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HomeMy WebLinkAbout1500 SOUTH COUNTY ROAD - Health 1500'South County. Road.- Osterville P A = 120 001 AI �i r i u 5 F P 4 ° P � 9 ` Jai GYM/- ODZ Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1500 South County Road Property Address Robert Bodjiak Owner Owner's Name y information is Osteryille MA 02655 10/23/15 required for every -� page. Cityrrown 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, U use only the tab 1. Inspector: key to move your cursor-do not Richard T. Johnson use the return Name of Inspector key. D&J Environmental Services Company Name P.O.Box 764 Company Address Buzzards Bay MA 02532 Cityrrown State Zip Code 508-735-8740 S113545 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 b the Local Approving Authority 10/23/15 Ins or'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. A ond V5 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1500 South County Road Property Address Robert Bodjiak Owner Owner's Name information is required for every Osterville MA 02655 10/23/15 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: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1500 South County Road Property Address Robert Bodjiak Owner Owners Name information is required for every Osterville MA 02655 10/23/15 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 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): ❑ 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: ❑ 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments lug 1500 South County Road Property Address Robert Bodjiak Owner Owner's Name information is required for every Osterville MA 02655 10/23/15 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 an Y � PP � Y) 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 %day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1500 South County Road Property Address Robert Bodjiak Owner Owners Name information is required for every Osterville MA 02655 10/23/15 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 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. ❑ ® 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-3/13 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 5 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1500 South County Road Property Address Robert Bodjiak Owner Owner's Name information is required for every Osterville MA 02655 10/23/15 page. Cityrrown 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)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440GPD t5ins-3/13 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 1500 South County Road Property Address Robert Bodjiak Owner Owner's Name information is required for every Osterville MA 02655 10/23/15 page. City/Town 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 ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ® Yes ❑ No Last date of occupancy: presently 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•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 yy. 1500 South County Road Property Address Robert Bodjiak Owner Owner's Name information is required for every Osterville MA 02655 10/23/15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Presently Date Other(describe below): General Information Pumping Records: Source of information: 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): 1500 gal tank&2 leaching pits 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 1500 South County Road Property Address Robert Bodjiak Owner Owner's Name information is required for every Osterville MA 02655 10/23/15 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: 1999 per BOH records 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: 25 feet Comments(on condition of joints, venting, evidence of leakage, etc.): joints structurally sound, no signs of leakage. Septic Tank(locate on site plan): Depth below grade: 1 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: 1500 Gal. Sludge depth: 1" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1500 South County Road Property Address Robert Bodjiak Owner Owner's Name information is required for every Osterville MA 02655 10/23/15 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 33" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Field measure/MFG Specs. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet/outlet tees in good condition, tank structurally sound, no evidence of leakage. Recommend annual pumping to extend life of components. 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•31113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1500 South County Road Property Address Robert Bodjiak Owner Owner's Name information is required for every Osterville MA 02655 10/23/15 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•3113 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 M " 1500 South County Road Property Address Robert Bodjiak Owner Owner's Name information is required for every Osterville MA 02655 10/23/15 page. City/Town 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 n/a Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(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-3113 Tide 5 official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1500 South County Road Property Address Robert Bodjiak Owner Owner's Name information is required for every Osterville MA 02655 10/23/15 page. Cityrrown 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:❑ g e , ❑ 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.): no signs of hydraulic failure, no damp soil, normal vegetation. No high staining observed. 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 Forth:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1500 South County Road Property Address Robert Bodjiak Owner Owner's Name information is required for every Osterville MA 02655 10/23/15 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 Official Inspection Form Subsurface Sewage Disposal System foam-Not-for,Voluntary Assessments " 1500 South County Road Property Address Robert Bodjiak Owner Owner's Name information isOsterville MA 02655 10/23/15 required for every page. CitYRown 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 ail 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 separatoly 1 ao fib, • a ash« �r6 3 sb.iiii"glow Y� GAS o 1 i I , 3 r7 3 ti e. 15ins a 3113 Title 5 Official hmpedion Form:Subsurfma Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1500 South County Road Property Address Robert Bodjiak Owner Owner's Name information is required for every Osterville MA 02655 10/23/15 page. CityrTown 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: 14.4 feet 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: copy of high ground water computation report attached ref: 91 Bumps River Rd. ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Obtained from site observation, visual elevation, examined high ground water computation report on file with BOH Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1500 South County Road Property Address Robert Bodjiak Owner Owner's Name information is required for every Osterville MA 02655 10/23/15 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. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1500 South County Road Property Address Hans Heussler Owner Owner's Name information is required for every Osterville MA 02655 November 5 2013 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, use only the tab 1. Inspector: key to move your U cursor-do not Frederick Swain y use the return Name of Inspector key. Wind River Environmental rab Company Name 1958 R Broadway Company Address Raynham MA 02767 City/Town State Zip Code (508) 822 -2003 651 Telephone Number License Number UU B. Certification I certifylthat 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 1� sewage disposal systems. I am a DEP approved system inspector pursuant to Section.15.340 of C Title 54(3:10 CMR 15.000). The system: • d p rr, hRasses ❑ Conditionally Passes ❑ Fails E-- i 1j ^� ❑ Needs Further Evaluation by the Local Approving Authority November 5, 2013 Inspector 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 DER. 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. �� 5 A J t5ins•3/13 Title 5 Official Inspection Form:Sub u Vewage sposal System•Page 1 of 17 •1 Commonwealth of Massachusetts W Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ^M 1500 South County Road Property Address Hans Heussler Owner Owner's Name information is required for every Osterville MA 02655 November 5, 2013 page. Cityrrown State Zip Code Date of Inspection B. Certification (cost.) 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: Recommend annual service to tank, recommend filter in outlet baffle of tank. 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 1500 South County Road Property Address Hans Heussler Owner Owner's Name information is required for every Osterville MA 02655 November 5, 2013 page. Cityrrown 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 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 ❑ 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1500 South County Road Property Address Hans Heussler Owner Owner's Name information is required for every Osterville MA 02655 November 5, 2013 page. City/Town 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 aseptic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has aseptic 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 ❑ E 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1500 South County Road Property Address Hans Heussler Owner Owner's Name information is required for every Osterville MA 02655 November 5, 2013 page. CitylTown 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. ❑ ® The system fails. l 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•3/13 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 1500 South County Road Property Address Hans Heussler Owner Owner's Name information is required for every Osterville MA 02655 November 5, 2013 page. City/Town 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? 1 ® ❑ 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: ' 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(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#.of bedrooms): 440 gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 1500 South County Road Property Address Hans Heussler Owner Owner's Name information is required for every Osterville MA 02655 November 5, 2013 page. City/Town 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 ❑ Yes Z No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 61 GPD 9 ( Y 9 (gp ))� Detail: 5950 gallons from water department on 11/05/2013, converted to 61 GPD Sump pump? ® Yes ❑ No Last date of occupancy: 11/02/2013 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1500 South County Road Property Address Hans Heussler Owner Owner's Name information is required for every Osterville MA 02655 November 5, 2013 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: Wind River Environmental (09-14-2011) Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1,500 gallons gallons. How was quantity pumped determined? Tank size Reason for pumping: To check tank integrity 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'l/A system�by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ® Other(describe): Tank to Pit#1 to Pit#2 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 1500 South County Road Property Address Hans Heussler Owner Owner's Name information is required for every Osterville MA 02655 November 5, 2013 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: March 4, 1999 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1 ft 8 inches or 20 inches feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 25 ft feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good clean joints, no evidence of leaking. Septic Tank(locate on site plan): Depth below grade: 1 ft p g feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) Tank is 15000 gallons If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10 ft x 5 ft x 5ft Sludge depth: 4 inches t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1500 South County Road , Property Address Hans Heussler Owner Owner's Name information is Osterville MA 02655 November 5, 2013 required for every 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 _ 38 inches Scum thickness 1 inches Distance from top of scum to top of outlet tee or baffle 6 inches Distance from bottom of scum to bottom of outlet tee or baffle 10 inches How were dimensions determined? Tape Measure and 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 proper level, inlet tee and outlet baffle intact. No evidence of leaking in or out. Permit said 1000 gallon tank. Tank is 1500 gallons, 10 ft x 5 ft x 5 ft. 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 Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1500 South County Road Property Address Hans Heussler Owner Owner's Name information is required for every Osterville MA 02655 November 5, 2013 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.): l *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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1500 South County Road Property Address Hans Heussler Owner Owner's Name information is required for every Osterville MA 02655 November 5, 2013 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 N/A 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.): t, 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 Commonwealth of Massachusetts W Title 5 Official Inspection form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1500 South County Road Property Address Hans Heussler Owner Owner's Name information is required for every Osterville MA 02655 November 5, 2013 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type. ® leaching pits number: one 6 ft x 6 ft leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number,)ength: ❑ leaching fields Ynumber, dimensions: ® overflow cesspool number: One ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Overflow cesspool, block with outlet to second pit. Second pit dry at this time. No evidence of high stainig in either pit. 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 1500 South County Road Property Address Hans Heussler Owner Owner's Name information is required for every Osteryille MA 02655 November 5, 2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level ofponding, 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 Official Inspection Form Subsurface Sewage.Disposal System Form -Not for Voluntary,Assessments M 1500 South County Road Property Address Hans Heussler _ Owner Owner's Name information is required for every Osterville MA 02655 November 5, 2013 — page. CityrTown 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 3 G Ar i j G✓k7<r �{ 3 dr Title 5 Official twpecW Forth:subvxtace sewage O*Posai Sy— Page 16o,17 &•3f13 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 1500 South County Road Property Address Hans Heussler Owner Owner's Name information is required for every Osterville MA 02655 November 5, 2013 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope Z Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: fee 14. ft t 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: pate ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Back nieghbor, 91 Bumps River Road ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Attached copies of high ground water level computation report from back neighbor, 91 Bumps River Road. Groundwater 14.4 ft form BOH office. 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 1500 South County Road_ Property Address Hans Heussler Owner Owner's Name information is required for every Osterville MA 02655 November 5, 2013 page. City/Town 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Permit Number: Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION �C/ Z�La�� 5 �7 - Site Location: I �1�, Lot No. Owner: 6 . Address: Contractor: �� J Address: L� c1i Notes: STEP 1 Measure depth to water table to nearest 1/10 ft. .............................................................................. .Date l fGj month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OAppropriate index well.................................................... © Water-level range zone ...................................................... STEP 3 Using monthly report "Current Water Resources Conditions"- determine current depth to water level for index well...................:....... month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A),-current depth to water level for index well (STEP 3), and water=level zone (STEP 26) �r / determine water-level adjustment ."...................................................................................... (� STEP 5 Estimate depth to high water by subtracting the water level adjustment (STEP 4) from measured depth to water level at site (STEP 1) .................................................. Figure 13.—Reproducible computation form. 15 AsBuilt Page 1 of 1 TOWN F BARNSTABLE e( � LOCATION . 1560 S. CQ()/1 SEWAGE# Y �I VILLAGE QMrAL ASSESSOR'S MAP&LOT load 40/ INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY n LEACHING FACILITY: (type) ) �� riT (size) NO.OF BEDROOMS BUILDER OR OWNER PERMrrDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet _Private Water Supply Well and Leaching Facility (If any wells exist on site or within 206 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) —�- ) Feet Furnished by '7~/I SOG o/1 U. .ror G 109 f 1 2aO 116 P a a� as O 3 3 So Yq 'ittp:Hissgl2/intranet/propdata/prebuilt.aspx?mappar=120001002&seq=1 10/18/2013 vlap Page 1 of 1 down of Barnstable Geographic Information System New search Home Help Parcel Viewer Custom Map Abutters Map Size ■ Zoom Out m fl ME M'M,M E In r r "" Q tF ® � Cc 3PG Map: 120 Parcel: 001-009 Full .. y3� I::; _ Property 0970" 097013 097012 6�. Info 12013e 12DDo5 Location: 71 BUMPS RIVER ROAD g1593� q17 q10 0182 q54 120137 120003002 0970t5 g88A 9183% 1t,/ Owner: NEGER,MARC A 015a 1 120001007 04, 120002 'N 172 —^—'--^— ! q21' '�� g189 �100 t2o0ot0o8 ' �Fq t2005t00t !Location Information 097%2001 N45a 4o g180 t Map&Parcel 120001009 q tt135 m - Location 71 BUMPS RIVER ROAD 120001009 Acreage 1.21 acres y i 20q 31006 q 71 12000001100110 1 r 097037002 A �ICurrent Owner 097024 • 120001012 q00 q25 q 101 Mailing Address NEGER,MARC A ® 71 BUMPS RIVER ROAD 120001013 120001002 g1i1 OSTERVILLE,MA 02655 - q 150D 720DOt011 ti� lie 097037001 #91 ]Appraised Value(FY 2013) 045 120001014 Extra Features - $55,300 E� 12p0a01100490 5Ltie is y q9 out Buildings $37,300 4 Land $435,500 ., 120001015, Buildings $243,100 +>i '81 120W Total Appraised $771,200 �.� 098004001 12g148D 4 q 92 0N77 D#24 q0' F° Assessed Value(FY 2013) [ q 77 q 24 0 120001016 �— - 1200ot003 Qq� • Extra Features $55,300 0 263 Fie q I D �,. 120145 g50Out Buildings $37,300 �97034 g345 120001017— Land $435,500 t q50 qai Buildings $243,100 Total Assessed $771,200 Set Scale 1" = 263 I Aerial Photos I MAP DISCLAIMER [` Copyright 2005-2010 Town of Barnstable,MA All rights reserved.Send questions or comments to GIS BarnstableMA v1.2.4748[Production] i c http://66.203.95.236/arcims/appgeoapp/map.aspx?propertyID=120001002 11/5/2013 f COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED MAY 1 9 2004 1 TITLE 5 TOWN OF HEALTH DEPT. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1500 South County Road MAP Osterville, MA 02655 ®® PARCEL Owner's Name: Hans Heussler Owner's Address: LOT _ Date of Inspection: May 8, 2004 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature:. Date: May 15, 2004 The system inspector sha\submcopy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1500 South County Road Osterville, MA Owner: Hans Heussler Date of Inspection: May 8, 2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes:, One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,-upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 1 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1500 South County Road Osterville, MA Owner: Hans Heussler Date of Inspection: May 8, 2004 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1500 South County Road Osterville, MA Owner: Hans Heussler Date of Inspection: May 8, 2004 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool , ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone lI of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1500 South County Road Ostmille, MA Owner: Hans Heussler Date of Inspection: May 8, 2004 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ _ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up ? ✓ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS, located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1500 South County Road Osterville, MA Owner: Hans Heussler Date of Inspection: May 8, 2004 FLOW CONDITIONS RESIDENTIAL - Number of bedrooms(design): n/a Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 5 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped 1 year aQo-per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: A pit was added 10/11191 -per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1500 South County Road Osterville, MA Owner: Hans Heussler Date of Inspection: May 8, 2004 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 8" Material of construction: ✓ concrete _metal _fiberglass polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 8" How were dimensions determined: Measurinz 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.): Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage. GREASE• TRAP: None (locate on site plan) Depth below grade.- Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 I Page 8 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1500 South County Road Osterville, MA Owner: Hans Heussler Date of Inspection: Mav 8. 2004 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: Gallons Design Flow: Gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1500 South County Road Osterville, MA Owner: Hans Heussler Date of Inspection: May 8, 2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 -6'x 6'(1000 Qal.) leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: ✓ overflow cesspool,number: 1 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.): The overflow cesspool was S'W x 3'T x T bottom to grade. Liquid was up to the outlet tee. 0"of scum. A tee was present. The cover was 3"below grade. The leach pit had 1'of water on the bottom. The scum line was 2'up from the bottom. There did not appear to be any signs offailure. The bottom to grade was 8'. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1500 South County Road Osterwile, MA Owner: Hans Heussler Date of Inspection: May 8. 2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. n B �r n F o a aa� � a03 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: 1500 South County Road Osterville, MA Owner: Hans Heussler Date of Inspection: May 8, 2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30 +/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: Topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using a Barnstable topographic map and water contours map, the maps were showing approximately 30'+/-to Around water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. ]1 sessing As-Built Cards ,F" http://www.townofbamstable.us/Assessing/HM(isplay-asp?mappar-._ MORTGAGE INSPECTION PLAN Applicant ,.tie ksav, I r Location: OSWYOCI I B� T�\ !:'`. T 14f Segpuct- MC. lit " 5��'_ bC1L11Z V\LV1 L68.9� h ! M LPL .V� 138, gara i 1 h 1 r L � 150Q o O. RN e j t_j-ice-! To �A � J \ _ 18 d� _ i i F Ltl': I; _; p 253. 10' vtJ� Jeap a I t' lor Of r " 1 fi�,�TN�7`3 �o T. -a Yeef.• 6t;F Wa40 IZ_3lood panel: 9560 C054 - �' flood Zone:.x ti CROv 9 hereby certiN that this mortgage inspection was prepared for f The dwelling shown hereon dXs�all in a special 'C-M.7t. flood zone {I"or-V,with an effective date of 1:&-14- and the location of the dwelling �conforlm to the local zoning by-laws in effect at the time of Scale:1 66 construction with respect to horizontal dimensional setback requirements hate: or isexemptfrom'violation.enforcement action underM.G.L:eh.40Asect.7. 7ileNo_ 1y- 1449 please note:Vie structures shown on this mortgage inspection are shown approx�mate only.An instrument survey is necessary to determine a predce location of structures and property lines.`l=his mortgage inspection must not be used fnr recording purposes or far use in preparing deed descriptions and must notbe used fvr variance orbuilding depa►tment purposes.Veri�tcation of building locations. propery line dimensions,fences or lotconfiguration can only be accomplished by an accurate instr im�rtsurvey which may repectdiff�rent information than.whatisshown herFon. NOTE THIS IS NOT A BOUNDARY SURVEY AND IS FOR MORTGAGE PURPOSES ONLY. COLONIAL LAND SURVEYING COMPANY, INC. POST OFFICE BOX 350 HUMAROCK,MA 02047 • P.781-826-7186 - P 781-826-4823 . E:COLONIALSURVEWGMAILCOM No.?/- .. ......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Bi"oiial Works Towitrurtion thrutit Application is hereby made for a Permit to Construct or Repair (Z4—alrindividual Sewage Disposal System at: ................ ---------------- A---------------------------------- Vk4c r e s or Lot No. 'r'4r 'Y....................................... .................................................................................................. (!wnerd, res r .............. .. .................................... ............... .F 3.... ....... Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.._..- ...................................Expansion Attic Garbage Grinder Other—Type of Building ............................ No. of persons............................ Showers Cafeteria Otherfixtures ..................................................................................................................................................... Design Flow....:-4�. .......gallons per person per day. Total daily flow..._.._3 ...................gallons. 1:4 Septic Tank—Liquid*capacity............gallons Length................ Width........___.___. Diameter-------------_ Depth................ Disposal Trench—No..................... Width............._____.. Total Length_......_......._.... Total leaching area....................sq. f t. Seepage Pit No_____________________ Diameter.........___.__..... Depth below inlet.............._..... Total leaching area..................sq. f t. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit._____..........._.. Depth to ground water.__..................__. f� Test Pit No. 2................minutes per inch Depth of,Test Pit--- ................ Depth to ground water......_._....._......... P4 ............................................................................................................................................................. 0 Description of Soil....................................................................................................................................................................... U ...............................................................................................................................................................................................1......... W .................................................................................................... ........ .... ,a -------- ----------------------------------------------------- U Natur�pf Repw'p or Alter ions—Answer when h /--4pp ica ------_. .....0....0.....r. ........ A--------------/. ................ /7e........... S-rr-.41..................................................................................... 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 as b edby the b of health Signed O /.-4 '-­'�''"/ Application Approved B<y .:---_ z7---,�- ;-—_�, Dace e --------------- -------------------- ......... .................................... _........------Dace-r-e--- Application Disapproved for the following reasons: ....................................................................................................................................... .......................................................................................................................................................................................................... .................................... Ca '/ — Date Permit / ...... Issued .................................................................... No. 1,------- ... .... ----------_------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratinn for Uhipasal lVorkg Tonotrnrfiun rantit Application is hereby made for a Permit to Construct ( ) or Repair ( �}`--an"Individual Sewage Disposal System at: ,( ,f� ...../_�_-;:�.__�.�__Q .-•--`��?•C.1- ��j ?.C.?. t.!__l_- !�� _--__------•----( -t! Gr <. ...............•---•.......---- Lo t n-Address 7" or Lot No. �.. . .. ................... =-------------------- ............................................. Owner `dress �.... ... ................................... .....5 ----•--,�-:. ..--- -.....-...---- a Installer Address Type of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms____ _______________________________Expansion Attic ( ) Garbage Grinder ( ) a`4 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-------?_3_.�_...................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 ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water__-____-_____-_______--. f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_-.___-_:............... ------•------•---------------------•---••-•••••--•-------•••••---•---•---•----•-----..__..__..__._....._....__.....:..__:____-----•-•----......------ 0 Description of Soil...............................................................................------------•-•----------------------•------------------------_._--•-----••-•----_----•- x : x ••--••-•---••---....--•------•-------------••--•------••••----------•--•--------------•---••---•--- - - - -------------- U _ Nature of Repays or Alter ons—Answer when applicable.._ = ------------��... •--------------•-------•--••--•-----= Agreement: The undersigned agrees to install t e 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 'sued by-,the bo ,of health. �, "' r Signed -.�`�"`.-.-.. .. Da Application Approved BY - �----., ---------------------------------- --------------- Dace Application Disapproved for the following reasons: .. .............................. ...... ................................................................................... ................----- ----- -- ---------------- -- -------------------------------------------- ------------------------ ------- ------- - ------------------------------------------ ----............................... Permit No. /�y'S Date Issued Dare THE COMMONWEALTH OF MASSACHUSETTS .t BOARD OF HEALTH TOWN OF BARNSTABLE &rtifi ate of C ontylia nce THI/ IS (0 RTTFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by � /1... �" ---------------------------------------------Aw -----------------..................-�---------------------- at ........,/r �.- C .4 .-t ' .--..C./h. ............. �`� `[// �---��..---.......... has been installed in accordance with the provisions of TIT E 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ................................................ dated -.--.---...---....----.----...---............... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. 1 DATE-------------- - .. . .. t Inspector . . t �- fr r ►r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH !/�/�/�. TOWN OF BARNSTABLE Q d No.... �............. J FEE. ................... ... rkp Tomitrnrtion rrntit Permission is hereby granted__.. __.._. ____________ _ to Construct ( ) or Repair (4-)-an Jn ividual Sewage Disposal S, at No.. "'!26? � _'..t t ! J �� L-_.._1 ..... Stret4¢ p (� as shown on the application for Disposal Works Constructio Perrit Dated-- f__':_ : /.._- .�--r.�C_./ DATE............. Board of Health_...•••--••••--------------••--------__ f FORM 36508OBBS&WARREN,INC..PUBLISHERS TOWN F BARNSTABLE LOCATION 15,(A) Is. C--A y SEWAGE # `1I 7 y� VD=LAGE O MfV t l6— ASSESSOR'S MAP & LOT�000/1 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY I LEACHING FACILITY: (type) 1 SDI �iT (size) NO.OF BEDROOMS BUII.DER OR OWNER NAA.S Peuss e/ PEF-MITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility). Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Peet Furnished by 'T/)SQC30e1 FQI,�__ W w _ J TOWN OF BA INSTABLE 1.5oo sn(A �VNT 0 LOAN %l5vQ jV- C0t��;%Jl( -� - SEWAGE # ' "'cIWs r VILLAGE Z+e ASSESSOR'S MAP & LOT 0— f , STALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) 'NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER .. if/! r DATE PERMIT ISSUED: ( ct f DATE COMPLIANCE ISSUED: I VARIANCE GRANTED: Yes No r 1 I� , � - � � � � i � ��+ 0 . �� 0 �.�. LOCATION SEWAGE PERMIT NO. VILLAGE. IN SOA LLERIS N Z ADDRESS 9 OR OWNER Z' -0 4) DATE PERMIT ISSUED DATE COMPLIANCE ISSUED �-,,� 6--- � 'l 1 .� \ _._.. �- .� � Iry ��i � �� � � i�; .� CO_ CATION SEWAGE PERMIT NO. �ag VILLAGE INSTALLER'S NAME A+ ADDRESS 0 e UILD R R OW El! . DATE PERMIT I S S U E 0 DATE COMPLIANCE ISSUED A r �� �� r J® �� t n t y v _j R..,d 1,z5.... Fm$.... 0................. D THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH a� Inw ..................OF...... .- .�.....__._.._...................... Appliratioit for Bispoii al Workii Towitrur#ivat ramit Application is hereby_made for a Permit to Construct ( ) or Repair (1,11"'an Individual Sewage Disposal System at: ---------- 1 ..._. W I -P ... ................. A.. --------------------------------------- ------- L at'on ddress or t No. W Owner 1 ( Address ................\ ----- . Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.__-.Z.................................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building No. of persons............................ Showers — Cafeteria Pa Other fixtures -------------------------------• - W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid-capacity.Z5QA.gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................mmutes 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........................ --------------------------------- •----•-- -------------- •------------------------------------ --- .-------------------------•-- ------------. 0 Description of Soil........................................................................................................................................................................ x w x ------------------------------------------------------------------------------------------------------------------�--------------....................... U Natu Repair Alte tions— er whe ble.... _ _____)�Q__......��+t\�--'A-_���---xQy...... 0 Agreement: The undersigned agrees to insta I the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITU 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. tgne . •-------------- ---•-- 4-S----- at ApplicationApproved BY-----= ....... ...................................................... ----�� .......................... Date Application Disapproved f t following reasons--------------------------------------------------------------•-----------------------------------•---•---...... --------------------------------------•---------------------•--------------------•---------•----------------•-----------•---------•--------............................................................ Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOAR OF H A ..�! ..........:............o F... ................ ..... ..................-::........................... TntifirFa#r of ToutpliFaurr S TO ERT , That the Individual Sewage Disposal System constructed ( ) or Repaired by 1... -- ---------•-•- ------ er at..... �•-••---• f`J lJ has been installed in accordance with the prow' ions of LB " The State SanitarCod as e-cribed in the application for Disposal Works Construction Permit No$_ ________________ dated_- ._ __1-__--- _.__________--_-_-_-------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A UARANTEE THAT THE SYSTEM idJ1A FUNCTION SATISFACTORY. DATE••-- •-6—._...3...................................................... Inspector........ --- •-•-••-•-•••••••-••••---••--------......------------.....---•-•••-- - k ......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ---------------------..............-.....OF........................................................... ............... Apli iration for Uispn,ial Workii Toustrnrtilan Vvermit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ..-----•-----.................................................................................... --••--..........••....•-•-••-•-•--••-•-•--••-•-•-•-•-•.....•-•-•-•-----------•---...............-• Location-Address or Lot No. ......................_.......................................................................... ..._........•.......----••......_....•.................._......._..............__.._...._......--- Owner Address W Installer Address Type of Building Size Lot----------------------------Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a`4 Other—T e of Building .............. No. of ersons............._.._....._.___. Showers YP g -----•-------- P ( ) — Cafeteria ( ) d Other fixtures ------------------------------------------------------------ ••••-----•-----_------ 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. Other Dos Z Percolation Distribution ing tank Test Res Its ) Performed by ( ) . r 3'4 .� ...... Date........................................ Test Pit No. I.................mmutes per inch Depth of Test Pit........Y_._._... Depth to ground water........................ r3� Test Pit No. 2................minutes per inch Depth of Test Pit................. Ct,Depth tv ground water........................ R+' ................................ . .. ................................................. Description of Soil .. U ............................................. �..r .............................•---........_._..._.................._..._...__........._........... W .........................................................•------------- ,:'' .:: U Nat t Repair It ktions— er whe Kable................................................................................................ ............. • ............ ........ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI.L 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. igne _.....-----•------••..............•-----•-•--------------....-----••--•••--••-••---•- Application Approved By...... .... .....At ------------------------------------------------------------- .�O................... Date Application Disapproved f r t e following reasons:---•.............•-•-•------------------.............--•---------•---•-•-•-----•----•--•---••------•-•----...... ..-------•---------------------•--•----•--•--•---...-•-------•---.._......--•--•----......_..-----.....--------------------------•-------------------•-•---•-•------------------...-Date-•--------..._ PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS . BOAR F H A�.:. ...,.......�...........................O F.... ?LO .............. ..... ......:......................................... '" if iratr of Toutphattre � b I„ S T0,2ERT , That the Individual Sewage Disposal System constructed ( ) or Repaired Y .r .. --- ------ .------ ----•-.....••---•..............•-....----•-•-•............--------.._...... ------••-- yam''" ---- ------ ..,.d' ,, ns er ,. at4-------------- --- •-----.....f...t- �- ------------•-------------•-------------------------------------/UARANTEE ---......................... has been installed in accordance with the rov' ions of TLE The State Sanitary Cod . •cribed in the application for Disposal Works Construction Permit No3' � ................. Y date . THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH rq ...........................................OF...................................................................................... N 1 �'>/ ... FEE.�O................. hill olo t1 nrkii k"15.I1nitra ion .ernti# Permission is hereby grant ed... ------• -- ..._..-• -----••--•••----•-•--•-••-••••....--•-••-•--•-....--••...................................... to Construe ) or2epair n I fluid )� Sew=age isposal System at No........- D_0 .�� .�. Street .................. a as shown Xthepli tion for D'-p Works Co truction Permit No.................. _ tied .J /-----------•-•-••--••••••--•................... ........................•....________................------------------------------------------------------- FORM Bo d of Health DATE-1-- 1255 HOBBS & WARREN. INC.. PUBLISHERS