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HomeMy WebLinkAbout0117 ROBBINS STREET - Health 17{ ®bbns Street ; Osfervihle. 4 -- ---- - - - - A 142: .••I.16 P— Fee �7s'. No. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACH Yes'USETTS 01pplitation for Misposai Opstem Construction hermit Application for a Permit to Construct( ) Repair P< Upgrade( ) Abandon( ) ' ❑Complete System L �ividual Components Location Address or Lot No. Ill ROSSINf ST, 0 -4t11t. Owner's Name,Address,and Tel.No. GAILY IFr10 S6r4SA eA f" Assessor's Map/Parcel 14 2. 1 11(o 15 Foor%ot0.i w J%y OrA4K%T , N 3 o 3 1 Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. 363 w1Ac1 ?A-W Scent -14rmodlVi OZ(,(,y Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 14S- ���+,,a D[33 �}Io 1�07t t.. 0 Rl us (o (3c/0W G Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Heal Signed Date z .2.0 Application Approved by Date J Application Disapproved by Date for the following reasons Permit No. Date Issued 7 8; No.cam-. ! � � n ,,._Yee., THE COMMONWEALTH'OF MASSACHUSETTS Entered in computer: Ye - PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS V Jpflcatlon for Misposal 6pstem Cons trUttlotl-Vermit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete SystemIvidual Components i Location Address or Lot No.I t l R015131i-4S ST, 11Z}e04,11114 Owner's Name,Address,and Tel.No. _1 GA XY iiw) 5e N44 r-A t," »«. _ Assessor's Map/Parcel 14 2•4 11(D 15 rc ur,oc rL S n•( !}V'il F�tZ 1 , M M 0 3 0J { f Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. a t 3163 yttVW0jT" OZG( 4 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) t Other Type of Building No.of Persons Showers( ) Cafeteria( )f Other Fixtures Design Flow(min.required) gpd Design flow.provided 1 gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) �r►��1��� 1�1P,� D6 ( 1 O 'go( L.J. 7' RI bk5 gc l L't•,i et ( t Date last inspected: ,✓ Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed %�* t Date _ Z D Application Approved by """"'"" Date. / Application Disapproved by Date for the following reasons Permit No. f" � wC�` Date Issued' <C 5 � , `' THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )by at / ic!/_9 k h J C- has been constructed in accordance J with the provisions of Title 5 and the for Disposal System Construction Permit No idated �dj 7/.2 G Installer Designer #bedrooms h 14- Approved design flow A,/r A gpd 1 �-� The issuance of this peen iit s all not be construed as a guarantee that the system will'function as designe'. Date p J Q Inspector 1�•e 1; Y No. Fee _l- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction Permit " Permission is hereby granted to Construct( ) Repair( ) �Upgrade( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title'5 and the following local provisions or special conditions. �r Provided:Construction,must be completed within three years of the date of this permit. Date ✓� / �I ��c' � Approved by�� �. 7 � / � �� 5 �� 2dad " aS� ) �+ K f� P �- ��✓2 .� _ .. . Z 3 .� �"S �, f Commonwealth of Massachusetts rya_ NO Title 5 Official Inspection Form I Disposal Form forAssessments Subsurface Sewage D s osa System o of o - 9 p Y 117 Robbins St Property Address ' Sonja &Gary Cain Owner Owner's Name information is required for every OStervilleI✓ Ma. 02655 8-7-20 page. City/Town State Zip Code Date of Inspection 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 filling out forms A. Inspector Information ILI`68 on the computer, use only the tab Michael Sears key to move your Name of Inspector cursor-do not Robert B Our Co INC. use the return Company Name key. 363 Whites Path Company Company Address South Yarmouth Ma. 02664 City/Town State Zip Code Man 508-477-8877 S114430 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ❑ Passes ``a�tuuutmu►►►i IN OF 1ygS��i��i 2. ® Conditionally Passes �.' MICHAEL '.N 3. ❑ Needs Further Evaluation by the Local Approving Authority" S o; SEARS ) No.SI14430 4. ❑ Fails S 'r'�FRrIF�`D o.-. 8-7-20 Inspector's Sip4ture 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 y + lip" Commonwealth of Massachusetts Title 5 Official Inspection Form �i� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 117 Robbins St Property Address Sonja & Gary Cain Owner Owner's Name information is required for every Osterville Ma. 02655 8-7-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described . in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) 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): D box wall are gone, needs to be replaced t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 117 Robbins St Property Address Sonja &Gary Cain Owner Owner's Name information is required for every Osterville Ma. 02655 8-7-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ® 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below): D box walls are gone, needs to be repaced ❑ 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 ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) 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. a. 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: _ t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l; � 117 Robbins St V Property Address Sonja & Gary Cain Owner Owner's Name information is required for every Osterville Ma. 02655 8-7-20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No El ® 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form �i� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 117 Robbins St Property Address Sonja &Gary Cain Owner Owner's Name information is required for every Osterville Ma. 02655 8-7-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 'h day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 cam, Commonwealth of Massachusetts �n Title 5 Official Inspection Form +_ III Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 117 Robbins St u� Property Address Sonja & Gary Cain Owner Owner's Name information is required for every Osterville Ma. 02655 8-7-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® 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(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 C Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 117 Robbins St Property Address Sonja &Gary Cain Owner Owner's Name information is required for every Osterville Ma. 02655 8-7-20 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. 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 Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ® Yes ❑ No Water meter readings, if available last 2 ears usage d NA 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: presentDate i t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c Commonwealth of Massachusetts �w Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 117 Robbins St Property Address Sonja & Gary Cain Owner Owner's Name information is required for every Osterville Ma. 02655 8-7-20 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. 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: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 c Commonwealth of Massachusetts �v Title 5 Official Inspection Form �1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V � 117 Robbins St Property Address Sonja &Gary Cain Owner Owner's Name information is required for every Osterville Ma. 02655 8-7-20 page. Cityffown State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: NA Were sewage odors detected when arriving at the site? Q Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 21"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 117 Robbins St Property Address Sonja & Gary Cain Owner Owner's Name information is required for every Osteryille Ma. 02655 8-7-20 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 11feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) 1000 gal If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle 29„ Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Sludge judge, tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000 gal tank with in and out tees, both covers at 11" below grade t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts 1. Title 5 Official Inspection Form 5 11 Subsurface Sewage Disposal System Form Not for Voluntary Assessments `F � 117 Robbins St Vl Property Address Sonja & Gary Cain Owner Owner's Name information is required for every Osterville Ma. 02655 8-7-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .� � 117 Robbins St Property Address Sonja &Gary Cain Owner Owner's Name information is required for every Osterville Ma. 02655 8-7-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. 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 16x21 with 2 outlet pipes, cover at 19" below grade D box walls are gone and needs to be replaced t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 f Commonwealth of Massachusetts �v , - Title 5 Official Inspection Form �1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 117 Robbins St V� Property Address Sonja &Gary Cain Owner Owner's Name information is required for every Osterville Ma. 02655 8-7-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 117 Robbins St V Property Address Sonja &Gary Cain Owner Owner's Name information is required for every Osterville Ma. 02655 8-7-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS is 2- 1000 gal pits Pit 1 is 30"with cover at 13" below grade dry and clean Pit 2 is 28" with cover at 17" below grade dry and clean No sign of failure 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form �1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 117 Robbins St Property Address Sonja &Gary Cain Owner Owner's Name information is required for every Osterville Ma. 02655 8-7-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonweal th of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 117 Robbins St Property Address Sonja &Gary Cain Owner Owner's Name information is Osterville Ma. 02655 8-7-20 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 / Fear Al � 3 a - As 10 3-3I q - S)� 10 0 S :3 - � q - y 3 ~ a w l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 117 Robbins St u Property Address Sonja &Gary Cain Owner Owner's Name information is required for every Osterville Ma. 02655 8-7-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 2 fe eett 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: Behind lot shows 20' drop off with no sign of ground water Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 117 Robbins St Property Address Spa &Gary Cain Owner Owner's Name information is Osterville Ma. 02655 8-7-20 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank-Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included cl �j I A.,o (7 rrov�frYwYl s t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Commonwealth of Massachusetts w Title 5 Official Inspection Form — FILESubsurface Sewage Disposal System Form - Not for Voluntary Assessments COPY 117 Robbins Street, Osterville Property Address Adam Lepire Owner Owner's Name information is Osterville MA 02655 Aril 22-2014 required for every _p page. City/Town State Zip Code Date of Inspection 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 filling out forms A. General Information on the computer, [��I use only the tab 1. Inspector: key to move your cursor-do not David B. Mason use the return Name of Inspector key. David B. Mason 2y Company Name 4 Glacier Path Company Address , East Sandwich MA 02537 Cltyrrown State Zip Code 508-367-1617. S1287 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 ❑ Faiis ry �. .� ❑ Needs Further Evaluation by the Local Approving Authority, o .v April 23; 2014 Inspector's Signature Date The system inspector shall submit a copiof this inspection report to the Appro,6g AuthO'rlty(Bo rd of Health or DEP)within 30 days of completing this inspection. If the system isia shared/�steq�,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 Inspe n rm:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 117 Robbins Street, Osterville Property Address Adam Lepire Owner Owner's Name information is Osterville MA 02655 April 22 2014 required for every p 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 observed condition of the system represents the condition observed on April 22, 2014 at Noon and does not guarantee the continued operation of the system. 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): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 117 Robbins Street, Osterville Property Address Adam Lepire Owner Owners Name information is Osterville MA 02655 April 22 required for every p.�il , 2014 page. CitylFown 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 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 pipes) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ -obstruction is removed ❑ Y ❑ N '❑ ND(Explain below): ❑ distribution box.is leveled o(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 ❑ 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: El 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 117 Robbins Street, Osterville Property Address Adam Lepire Owner Owner's Name information is Osterville MA 02655 April 22 2014 required for every p �il , page. Citylrown 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 ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® - Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 117 Robbins Street, Osterville Property Address Adam Lepire Owner Owner's Name information is April A Osterville MA 02655 22 2014 required for every _ p � , page. Cityrrown 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 portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for 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. 0 ® 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: ►o 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 ll of a public water supply well If you have answered es to an y y y 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection ' Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 117 Robbins Street, Osterville Property Address Adam Lepire Owner Owner's Name information is Osterville MA 02655 Aril 22 2014 required for every p , page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑. Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ 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 5 P ) I O] D. System Information 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-3/13 Tide 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 G M ,•�°y 117 Robbins Street, Osterville Property Address Adam Lepire Owner Owner's Name information is Osterville MA 02655 Aril 22 2014' required for every P , page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 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? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Yes 9 ( Y 9 (gP ))� Detail: 2012; 26,000 gallons and 2013; 36,000 gallons. Sump pump? ❑ Yes ® No Last date of occupancy: CurrentDate 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•3/13 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 M 117 Robbins Street, Osterville Property Address Adam Lepire Owner Owner's Name :information is Osterville MA 02655 April 22 2014 required for every P Page. Cityrrown State Zip Code Date of Inspection D. System.Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records:. Source of information: Board of Health Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Pump tank sight glass Reason for pumping: Routine Maintenance required. 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): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 117 Robbins Street, Osterville Property Address Adam Lepire Owner Owner's Name information is Osterville MA 02655 Aril 22 2014 required for every P page. Citylrown State Zip Code -Date of Inspection D. System.Information (cont.) Approximate age of all components, date installed (if known)and source of information: December 1991 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 1 feet Comments (on condition of joints, venting, evidence of leakage, etc.): Observable components appear in adequate condition. Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ 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 gallon typical • Sludge depth: 411 t5ins•3/13- Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 117 Robbins Street, Osterville Property Address Adam Lepire Owner Owners Name information is April Osterville MA 02655 A 22 •2014 required for every p � , page. City/Town 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 4011 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, ' i How were dimensions determined? scour stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): . I. effluent is level with outlet invert. Observable portions appear in adequate condition. ? a t 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 117 Robbins Street, Osterville Property Address Adam Lepire Owner Owner's Name information is April Osterville MA 02655 A 22 required for every p • , 2014 page. Cityrrown 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 Form: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 117 Robbins Street, Osterville Property Address Adam Lepire Owner Owner's Name information is Osterville MA 02655 Aril 22, 2014 required for every _P page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): . a Depth of liquid level above outlet invert Level with 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.): Dbox is 16" below grade. Within 8"of grade due to risers. No evidence of solids carryover. P , 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: Utilized camera to view leaching pit. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .�� 117 Robbins Street, Osterville Property Address Adam Lepire Owner Owner's Name information is. Cisterville MA 02655 Aril 22, 2014 required for every p page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type. ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 6" of effluent on the bottom of the pit. There is evidence of staining 12"off the bottom of the pit. No signs of full hydraulic failure. Increase in use may lead to failure. 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 a - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 117 Robbins Street, Osterville Property Address Adam Lepire Owner Owner's Name information is Osterville MA 02655 April 22 2014 required for every p 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 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 .0fficiaHn'pection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 117 Robbins Street, Osterville Property Address Adam Lepire Owner Owner's Name information is Osterville y MA 02655 A ril 22 2014 required for every p � - page. City/Town 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�iin the area below ® drawing:attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 117 Robbins Street, Osterville Property Address Adam Lepire Owner Owner's Name information is Osterville MA 02655 April 22 required for every p �il , 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope , ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 20 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: December 1991 Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Groundwater contour map ® Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Utilized existing information on file. 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments wM , 117 Robbins Street, Osterville Property Address Adam Lepire Owner Owner's Name information is Osterville MA 02655 Aril 22 2014 required for every p , page. Citylrown 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 ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 17 of 17 Assessing As-Built Cards Page 1 of 2 I TOWN OF.BARNSTABLE LOCATION c,J� Ln&Lore _ SEWAGE if 9 VILLAGE ('J,SierriN� ASSESSOR'S MAP& LOT 14� INSTALLER'S NAME& PHONE NO.��, SEPTIC TANK CAPACITY LEACHING FACILITY{type) }7T (size) ged- Q NO.OP BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER Owo R. 1y4 fvy DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No y � J r -72 l v o http://town.bamstable.ma.us/Assessing/HMdisplay.asp?mappar=142116&seq=1 4/24/2014 i l , l 1 , �- % 31-7 4 - ! -�- I 7n i AL I - f E io ri I E a IT f I � n _r; TOWN PF BAR STABLE LOCATION �/ � /�G�J6r�f _ SEWAGE VILLAGE ASSESSOR'S-- MAP & LOT INSTALLER'S NAME PHONE NO.� I I L ��n��r►�p� ycS� ,/�G: SEPTIC TANK CAPACITY LEACHING FACILITY:(type) RT- (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER O&- R yt1�/yJ 11� ' DATE PERMIT ISSUED: /1 DATE COMPLIANCE ISSUED; VARIANCE GRANTED: Yes No d� �%' �; ,... :< � ��` � � � k �\ � �� � � � � 3- \� � � �� � � ���- �f\� ./ � � / ,�/ %' / M // //�i -�� yy� Fss.....$....30_00 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH APPROVED Barnstable Conservation CeAnrUnont TOWN OF BARNSTABLE �r `a J1 Appltratiou for Bhip 1sal Workii Tomitrurti W'rUti Do Application is hereby made for a Permit to Construct ( ) or Repair U) an Individual Sewage Disposal System at: 117- Robbins Street Osterville ................_... ... -.... •- ................................................. ......_--•---••-•-•••---••----•-•-•••---------..•..--•------•---------............................ Location-Address or Lot No. Plummer - --- --- _••----.e_r-..JrOwner A.-•-- J.P.Macomb er ...-•.......................................... ..........-•.................................--ddress•••-•-.-...._._._..-•----------................---- W Installer Address Type of Building Size Lot............................Sq. feet U Dwelling y No. of Bedrooms.........:....2...........................Expansion Attic ( )" Garbage Grinder ( ) aa Other—T e of Building No. of ersons____________________________ Showers YP g --------------------•------- P ( ) — Cafeteria ( ) Otherfixtures ------------------------•-----------------------•-•---•----•------•--••--••---------•-------•--•---••-•._.._...__....--•--------•---.._..._...•-•-_.. W Design Flow............................................gallons per person per day. Total daily flow..............................._............gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ 04 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_______-__________.____- 44 Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................ a ........................................................... -•-•-•----------------•--------•---------- -•.... _----------------------------•-••-•---------•-•---- 0 Description of Soil.......Sand-&.Grd,ve 1 x - - -- U •-••--••--•-•••--••--••---•-----••-•----------•----••-•---•-•-•-----------•••---------------------------•-••--------------------------_.. W ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•--•--------•-------- U Nature of Repairs or Alterations—Answer when applicable._______________________________________________________________________________________________ ---------------------------------------------------------------•-----•-------1-1J gallon leach--Pit Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by the boar of health. Signed ... -- y//A 12/1'J/91----- -- Date Application Approved By ................ ----...-.-..----- ---------------------------- -- /a //�_�t 16 Date z---- Application Disapproved for the following reasons- --------------------------------------- --- -- ---- -------------------................................................... ----------------------- ------------------------- -- -- ---- -- ---- --- ----------------- --------------------------------- ---- --------------------------------------------------------- ---------------------------------- No . ?/" - -------------------------------------- ----------------Date Permit .................................................. Date .a No.... FEs.....$...3 ....00 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE ; Applidtfion for Dispu,ial Mirks Towitrurtiun frrutit Application is hereby made for a Permit to Construct ( ) or Repair �X) an Individual Sewage Disposal System at: 117 Robbins Street Osterville ........... ......•------••------•-------------------------- •-•--•--•--•---------------........... ._.. .......-•- Location-Address or Lot No. Plummer W J.P.Macomber Jr Owner Address Installer Address d Type of Building Size Lot............................Sq. feet U DwellingNo. of Bedrooms..............?...............__._.......Ex Expansion Attic p ( ) Garbage Grinder ( ) Other—Type T e of Building No. of persons............................ Showers � yP g -•----•---------------•.-•-- P ( ) -- Cafeteria ( ) Otherfixtures -------------------------------•--------------------...-----------------------------------------------------••-•--•• ......--•- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) I ~' Percolation Test Results Performed by.................................. -----=• ..... Date.....................••-••-•------.... W _ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water----------_............. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 -------•••-••-•-••- •-••••••-•-•.......--•••-••-----•-•----•-•...•---•-••...................•-•••-_..........---•---------••-----•-•---••------•-•-----...... O Description of Soil........aand & Gravel x ------•... ----------------------------------•------------------------------------------------------------------..............--------.--••- W -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-•---....... U Nature of Repairs or Alterations—Answer when applicable................................................................................................ -------------•-------------------------------•-•-•---•-••-•--•1-10J p;a l lon•. leach p i t --------- Agreement: ' The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further.agrees not to place the system in operation until a Certificate of Compliance has bee issued by th(,boar of health. _ Signed �Lci� l ... - 12/10/91..... .,. ..a-------------------------- Date Application Approved B - ------------------------------------------------------PP PP Y - y u � Late Application Disapproved for the following reasons: .......................................................................... -----------I............-------- ...........---- ------------------------------------------- -- ---- --- /--- . --..............------..................-------------------...-----------------...--- ---.............. ------------ ....... ---........-...................------- Permit No. ! "' r✓ ,✓��J _.. Issued - Dare.................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Q'Irdifira e of Q-11omplianu THI�IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired.`(XXX)X by J.P.- acomber Jr. ------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Installer at .117.....Robbins Street Os-te-rvi-lle.............................................. ............ ..... .. ............................... has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .......c?..l.--..--,.575-5........ dated --............................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION S ATIS ACTORY. �'' c...... ........ ... _ -�� ..--. J.:,...DATE............. . ecto THE i COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ?/ �- TOWN OF BARNSTABLE 30.00 ..�.. .. FEE........................ �i���a,sttl nr�� �nn�#� uan �eruti� Permission is hereby granted.....J.P,•MacOmber---Jr. �'X�' to Const uct ( or Repair Q� � an Individual Sewage Disposal System at No 1_T._.R bbins Street Osterville ._... ----•-•-••-........--•-••-----•---•-•......•-•-••----------.----• •-----------------••-••••-•--•---•-•--•••-•--•--•••••••-••-••-•-•--•--•-......_......... Street / as shown on the application for Disposal Works Construction Permit No.__.._.�/ 5_.�7_J._____ Dated.......................................... ---------•••---•--••••---•-•-•-•--• ,» --------------•--•---------....---------........._ - --------- .------•"•.•......... Board of Health DATE...........!_....:....1 1 FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS LO' A°T'ION SEWAGE PERMIT NO. VILVAGE INSTALL R'S ME A ADDRESS _ � I e OR OWNER DATE PERMIT ISSUED DAT E C 0 M P L I A N C E ISSUED „�--- -„ _'-- r I ��,� � ., �- �� �Q � �� � � r 4 { No. . l.1�..3_I. Fins..3.d....- 1. THE COMMONWEALTH.OF MASSACHUSETTS BOAR® OF -HEALTH .....' -v'....-...........0F..���' ':-. .�.......................................... ApplirFation for Disposal 3 oxks Tungtrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ......1 _....L _ � -................ .................. -----. ....... .....------------•--..........----------- � N Location-•Addr..ess � y Lot ATq.,— 2%�' Owner �ress W �i ..../ ,: .a.tw.--•-•-•-----•-••-•----•-------------•--•-----_-_ ?!✓. '�.. �..---.. 7!Lk If '.........._............ Installer Addr ss Type of Building f,. Size Lot____,r� .......... feet U Dwelling—No. of Bedrooms..............................................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building No. of '. ersons.......z................. Showers / — Cafeteria Other fixtures --------------- -------•------• - --"' -------------------------------------------••••-----•••- ---........ Design Flow............................................gallons per person per day. Total daily flow_._._.__.___.-___.__35k....._______.gallons. Septic Tank—Liquid capacityjl�g__gallons Length................. Width................ Diameter............... Depth................ Disposal Trench—.No_____________________ Width.................... Total Length...... ..........._.Total leaching area....................sq. ft. x Seepage Pit Diameter.................... Depth below inlet......`............. Total leaching area..................sq. ft. Z Other Distribution box Dosing tank ) a Percolation Test Results Performed by- oCl. ,te.- _. --r______________':_-_____________ Date...... V4/_V_ --------------- Test Pit No. 1................minutes per inch Depth of Test Pit.-.._-___________-__ Depth to ground water........................ G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a' =------•---------------------------------•---•------------._.......-------•--•........................................................ O Description of Soil........... V ---------------------------------------•--•----............-•-._.............._..__...---------------.......-------------------...-•---•-----------------••----------------------•-......:------------- W VNature of Repairs or Alterations—Answer when applicable......................................................................•---._-._.__._.._.__.__.. - --------------------------•-••---...-•••r-e Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordathe provisions of iIME 5 of the State Sanitary Code— The undersigned further agrees not to place the operation until a Certificate of Compliance has been issued by the and of health. ,. 4` ep__d__..._ f Application Approved BY --- '- lC� ✓z:%�� ............... •........... ...•-- ----•� /Lf--�1-------- Date Application Disapproved for the following reasons:----•-------•------------------------------------------•---------------------------------------••--------------- --..........•--•.............•----•------••..__...---•-•-----............--•-------•--------•-------•---------..__._........----••----------••----------•-------------------•------•-----------...--•--- Date V rmlt No....... 1- F---. ---------------------------•-----------. Issued_......j--1P-= 7( . ... Date Noa..%. .t J Finc..:2...................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............oF........, ':: ,.c�a+ -'/` , , ppliration for Uinpootal Works Tomilrnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ......f �_......x;F....-•.- .........�^�.= .............. ...............-------••--••---.................................... Location-Address - J or Lot No, ✓ :6 '1 :_^__: _'4.�........... ...................................... ... : . .;C/ L',./i...l�..i'7[ ..../Gh' .I,IL..t:�:: ...... Owner } ( f Address—y --------------•-•-------.-.----.---•---•--•-----. 1�f� ?l a( ✓ ���!GC d`r.�e...�P� ... Installer Address Type of Building Size Lot.... . .........Sq. feet Dwelling—No. of Bedrooms.............3............._...•..___.__.Expansion Attic ( ) Garbage Grinder ( ) `4 Other—T e of Building .... No. of persons....... --............... Showers / — Cafeteria P4Other fixtures --------------------------------------------------•----•------------•-••----••••---•------••--•••-•-----------------..........---..........-••-•-_---- W Design Flow............................................gallons per person per day. Total daily flow..............._....33.©..............gallons. WSeptic Tank—Liquid capacityAe )_..gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length......................Total leaching area....................sq. ft. Seepage Pit No.. ..�'?_�__.. Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( �j°" Dosing tank( Percolation Test Results Performed -4-=------------------------------- Date..... !....________... Test Pit No. I................minutes per inch Depth of Test/Pit..........._......._ Depth to ground water........................ rX4 Test Pit No. 2................minutes per,inch Depth of Test Pit.................... Depth to ground water........................ ----------------------...................................................................................................................................... O F. Description of Soil..........0_ ... V ....:-•----------•••-•--•--------•••--••--•---•...----•...-••-•••••-••--------••---------------•--•-•••--------•---••----•--•-••------•-----••--•-----....-•••-•-•......•-- W UNature 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 TITL% 5 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.-_ Date Application Approved By------ c ...... G /L .. Dat' e Application Disapproved for the following reasons-------------------------•----•------------------------------------------------------------------.........••--•-. ........-•--------•--•-------•-------•••-•----•----•----•••••..............•--•-----------•----......••...__....__...-•-.....----•••••---••-•-•-•------•--••-••----••-----•--------••-----•-•------•---•- Permit No........?./ Issued---•- ............................................. Date Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH/ S. OF.... �E �-2.�<r1.�1:.............. uprrtif iratr of Tuntplitanrr�-r ; THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by................,-.......faL_�_'�':'........./'" &I ee/o. ...........................................................•----....----...............----------•---..............................._......._ � r. Installer at --------------....... .......................................................................................................................................................... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.___.......y.. el................. dated-....... _r_._�'�?._.. �.............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION S TISF CTORY. DATE . J ... Inspector.....:..4Y/� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF' HEALTH k `y/i4 / /t/ .............,.... :(':...`.............OF..............:��!�''` ... r .. ., No......................... FEE.......... --•-- •.A Disposal 1VOrkii Tonntrnrtion antit . Permission is hereby granted................. to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at No.. 7 r e//, , first ' r Street as shown on the application ko Disposal Works Construction Permit No..j f ...... Dated.......l_...............................•t --- ••- -----------------------------------------------------_ .Board of Health DATE................. 1.. � L" ----------_------------------ FORM 1255 HOBBS & WARREN, INC., PUBLISHERS T —�----- I LA- -S l Tom- Cir lv1 eT ffu--/ f x "0 GAa2SAG6 E.RI�.b�. I c7v GU ;s t>,&t a tIo V. 3 • 330'G.pv 99+4 9q•G SWA=--rI c'TA*J K- s 330,. lS0 6.P D. •�� U Ste- t OOG� 6.4 c..: � �� 45.0 � . DISPOSAL PIT USE locx=t, G24 ay.. Q • ISo SF 2.S • 3"1S '.ci 8d1t7'l7�ll AQUA� Sfl ST=. � .� • . � ��� O Ae�'A 5� fry'. f 1 .o ti 50 C�;PD. TCn'At. 'DESIla1J =425 G.PF->. � I rxA?e. 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