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HomeMy WebLinkAbout0011 ROBBINS STREET - Health 11 Robbins Sheet. { I -13 Os#erville P - ° ° ° - ^ ° a , n ° w u �T Y � i y ° d� _ f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 11 Robbins Street Property Address N William Crawford CIO Owner Owner's Name information is required for every Osterville i� MA 02655 3-17-16 page. City/Town State Zip Code Date of Inspection N Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information. „►tt►tt,,,, filling the computer, .�(�N oout forms use only the tab 1. Inspector: key to move your JAMES • G cursor-do not James D.Sears (Puse key.the return Name of Inspector F* Ca ewide Enterprises, LLC .O o.� p p �y Company Name 153 Commercial Street ipF�st INs?E�p��� Company Address Mashpee MA 02649 City/Town State Zip Code 508477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 3-18-16 pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 ojjv�. VS Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 Robbins Street Property Address William Crawford Owner Owner's Name information is required for every Osterville MA 02655 3-17-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1000 Gal. Tank D Box and three chambers. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old' or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic_tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): f I t5ins•3/13 t Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 Robbins Street Property Address William Crawford Owner Owner's Name information is required for every Osterville MA 02655 3-17-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ' ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or breakout or<high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ °obstruction is,removed ' ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑, N ❑ ND (Explain below): The system required pumping more than 4 times a year due to broken or.obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y �n N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C)_ Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. - 1. System will pass unless Board of Health determines in accordance with 310 CMR. 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts , Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 11 Robbins Street Property Address William Crawford Owner Owner's Name information is required for every Osterville MA 02655 3-17-16 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: . You must indicate "Yes" or"No"to each of the following for all inspections: Yes No I ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in asupval is less than 6" below invert or available volume is less than %day flow E4 elll v6: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts a - Title 5 Official Inspection Form • Subsurface Sewage Disposal System Form Not for Voluntary Assessments r 11 Robbins Street Property Address William Crawford Owner Owner's Name information is required for every Osterville MA 02655 3-17-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portionof a cesspool or privy is within a.Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ E Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy.of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure: E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section-D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑- the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 11 Robbins Street Property Address William Crawford Owner Owner's Name information is required for every Cisterville MA 02655 3-17-16 page. Cityrrown State Zip Code Date of Inspection C. Checklist G Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? I ® ; El available as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑' Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® " Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)1310 CMR 15.302(5)] D. System Information 11 Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 • t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Robbins Street Property Address William Crawford Owner Owner's Name information is Osterville MA 02655 3-17-16 required for every ' page. CityrFown State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal. Tank D Box and three chambers. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection , El Yes No information in this report.) ` Laundry system inspected? ❑ Yes ® No Seasonaluse? t ❑ Yes ® No Water meter readings, if available last 2 y ears usage d 2014-74,000GaIs g ( Y g (gp ))' 2015-55,000 Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Robbins Street Property Address William Crawford Owner Owner's Name information is required for every Osterville MA 02655 3-17-16 City/Town/Town State Zip Code Date of Inspection a e. Y P P P9 D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped:.. gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): 3 l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 f Commonwealth of Massachusetts w - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 Robbins Street Property Address William Crawford Owner Owner's Name information is required for every Osterville MA 02655 3-17-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: i 1990 Permit 90-568. Were sewage odors detected when arriving at the site? El Yes ® No Building Sewer(locate on site plan): 22" Depth below grade: feet Material of construction: El cast iron 0'40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC .SCH 40. Septic Tank(locate on site plan):. " 101, , Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass El:polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast H-10 Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts s v W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form- Not for Vcluntary Assessments 11 Robbins Street Property Address William Crawford F Owner Owner's Name information is required for every Cisterville MA 02655 3-17-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness oil. Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? A Sl uilt-Plan -Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank and covers at 10" below grade. Inlet tee, outlet baffle. No sign of leakage or over loading. Grease Trap (locate on site plan): Depth below grade: feet" Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Y u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 11 Robbins Street Property Address William Crawford Owner Owner's Name information is required for every Osterville MA 02655 3-17-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑'concrete '❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow; gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 11 Robbins Street Property Address William Crawford Owner Owner's Name information is required for every Osterville MA 02655 3-17-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan).. Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-20" below grade. Box is clean and solid Wone line out. No sign of over loading or solid carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 Robbins Street Property Address William Crawford Owner Owner's Name information is required for every Osterville MA 02655 3-17-16 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.). Type. ❑ leaching pits number: ® leaching chambers number: 3 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.): Leaching is three flows w/3'stone. Flows at 30" below grade. Ck D Box and camera out to flows. No sign of over loading or solid carrry over. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M ,.•''� 11 Robbins Street Property Address William Crawford Owner Owner's Name information is required for every Osterville MA 02655 3-17-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Off.cial Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t 11 Robbins Street Property Address William Crawford Owner Owner's Name ` information is required for every Osterville MA 02655 3-17-16 ` page. Cityrrown State Zip Code Date of Inspection D. System Information,(cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch.in the area below ❑ drawing attached separately Q , „ 3 , ,t . y t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 • Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 11 Robbins Street Property Address William Crawford Owner Owner's Name information is required for every Osterville MA 02655 3-17-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) , Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Vo 8' Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed- Date - ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Auger T.H. 8' no G.W.. Bottom of flows at 4' below grade. Bottom of flows at 4' above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection . Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 11 Robbins Street Property Address William Crawford Owner Owner's Name information is required for every Osteryille MA 02655 3-17-16 page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D'(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file c t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 jl TOWN OF BARNfSTABLE � LOCATION L,a- # 4`C (�b��iihS <;+ '=e 7 SEWAGE # cjILLAGE 1��,-I ccJ ASSESSOR'S MAP Cz LOT (INSTALLER'S NAME & PHONE NO. -�. e ���� 7`71 - l t�H.a XEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size)`l X v+ NO. OF BEDROOMS 3 PRIVATE WELL ON fPU:BLICWA�TER BUILDER OR OWNER S v �i)V� i t� Co 771"d Sq-/ DATE PERMIT ISSUED: �� �� q l DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No T 6 J 1/41 No.� ........ ISO Fs...................... THE COMMONWEALTH OF MASSACHUSETTS /,�fo­ov 0 BOARD OF HEALTH A.................0 F...t'Boi.lc Z, .a.............................. �Zo .........0. L�i Nppliration for Disposal Works Tonstrurtion Permit Application is hereby made for a Permit to Construct (k) or Repair an Individual Sewage Disposal System at: L at' , ddress or 2- ....E.L�_C,44 .............. ...tylA.w ......... Owner Address ................. ................................. .................................................................................................. Installer Address Type of Building Size LotAe.)5TT!)....sq. f t U oms....3....................................Expansion Attic A) Dwelling—No. of Bedrooms._. Garbage Grinder 1.4 04 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria 04 Other fixtures ...................................................................................................................................................... — Design Flow.........ITS...............................gallons per person pFr day. Total daily flow.......�15­0.......................21ions. Septic Tank—Liquid'capacity.ICM..gallons Length..&-G... Widthl'1-10.. Diameter......-......... Depth..19...S" Disposal Trench—No....A............... Width...1.0............ Total Length..:MtP........ Total leaching area..ZZ .....sq. ft. Seepage Pit No................ ... Diameter.................... Depth below inlet.................... Total leaching area..................sq. f t. Z Other Distributionq6s Dosina tank A(J> Percolation Test Results Performed ................... Date.��"A�.-.e6........... ,.-I Test Pit No. 1..4 .....minutes per inch Depth of Test Pit......19........ Depth to ground water. ...... Test Pit No. 2.../,Zr.....minutes per inch Depth of Test Pit.......V.Q...... Depth to ground water. . ..............................0...............................................L;�.................................................... 0 Description of Soil TK—L 1-ft ?. .....Q=Z----BOR- .. ..... ......0 &.7F.1.6A.e.ep......... .......... ..............................................................................................................................tN4oT-ALtATtON--AND--CERT-1FY--IN--V,,A-7,,—f'."O U Nature of Repairs or Alterations—Answer when applicable.....................T.KE-.SyST.EM..WAS--INGT-AL-LED-i*--ST-il;C' I ...............................................................................................................................ft�,-0"QMCE--T0-P%Mv........................---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TAITa 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance h e * s ed b,Sloar Ith. .... ..... A w...-....../...Z.. . Application Approved By... . _/ ! ... ,.......... . ................Date Application Disapproved for the following reasons:.............................................................................................................. ....................................................................................................................................................................................................... Date Permit No......9ral ......I........................................ Issued....... Dste %. No . ..� l_o T 3U Fxs.......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......... .1 4 .............OF........�✓..�.b�.l-l.f<..t'7�~�.L�_�.. Appliration for BiupnuFal Vorkg Tnntrudinn 1hrutit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: �� . f mi..- - L� __ Lo tion- lddress or l_ No. L � .�. +?.: ..................... !AaA...�''�,�:t_! ..�sa r._ .45 K �LL ._..... Owner Address W Installer Address Type of Building Size Lot...��^1_ �t ...Sq. feet Dwelling—No. of Bedrooms.... ...................................Expansion Attic AD Garbage Grinder ('��j `04 4 Other—T e of Building No. of persons............................ Showers — Cafeteria 04 Other_fixtures ............................ Design Flow..........`?. ..........................gallons per person day. Total daily flow...... .......................gallons. /� W Septic Tank—Liquid'capacity-�. .t0gallons Length..6�G.. Width..'.C.— p. Diameter..._._--"_____ Depth... _.C�. x Disposal Trench—No. .__.A.............. Width....1 ........... Total Length...7&!�0....... Total leaching area_-!- J---•-sq. ft. Seepage Pit No-----------....... .. Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (�( S Dosi tank (1�11}J _ Q '~ Percolation Test Results Performed by. '�x .� ...1�1 �__��.L................. Date...._�_..... -�-.......... a Test Pit No. 1...4GZ.....minutes per inch Depth of,Test Pit...... ....... Depth to ground water..�_3.: ,_.... Test Pit No. 2...�4tZ....minutes per inch Depth of Test Pit....... 0...... Depth to ground water__E L-._3`.r_�__._ - ..................................................... Description of Soil.....(...... •-1 - �J" -- k c�CZ_Ce: ._tom_, C = -----��-AD ............. xZ- ! a f!1 tom, �.....-'-� `�'�� t '.... ..e- ----------------------------------............................................ W -- w x ------••-----------•---------------•--••--•••-------•-••-•-•---•------............•---------•--•--•-----------••----------•-------•-------- V Nature of Repairs or Alterations—Answer when applicable--------------,�i-_S1GNING ENGINEER MUST Sl;ij r^.V�, ------------------------------------------------------------------------------------------------------------------------�3-•'•A--L--L-••A-•T--vI® �IV_VAKN�D OV��iRAY'IFt=' dV'tii� ii1`9 1:iAgreement: NL SYSTE `.k-' a 'gORDAI`ICE TO PLAN. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of t?THE, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha een d by oar Lalth, = Z. e � - u; z )O - pt C, Application Approved By---....``--:c ............................... ---s_...__... ........ ..l__.._ -•-- Date Application Disapproved for the following reasons:................................................................................................................ --------------------•----.....---•-•----------........--•---•--•-•-•.....•--•---- Date PermitNo................................................ Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS � �11 t-WaI O-a-1 MUST vL 1.-T,%' V.TI0N AND Qgiff f-'-f J�j 4 OARD OF HEALTH THE aYSTV-4 WAs IMI�TAM9 IN Sr i v: oF................. !`.SS r":���Ct�RDANCE TO PLAN, Trrt f iratr of Tuntpftanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repairedby ( ) -------------------------.------•----------------------•----.-----..-------.-.-----------------------•----------•---------------.---•-•--------------------------------•-----------•--- 1t Installer _"' at da. ++ ? �r ._: CAS ! has been installed in accordance with the provisions of I I 5 Te State Sanitary Code a , escribed in the T �"7 V i `7 application for Disposal Works Construction Permit No...................................... dated-_...-_.--.�7RAN' ` -.......-L.�'_.._......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS E® AS A GUTI THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE. ---�1----�1..--•-•----•--....----•.................................... Inspector..... ._ THE COMMONWEALTH OF MASSACHUSETTS G-,,,ING ENGINEER MUST BOARD OF HEALTH I-" ,-A,LLATION AND CERTIFY 114 rF;7 SYSTEM WAS INSTALLED IN 13?i,,,C, ..................?"°v........OF...................................................� ` ��-� stl-G C raanl� TO PLAN.-. .... ..•• :. ............ FEE............... Disposal Works Tonstru ion rrntit Permissionis hereby granted.............................................................................................................................................. to Construct ( ) or Repair ( ), an Individual Sewage Disposal System at No......... - l Street as shown on the application for Disposal Works Construction Permit NoS-9....... ..�. Dated........-:-�.�.J..�.��_...... DATE......................................... ............................. /% ! FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 1 • Nda�5za;K��:� s ss=f Y"��'t.f%5t '+3 ��" :fit.-�ti fi.; s ^y,. - .� � yA •5f K,` j: <l 1 •g• T RrU - �'a't 2.F �Fvec� S 'hlp�`G�►7C8Aff:E.�• ����Z` � S cE Si-1 tr�'2�Z �'�, 5� �►.,�`� 330 x Aso�0 4495 ��D ,_� �5" f u6s 1po0 tea+--vr�'T,�►a1c- ��a�:H OF p �� 1-4 RICHARD '' LE►<LNI�L�— �1SG F1Aw�� �ussoz5 o A. p4 P#TSR <<` , BARTER � a SULLIVAN ; o No.24048 �a.`� " No. 2S733 "t> '^ts FCISTER`� Z 70OTZ'O M Xzr.7f? 5 r�t�'°� go To-T- --3;;IZ6I E , ,: --- /scL'A► l I FkA i�I�GCr II C ..�5�> .�!I �,; a ,'� . . _ Foe; ��Lt,'E>•( � � .�����f TF-- Z . ICE�8`�j SGA�E:FIS:f.IO '1 ^- YS 3`G L�E lU ENGINEER MUST S'U? , I GeuS�}�17�v'RaµE.r2 STZ11,!'E',6k-i6? ' ' LATIO N AND CERTIFY IN , . THE SYSTEM WAS IN IN STc3iCT �'�' Act t. i�1►.a f�?> ..6,::44 uORDANCE TO PLAN. a. h . ' a..'' `�'^�+►—� ' , IN- 1 . (Trk -1 7 4 ::-Z) ,: 1►�V U1V o,�i-.� $TOPS®t C. 14,Z., IODU. ►►.tv . ►k!J DIST I NvKO aAL i .` Go SA.ti41;> .SLR%„ 'QA b�4�.A-TIrO. A2 SL 5•b 'Q' ? �- a�u rlli�f�: 1 J T: I W - 85 ) !2V,AE C r ! tF 1, V t.Y�I.'d�F 172.CJe-I LE A �Z i w. OJUb1`Nlrl ITA mt- r S 4-1?F-L ;i4;ElE�n aAc 1 Cam-1�-Qj ;J i 111-7 1Z. Ill *a 1� OQ°IO W ^^ 1J ✓ in Z �� a`A4 S f r ►. �_ �F� k� 183��K Lo -i 5A S �4AP IA l '�T 130 t. )3 -7 I _ r i; � .� '` ; 5C�•�4 tom :+::�'�l"_ �O Y 5 I c PI T:-q IN ;,;;a 29 i I:•dc J! ,.. .. .ii :r.'r.•K.,!. I ' 1 ire OA 4�2�( G L ' ! � ?ZA4 '�►.�+0.t.� � � 1,C 18 3 Cod 1_ o _:1 5-A �.: ,��5E5$bZ•S.M�P ,1.q:1;1-b�- 130 �3 'g � ? HA Pf MR .�. ,.�._ � 1.�: _• � � �" v J I I 'IVI N I a 17 �r ra VU of Arieb `t 1 { �`�-511yc5�i:�:'F,.r:.ri�K 3`,.$�v ecbM.S � •_� GAZ$A6r� .,�l+.i�GZ . ... LJ GE .6 %\O =-6-10 ' s c. ti� = 33C� x\Sl3•l• =495 6?P ' USE 10o 3`T"!c►�lC. \P`\H OF b Ex,�+a 01v RI HAD C R �. s9 . LEh�t� L't� - USC. �t_ow ice«►=usso�.5 o A. '> s � PIJER y . - ,IDEW.ALL AQ.EA,. $(NSF: b BAXTER SULLIVAN �t r No.24048 • 'W7Ad IT-(: 00-.F a Z,S. Z_pp °'� 9fcr a`�° 41 No:29733 f d. j1 ^ VAL SLA"�O.S L 1 < fin^shy ssc �\�;-h d ('APAc_1 tom(:ZCC?$F s SP;7 T1 L I.�r /�SPOS�L'J67 �. o"C �q SOUTt� COt�1dT�� O�vS7 `A I M Sm Cif s se-v t I-I,.0 a pA%L.; 2�';Io 89 3GA�6:I�St.l01 e0 x � � M YG. , 3 goo •SiGiNiNG ENGINEER MUST �� �. 1" TALLA SU G a - TION AND RTIFY IN euSt�D �a►-�E. ZE, STaf� t�N�U� THE.. SYSTEM CE WAS INSTALLED IN STF! ''CCORDANCE TO PLAN. C r �. r. � �1.c•.���11.aE��;�E-q �6 .�JL•5c.�1g0 I -T o -7 ":TC1Q�?F Foc?NpAT10�•�l �Co.? S��'191198�3 •..?k'Sv�L�vq,..! 7 7 4- T 1 }t�j. 1M1 IMl bIST 11.tV r 4,� KO GAL (0 &�C 13, •o. �j ��i SI�.1-�17 r 40 13.2 4T'EL 12.2 l � 1� , 1 D J{u16 A SL gb2 SOPaltr Flt�ti'� I � 1 2Q u CapA.T A2 � 3•b "� 7 Tt au u s TSW - 8g ) :Eo AF C r , s� i � •�t� �I-U�P�S��cL�r 1 L.� � �7ATl.1t-!� �2,7 t „>, { � f`l ram.: .. . �—✓_,c-�a.�E. Ih 10 F GEZ7). N -mATr -Fou 1-4PAmC),PA 637.Z L\ jE � f ­5U 244E 0 -"7 q .V BAXTER & NYE, INC. Professional Land Surveyors and Civil Engineers 812 Main Street a Osterville, Massachusetts 02655 a Tel. (508) 428-9131 WILLIAM C. NYE, P.L.S. President PETER SULLIVAN, P.E. -Vice President-Engineering RICHARD A. BAXTER, P.L.S. -Vice President May 7 , 1991 Board of Health Town of Barnstable 367 Main St . - Town Hall Hyannis , MA 02601 Re: Lot 94 Robbins St ./-Main St . Osterville Dear Board : In accordance with the terms of your permit I have inspected the installation of the septic system for Lot 94 . The system has been generally installed' as per the plan of record . The location of the leach bed is as pe.r the plan of record horizontal and vertical . I• trust that this meets. your present needs . Very truly yours , Baxter & Nye, Inc . Peter Sullivan , P. E. i cc : B ,yside Builders -- inc . Pi'TER .- SULLI WAN r5, No. 29733. k• MEMBERS OF ' CAPE COD'SOCIETY OF PROFESSIONAL ENGINEERS AND LAND SURVEYORS I AMERICAN CONGRESS ON SURVEYING AND MAPPING ' MASSACHUSETTS ASSOCIATION OF LAND SURVEYORS AND CIVIL ENGINEERS i ` COMMONWEALTH OF MASSACHUSETTS ZZ�� EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEBVEED If JUL. 0 1 2004 TOWN OF BARNSTABLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION 1 TOAD Property Address: 1-1- Robbins Street PARCEL Osterville. . . Owner's Name: Marie Gant LOT _94 Owner's Address: Date of Inspection: - Name of inspector:(please print) W i 1 1 i am F_ • Robinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P 0 Box 1089 - Centerville, MA Telephone Number: (5081 775-8776 CERTIFICATION STATEMENT f 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: LiPasses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: .�i?�,�- Date: /' "© The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heathy 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 seat to the system owner and copies:sent to the.buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 i Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 11 Robbins Street Osterville Owner. Date of]nspection; Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: �X 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. Sys em Conditionally Passes: e or more system components as described in the"Conditional Pass.'section need to be replaced or repaired. he system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer y s,no or not determined(Y,N,ND)in the for the following statements.If`not determined"please explain. Th septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, xhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing is replaced with a complying septic tank as approved by the Board of Health. •A meta septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicatin that the tank is less than 20 years old is available. ND cxp ain: Observation of sewage backup or break out or high static water level in the distribution box due to-broken or obstz 6ed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with appr val of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND a plain: The system required pumping more than 4 times a year due..to broken or obstswcd pipe(s).The system will pass ' ispection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND lain: t I Page 3 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 11 Robbins Street Osterville Owner: Marie .Gant Date of Inspection: C. F rther Evaluation is Required by the Board of Health: C ditions exist which require fiuther evaluation by the Board of Health in order to determine if the system is failing t rotect public health,safety or the environment. 1. Syste will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the syste is not functioning in a manner which will protect public health,safety.and the environment: _ C sspool or privy is within 50 feet of a surface water _ C spool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System ill fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is fut clioning 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. Th system has a septic.tank and SAS and the SAS is within a Zone 1 of a public water supply. _ T e system has a septic tank and SAS and the SAS is within 50 feet of a private water supply.well. e system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more frond a priv a water supply well** Method used to determine distance •' his system passes if the well water analysis,performed at a DEP certified laboratory, for coliform b cteria and volatile organic compounds indicates that the well is free from pollution from that facility and e presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other ailure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of I 1 y OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 11 Robbins Street Osterville Owner: Marie Gant Date of Inspection: — 4 D. S em Failure Criteria applicable to all systems: You rrtu indicat4 -yes"or"no"to each of the following for all inspections: Yes No _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or cesspool iquid depth in cesspool is less than 6"below invert or available volume is less than'/,day flow equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Numbcr ttimes pumped y portion of the SAS,cesspool or privy is below high ground water elevation. y portion of cesspool or privy is within 100.feet of a surface water supply or tributary to a surface water supply. _ Any portion of.a cesspool or privy is within a Zone 1 of a public well. _ .Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 t et 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 conform bacteria and volatile organic compounds indicates that the well is free.from pollution from (fiat facility and (fie 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. Large Systems: o be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 g d. Y u must indicate either"yes"or"no"to each of the following: ( e 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 11 of a public water supply well If yo 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 vama ar operator of a"large system considered a sig ficant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15. 04.The system o%%wr should contact the appropriate regional office of the Department. 4 l PAge5of11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 11 Robbins Street nstPryi11P Owner: marip rant- Date of Inspection: Check if the following have been done.You must indicate''yes"or"no"as to each of the following: Yes Now _ ✓ Pumping information was provided by the owner,occupant,or Board of Health Q% Were any of the system components pumped out in the previous two weeks? -Z/_ Has the system received normal flows in the previous two week period? /Have large volumes of water been introduced to the system recently or as part of this inspection?. Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _ i.-' Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance. is unacceptable)[310 CMR 15.302(3)(b)] 5 e Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 11 Robbins Street Osterville Owner: Marie Gant Date of inspection: C —/%'—e, 7� FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):. 3 Number of bedrooms(actual): 75 DESIGN flow based on 310 CMR 15103(for example: 110 gpd x#of bedrooms):Jr f D Number of current residents: 1.-,14 d Does residence have a garbage der(yes or no):A Is laundry on a separate sewage system(yes or no)A o [if yes separate inspection required) Laundry system inspected(yes or no): Seasonal use:(yes or no): ±- Water meter readings,if available(last 2 years usage(gpd)): 2 0 0 3 1 4,0 0 0 Sump pump(yes or no):^- a 2002 — 23,000 Last date of occupancy:-4,;IA' COMMER IANDUSTRIAL Type of estab shment• Design flow( ased on 310 CUR 15.203): tTd Basis of desi flow(seats/persons/sgft,etc.): Grease trap resent(yes or no):_ Industrial ste holding tank present(yes or no):_ Non-sani waste discharged to the Title 5 system(yes or no):_ Water m er readings,if available: Last dat of occupancy/use: OTH (describe): GENERAL INFORMATION Pu ping Records Source of information: Was system pumped as part of the inspection(yes or no):_ If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYP F SYSTEM _ eptic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _lnnovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components date installed(if known)and source of information: se P Were sewage odors detected when arriving at the site(yes or no): .L 6 f )'age 7 of OFFICIAL INSPECTION FORM—NOT FOR VO LUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 Robbins street Osterville Owner: __ Marie Gant } Date or Itispecllon: BUILDING b EWER(locate on site plan) Depth below ade: Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(o ondition of jobiLs,venting,evidence of leakage,etc.): SEPTIC TANK:2(1ocate on site plan) Depth below grade: ! / Material of constructin.o • ✓coot ,rete me_.__ —metal_fiberglass_polyethylene 0 theKex l P a'�) If tank is metal list age:_ is age confirmed-by a Certificate of Compliance(yes or no):_(attach a copy of certificate) ►' 0 � �-Dimensions: G16 - Sludge depth:0-i" f Distance from top of sludge to bottom of outlet tee or baffle:c e 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:4��� 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.): r CREASE T P:_(locate on site plan) Depth below,gr de:_ Material of construction:_concrete metal. fiberglass_polyethylene_other (explain): Dimensions: Scum thicknes Distance from op of scum to top of outlet tee or.baffle: Distance from ottom of scum to bottom or outlet tee or baffle: Date of last p ping: Comments(o pumping recommendations,inlet and outlet ice or baffle condition,structural integrity,liquid levels as related to utlet invert,evidence of leakage,etc.): 7 Page 8 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 Robbins Street Osterville Owner: Marie Gant Date of Inspection:4—4 g-o 42 TIGHT or HOLDING K: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: allons Design Flow. TAlin allons/day Alarm present(yes or Alarm level: rking order(yes or no):Date of last pumping: Comments(condition float switches,etc.): DISTRIBUTION BOX: tf present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAT! ER: (locate on site plan) Pumps in work' g order(yes or no): Alarms in work ng order(yes or no): Comments(not condition of pump chamber,condition of pumps and appurtenances,etc.): �I 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1.1 Robbins Street Osterville owner: Marie Gant Date of Inspection: —/$--o 4/ SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation'not required) If SAS not located explain why: TYPe eac�hing pits,number: lhing 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.): A CESSPOOLS: ( esspool must be pumped as part of inspect ion)(locate on site plan) Number and configurat 'n: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspoo Materials of constructs Indication of groundwa er inflow(yes or no): Comments(note condi on of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locat on site plan) Materials of cons lion: Dimensions: Depth of solids: Comments(note ondition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 Robbins Street Osterville Owner: Mari P Gant- Date of Inspection: G— �- 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. e 6 I� G `I 10 Page. 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 Robbins Street Osterville Owner. Date of Inspection: 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: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Chpeked with local excavators,installers-(attach documentation) ccessed USGS database-explain: You must describe how you established the high ground water elevation: 11 ` ^ h. ;�� �' �� r--` is�,L�� ��f. Barnstable Assessing Search Results Page 2 of 2 Appraised Value $275,300 Living Area 1428 Assessed Value $275,300 Replacement Cost $ 162,954 Depreciation 7 Building Value 151,500 Construction Details Style Cape Cod Interior Floors CarpetHardwood Model Residential Interior Walls Drywall Grade Average Heat Fuel Gas Stories 1 1/2 Stories Heat Type Hot Water Exterior Walls Wood ShingleClapboard AC Type None Roof Structure Gable/Hip Bedrooms 2 Bedrooms Roof Cover Wood Shingle Bathrooms 2 Bathrooms Total Rooms 6 Rooms Extra Building Features Code Description Units/SQ ft Appraised Value Assessed Value FPL2 Fireplace 1 $2,800 $2,800 Property Sketch Legend BAS First Floor, Living Area FST Utility Area (Finished Interior) UAT Attic Area(Unfinished) BMT Basement Area (Unfinished) FTS Third Story Living Area (Finished) UHS Half Story (Unfinished) CAN Canopy FUS Second Story Living Area (Finished) UST Utility Area (Unfinished) FAT Attic Area(Finished) GAR Garage UTQ Three Quarters Story(Unfinished) FCP Carport GRN Greenhouse UUA Unfinished Utility Attic FEP Enclosed Porch PTO Patio UUS Full Upper 2nd Story(Unfinished) FHS Half Story(Finished) SFB Semi Finished Living Area WDK Wood Deck FOP Open or Screened in Porch TQS Three Quarters Story(Finished) http://www.town.bamstable.ma.us/tob02/Depts/AdministrativeServices/Finance/Assessing... 11/15/2004 Barnstable Assessing Searc`h.Results Page 1 of 2 r 70P 4 � Home: Departments:1�ssessors Division: Property Assessment Search Results Owner: Property Sketch Legend GANT,ANDREW P&MARIE C Map/Parcel/Parcel Extension 141 /130/ B Mailing Address 3 GANT,ANDREW P& MARIE C - 435 WEXFORD OVERLOOK DR f 3 16 ROSWELL, GA.-30075 Cx 'R '' r 2005 Assessed Values: m & Appraised Value Assessed Value Building Value: $ 151,500 $ 151,500 Extra Features: $2,800 $2,800 Outbuildings: $0 $0 Land Value: $275,300 $275,300 Interactive Property Map: Ma requires Plu in: Totals:$429,600 $429,600 I have visited the maps before Show Me The Map April 2001 photos available Bales History: Owner: Sale Date Book/Page: Sale Price: GANT,ANDREW P&MARIE C 6/15/1991 C123673 $ 155,000 BAYSIDE BLDG CO INC 3/15/1991 C122906 $58,000 MORIARTY, CATHERINE 11/15/1989 C118935 $ 1 OMEARA, ELLEN P C62565 $0 Tax Information: Tax information is currently not available for this parcel Land and Building Information Land I Building Lot Size(Acres) 0.38 Year Built 1991 http://www.town.barnstable.ma.us/tob02/Depts/AdministrativeServices/Finance/Assessin€... 11/15/2004