ecc, Liy�
(J v-villel
Owner. P f ^o
Date of Inspection: �0
Check if the following have been done.You must indicate`Wes"or"no"as to each of the following:
Y No
`
7_ Pumping information was provided by the owner,ocmgmnL 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)
4/ 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 es or tees,material of construction.dimensions,depth of liquid.depth of sludge and depth of scum
_ Was the facility own_ er(and occupants if different from ownery 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:
Y o
Existing information.For example,a plan at the Board of Health.
v — Determined in the field(if anv of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CUR 15.302(3)(b)]
• 3
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: We 4eccc. L�
eo-vclle.
Owner. CGWS
Date of Inspection: V
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):a2 Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): fl
Number of current residents: aZ
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system(yes or no).,ka [if yes separate inspection required]
Laundry system inspected(yes or no):LO
Seasonal use: (yes or no): !
Water meter readings.if available past 2 years usage(gpd)): ��A
Sump pump(yes or no): ti u
Last date of occupancy: ✓t
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft.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 ,� 1
Source of information: �'ti ''7{�y G C X9.0 '' Dw ku-v—
Was system pumped as part of the inspection(yes or no):
If ves,volume pumped:__pllons—How was quantiq 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 ves.attach previous inspection records.if anv)
_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 kno )and source of information:
// �
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(contimied) '
Property Address: 1,26' 4,4ercc. L-y .
Owner. L _
Date of Inspection:
BUILDING SEWER(locate on site plan)
Depth below grade--
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-4/ (locate on site plan) F
Depth below grade:
Material of construction: concrete_metal._fiberglass polyethylene
--other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(.yes or no):_(attach a copy of
certificate)
Dimensions:
Sludge depth:
Distance from top of�sludge to bottom of outlet tee or baffle: 3�
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to botto pf outlet t. orffl baffle:
How were dimensions determined: 6, - Za i
Comments(on pumping recommendations.inlet an utlet tee or baffle condition.structural integrity.liquid levels
a/$/mated to qutlet invert evidence of leakage,etc.):
7 / 1
GREASE TRAP:/Y (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 0utlet invert.evidence of leakage,etc.),
S
Page S of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner. a
Date of Inspection: f%a-
TIGHT or HOLDING.TANK:dV(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explam):
Dimensions:
Capacity: pUons
Design Flow: aallons/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/ �(jfnt must be opened)(lacate 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 carrvover.any evidence of
leakage into or out of box etc.):
/-0 — d— 1 6 SUJ
D[/t,o o v� �•
PUMP CHAMBER: /C lopte on site plan)
Pumps in working order(yes or no):_
Alarms in worldng order(yes or no):
Comments(note condition of pump chamber.condition of pumps and appurtenances.etc.):
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: ���� ��C &
Owner. ac' i a
Date of Inspection: 0-)—
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
TYP / S
leaching pits,number:
_leaching chambers,number:
leaching galleries.number:
leaching trenches,number,length: <:
leaching fields,number,dimensions:
_overflow cesspool,.number:
innovativdaltennative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation.
etc.): �i � //•
vvr�rvi J
:✓ _
CESSPOOLS: cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids laver:
Depth of scum laver:
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.):
PRIM': &/0ocate 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.):
i
Page 10 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: �E'
Owner. `�2S
Date of Inspection:
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.
i l .
l _ .
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: /�� �2 CC C, Z�X/
/ �Zs es
r. Cat �
Owner. „ --�_
Date of Inspection: U1
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water -3S yfeet
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: lWa ,15- .
Checked with local excavators.installers-(attach documentation)
Accessed USGS database-explain:
YouW ust Oescribe how you established the hi 6 n wafer elevation:
Hov
0 7�I
cn D 0 C2 L I
i 0.
1
uIr
COMMONWEALTH OF MASACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET BOSTON MA 02109(617)292-3500.
TRUDY CORE
Secretary
DAVID
ARGEO PAUL CELLUCCI Commi stoner HS
Commissioner
Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 128 REBECCA LANE OSTERVILLE, MA 02655 M146 P033
Name of Owner RICH PORTER
Address of Owner: 128 REBECCA LANE OSTERVILLE,MA 02656
Date of Inspection: 3116100 ,
Name of Inspector: JOHN GRACI
1 am a DEP approved system Inspector pursuant to Section 15.340 of Tftie 5(310 CMR 15.000)
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02636 j.�,p, CP
Telephone Number: 608-664-6813 FAX 608-664-7270
CERTIFICATION cTATEME ' s O
NT
I certify that I have personally Inspected the sewage disposal system at this address and that the information reported below is true,accurl
and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper,function and
maintenance of on-site sewage disposal systems.The system: = '`
X Passes
_ Conditionally Passes
_ Needs Further Evalu ion By the Local Approving Authority
Fails
Date:416100
Inspector's Signature:
The System Inspector shall su it a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the Inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
"The Inspection is based on criteria defined In Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.My
inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life"
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERYONE TO TWO YEARS FOR PROPER
MAINTENANCE.RECOMMEND REPLACING COVER ON OUTLET SIDE OF SEPTIC TANK.
revised 9/2198 Page 1 of 111
n
0
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 128 REBECCA LANE OSTERVILLE, MA 02655 M146 P033
Name of Owner RICH PORTER
Date of Inspection: 3/16/00
INSPECTION SUMMARY:. Check A, B, C, Or D:
A. SYSTEM PASSES:
I have not found any Information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluab
are indicated below.
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.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not.
pia, The septic tank Is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Complian
attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whet
or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system
will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipes)or du
to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health).
_broken pipe(s)are replaced
_obstruction Is removed
_distribution box is levelled or replaced
nLa The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass Inspection i
(with approval of the Board of Health):
_broken pipe(s)are replaced
_obstruction is removed
r
revised 9/2198 Page 2 of 11
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM IN£+PECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 128 REBECCA LANE OSTERVILLE, MA 02655 M146 P033
Name of Owner RICH PORTER
Date of Inspection: 3/16100
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the,Board of Health in order to determine if the system is failing to protect the public health,safety
and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well,
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm,Method used to determine distance n1a(approximation not valid).
3) OTHER
n/a _
revised 9/2198 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 128 REBECCA LANE OSTERVILLE, MA 02655 M146 P033
Name of Owner RICH PORTER
Date of Inspection: 3116/00
D. SYSTEM FAILS:
You must Indicate either"Yes"or"No"to each of the following:
_ I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is
identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet Invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth In cesspool is less than 6"below Invert or available volume is less than 112 day flow,
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped 0.
X Any portion of the Soil Absorption System,cesspool or privy is below the high ground eater elevation.
_ X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
_ X Any portion of a cesspool or privy is within a Zone I of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
_ X Any portion of a cesspool or privy Is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality
analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,
ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10.000 gpd or greater(Large System)and the system is a significant threat to public health and
safety and the environment because one or more of the following conditions exist:
Yes No
X the system is within 400 feet of a surface drinking water supply
n water supply
drinking Y
_ X the system is within 200 feet of a tributary to a surface g PP ,
_ X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well)
The owner or operator of any such system shall upgrade the system In accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further information.
revised 9l2/98 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '
PART B
CHECKLIST
Property Address: 128 REBECCA LANE OSTERVILLE, MA 02655 M146 P033`
Name of Owner: RICH PORTER
Date of Inspection: 3116100
Check If the following have been done:You must Indicate either"Yes"or"No"as to each of the following:
Yes No
X - Pumping Information was provided by the owner,occupant,or Board of Health.
X - None of the system components have been pumped for at least two weeks and-the system has been receivirig normal flow rates during that period.
Large volumes of water have not been Introduced Into the system recently or as part of this inspection.
X As built plans have been obtained and examined.Note If they are not available with NIA.
X _ The facility or dwelling was inspected for signs of sewage back-up.
f ,
X _ The system does not receive non-sanitary or industrial waste flow.
X - The site was Inspected for signs of breakout.
X - All system components,excluding the Soil Absorption System,have been located on the site.
X - The septic tank manholes were uncovered,opened,and the interior of the septic tank was Inspected for condition of baffles or tees,material of
construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been
determined based on:
X _ Existing Information,For example,Plan at B4O,H,
X - Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)1 5.302(3)(b)]
X - The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal
Systems.
revised 9/2/98 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 128 REBECCA LANE OSTERVILLE, MA 02665 M146 P033
Name of Owner RICH PORTER
Date of Inspection: 3/16/00
FLOW CONDITIONS
RESIDENTIAL;
Design flow: 110 g.p.d./bedroom
Number of bedrooms(design): 2 Number of bedrooms(actual):
Total DESIGN flow: 220 gpd
Number of current residents:2
Garbage grinder(yes or no):NO
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no): NO
Seasonal use(yes or no): NO
Water meter readings,if available(last two year's usage): n/a gpd
Sump Pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow: n/a gpd(Based on 15.203)
Basis of design flow:n/a
Grease trap present:(yes or no): NO
Industrial Waste Holding Tank present:(yes or no): NO
Non-sanitary waste discharged to the Title 5 system:(yes or no):NO
Water meter readings.if available: n/a
Last date of occupancy:n/a
OTHER: (Describe)
n/a
GENERAL INFORMATION
PUMPING RECORDS and source of information:
n/a
System pumped as part of inspection:(yes or no):NO
If yes,volume pumped n/a gallons
Reason for pumping:n1a
TYPE OF SYSTEM
X Septic tank/distribution boxlsoil absorption system
_ Single cesspool
_ Overflow cesspool
_ Privy
Shared system(yes or no)(if yes.attach previous Inspection records,if any)
_ I/A Technology etc.Attach copy of up to date operation and maintenance contract
_ Tight Tank Copy of DEP Approval
Other:n/a ,
APPROXIMATE AGE of all components,date Installed(if known)and source of information:
1976
®@wag@ odors d@t@ot@d when arriving at the§it@ (y@§or no). NO
revised 9/2/98 Page 6 of 11
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 128 REBECCA LANE OSTERVILLE, MA 02655 M146 P033
Name of Owner RICH PORTER
Date of Inspection: 3116/00
BUILDING SEWER:X
(Locate on site plan) ,
Depth below grade: 30"
Material of construction: _ cast iron X 40 Pvc._ other(explain)
Distance from private water supply well or suction line: Na
Diameter: 4"
Comments: (condition of joints,venting,evidence of leakage,etc.)
THE SYSTEM HAS TOWN WATER.
j • -
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 24"
Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other
explain: nla
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO
Age: nla
Dimensions: 1000G L 8'6"H 6'7"W 4'10""
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 32"
Scum thickness: 0"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING THE SYSTEM EVERY ONE TO TWO YEARS,
GREASE TRAP: _
(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other
Explain: n/a
Dimensions:nla
Scum thickness: nla
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle n/a
Date of last pumping: n/a
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
nla
revised 9/2/98 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 128 REBECCA LANE OSTERVILLE, MA 02655 M146 P033
Name of Owner RICH PORTER
Date of Inspection: 3/16/00
TIGHT OR HOLDING TANK: _ Tank must be um prior to,or at time of,inspection)
( pumped
(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other
Explain: n/a
Dimensions: n/a
Capacity: n/a gallons
Design flow: n/a gallons/day
Alarm present: NO
Alarm level:WA Alarm in working order:NO
Date of previous pumping: n/a
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
n/a
DISTRIBUTION BOX:_
(locate on site plan) `
Depth of liquid level above outlet Invert: n/a
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage Into or out of box;etc.)
n/a
PUMP CHAMBER: _
(locate on site plan)
Pumps in working order:(Yes or No): NO
Alarms in working order(Yes or No): NO
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
n/a
revised 9/2198 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 128 REBECCA LANE OSTERVILLE, MA 02655 M146 P033
Name of Owner RICH PORTER
Date of Inspection: 3/16/00
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
n/a
Type:
leaching pits,number:(1)1000 GAL 5 X G
leaching chambers,number: (n/a)n/a
leaching galleries,number: (n/a)n/a
leaching trenches,number,length: (n/a)n/a
leaching fields,number,dimensions: (n/a)n/a
overflow cesspool,number: (n/a)n/a
Alternative system: n1a
Name of Technology: n1a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) ,
THE LEACH PIT APPEARS TO BE FUNCTIONING PROPERLY,THE SYSTEM SHOWS NO SIGNS OF FAILURE.THE PIT HAD 16"OF LEACHING
LEFT AT THE TIME OF THE INSPECTION.
CESSPOOLS: _
(locate on site plan)
Number and configuration: n1a
Depth-top of liquid to inlet Invert: n/a
Depth of solids layer: n/a
Depth of scum layer. n/a
Dimensions of cesspool: n/a
Materials of construction: n1a
Indication of groundwater: n1a inflow(cesspool must be pumped as part of inspection)NO
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n1a
PRIVY:
(locate on site plan)
Materials of construction: n/a Dimensions: n/a
Depth of solids: n/a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n/a
revised 9/2198 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
IV Property Address: 128 REBECCA LANE OSTERVILLE, MA 02655 M146 P033
Name of Owner RICH PORTER
Date of Inspection: 3116/00
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
J
D A
OC
AD
CC 3�y
40
revised 9/2/98 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) - t
Property Address: 128 REBECCA LANE OSTERVILLE, MA 0.2656 M146 P033
Name of Owner RICH PORTER
Date of Inspection: 3/16/00
NRCS Report name: n/a
Soil Type: n/a
Typical depth to groundwater: n/a
USGS Date website visited: n/a
Observation Wells checked: NO
Groundwater depth: Shallow_ Moderate_ Deep_
SITE EXAM _ Slope
_ Surface water r
_ Check Cellar
Shallow wells '
Estimated Depth to Groundwater 12 Feet+
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property,observation hole,basement sump etc.)
Determined from local conditions
Checked with local Board of health
_ Checked FEMA Maps
_ Checked pumping records
_ Checked local excavators,installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS•12+FEET
Y
revised 912/98 Page 11 of 11
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