HomeMy WebLinkAbout0117 STARBOARD LANE - Health 117 Starboard Lane
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No. Fee /O VY
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ZIppgicatiou for Mi5pw6al *p5tem Con.5truction Permit
Application for a Permit to Construct( Repairgo Upgrade( Abandon( ❑Complete Systems Individual Components
Location Address or Lot No. I t17 574le,6 o,4A?I � �3' Owner's Name,Address,and Tel.No.
M 4 G C 1 Y_ 4 h/r elv
Assessor's Map/Parcel G S " a-9 7 / 1 9 54MI3 Q,4,0 /p— T
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
w-Y�if /n/;.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of,Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 4 - CM4
jx, C I til-,
Date last inspected:
Agreement: r
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by t is Board of Health.
Signed •Date "
Application Approved by Date
Application Disapproved by: Date
for the following reasons
Permit No. Date Issued
.No.4 CO2 C73 U Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS es
Application for TN.5ponl 4pgtem Construction Permit
Application for a Permit to Construct( ) RepairzK) Upgrade( Abandon( ) ❑.Complete System4K Individual Components
� LN
Location Address or Lot No. /� ST/r�l 0/�/�d 05 1` Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel /G. " 6 7 5711,p13 p,41PJ k,- 0 5T
Installer's Name,Address,and Tel.No. ��' lQ/ 7� L Designer's Name,Address and Tel.No.
.s-u ') -
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of.Septic Tank Type of S.A.S. e
Description of Soil
Nature of Repairs�or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code And not to place the system in operation until a Certificate of M
Compliance has been issued by t 's Board of Health. _ r
e Signed Date S w U
Application Approved by f _ Date
Application.,Disapproved by: ' Date
for the follo�,ing reasons
Permit No. % i Date Issued
----------------------- ---------
�� THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired Upgraded ( )
Abandoned( )by j -
at /11 5&Ldlikwud /41Z �i6riL1/iLl,/!_'Tconstructed
� 3�_7 IYA has been constructted22in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. r" ,R—_ dated
Installer Designer
#bedrooms e � Approved design flow gpd
The issuance of this permi shall)not be construed as a guarantee that the system w14 u i ctio as designe1". lei
Date T�/ ( r Inspector *YW, ��
No. Fee
y THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS
' A%,, n L�
1=i,5possal *V.tem Cott.5truction Permit
Permission is hereby granted to Construct ( ) Repair ( X Upgrade ( ) Abandon ( )
System located at <nv
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions. �-
Provided: Construction must i
/be completed within three years of the da e offer th�i perm' t:�
Date r � '�j /O Approve-by_ r^11
f
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL_ PROTECTION
10AP yta' RECEIVED
PARCEE4 ' ®�
LOT r AUG 2 5 2004
TOWN OF BARNSTABLE
TITLE 5 HEALTH DEPT.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: H7 Starboard Lane
Osterville, MA 02655
Owner's Name: Ruth&Michael Deeley
Owner's Address:
Date of Inspection: August 12, 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 rther Evaluation by the Local Approving Authority
ails
Inspector's Signature: Date: August 12, 2004
The system inspector sha\submi4�
copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
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: 117 Starboard Lane
Osterville, MA
Owner: Ruth&Michael Deeley
Date of Inspection: August 12, 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 I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: H7 Starboard Lane
Osterville, MA
Owner: Ruth&Michael Deelev
Date of Inspection: August 12, 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 with310 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
4
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: 117 Starboard Lane
Osterville, MA
Owner: Ruth&Michael Deeley
Date of Inspection: Au¢ust 12, 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 '/2 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 I 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 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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 117 Starboard Lane
Osterville, MA
Owner: Ruth&Michael Deeley
Date of Inspection: Auzust 12, 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
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Page 6 of I 1
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 117 Starboard Lane
Osterville, MA
Owner: Ruth&Michael Deelev
Date of Inspection: August 12, 2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 2
Does residence have a garbage grinder(yes or no): n/a
Is laundry on a separate sewage system(yes or no): -No [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIALANDUSTRIAL
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: Unavailable
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:
Installed 9123191 -per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 117 Starboard Lane
Osterville, MA
Owner: Ruth&Michael Deeley
Date of Inspection: August 12, 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: 2'
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: 4"
Distance from top of sludge to bottom of outlet tee or baffle: 28"
Scum thickness: 5"
Distance from top of scum to top of outlet tee or baffle: 4"
Distance from bottom of scum to bottom of outlet tee or baffler 10"
How were dimensions determined: Measuring 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.
Recommend installing risers.
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
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r
Page 8 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 117 Starboard Lane
P
Osterville, AM
Owner: Ruth&Michael Deeley
Date of Inspection: August 12, 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: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
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.):
The D-box was level. No solids were present.
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
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Page 9 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: !17 Starboard Lane
Osterville, MA
Owner: Ruth&Michael Deeley
Date of Inspection: August 12, 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'with 2'stone.
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
Innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.):
The-leach pit had 2'ofwater on the bottom. The scum line was at the same level. There did not appear to be any signs offailure.
The bottom to grade was 12'. The cover was 4'6"below grade. Recommend installing risers.
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: 117 Starboard Lane
Osterville, MA
Owner: Ruth&Michael Deelev
Date of Inspection: August 12, 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.
A
O a
GAfA �--
y
3
10
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Page 1 I of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 117 Starboard Lane
Osterville, MA
Owner: Ruth&Michael Deelev
Date of Inspection: August 12. 2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 20+/- feet
Please indicate(check)all methods used to determine the high groundwater 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 Barnstable topographic maps and water contours maps, the maps were showing a roximatel 20'+/_to round 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 andlor this report.
I
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03/11/2004 02:30 5084283526 PAGE 02
Dacng6arO17 03-11-2004 2903
UNSTABLE ILAW MIRT RE61STRY
00
RESTRICTION
0
WHEREAS, Michael Deeley and Ruth Deeley, of Osterville,
Massachusetts, P.O. Box 397, Osterville, Massachusetts, are the
owners of the real estate located at117 Starboard Lane,
Barnstable (Osterville) , Barnstable County, Massachusetts
(hereinafter referred to as "Premises") , and more particularly
bounded and described on Exhibit "A" attached hereto; and
WHEREAS, Michael Deeley and. Ruth Deeley, as the owners of
the Premises have agreed with the Town of Barnstable Board of
Health to a restriction as to the number of bedrooms which can be
included in any home built on said Premises as a precondition to
obtaining a disposal works construction permit in compliance with
310 CMR 1.5. 00 State Environmental Code, Title V, Minimum
Requirements for the Subsurface Disposal of Sanitary Sewage; and
WHEREAS, the Town. of Barnstable Board of Health as a
precondition -to granting a disposal works construction permit- for
a septic system in compliance with 310 CMR 15 . 200, State
Environmental Code, Title V, Minimum Requirements for. the
Subsurface Disposal of Sanitary Sewage, and authorizing the
issuance of a building permit, is ,requiring that the agreement
for the restriction on the number of bedrooms in. any house
constructed on the lot be put on record with the Barnstable
County Registry of Deeds by recording this document .
.NOW THEREFORE, Michael Deeley and Ruth Deeley, do hereby
place the following restriction on the Premises above-referred to
in accordance with this agreement with the Town of Barnstable
Boa.r_d. of Health, which restriction shall run with the land and be
binding upon all successors in title:
03/11/2004 02:30 5084283526 PAGE 03
EXHIBIT ►►A"
The premises commonly known as 7.J.7 Starboard Lane, Osterville,
being the land and improvements thereon situated in Barnstable
(Osterville) , Barnstable County, Massachusetts and more
particularly bounded and described as follows:
NORTHEASTERLY by Starboard Lane, two hundred ninety-
eight and 16/3.00 (298 . 16) feet;
SOUTHERLY by land now or formerly of' Donald Kirk
David, about five hundred ninety-three
(593) feet;
WESTERLY by North Pond; and
NORTHERLY by Lot 3, about three hundred ninety
(390) feet.
All of said boundaries, except the water lines are determined by
the Court to be located as shown on Plan 19680-A dated January 3,
1947 approved by the Court and filed, in the Land Registration
Office at Boston, a copy of which is filed in Barnstable County
Registry District of the Land Court in Land Registration Book
177, Page 5 with Certificate of Title No. 2335 and said land is
shown thereon as LOT 4 .
03/11/2004 02:30 5084283526 PAGE 04
I . The dwelling constructed on the Premises may have not
more than four (4) bedrooms .
2 . This restriction, shall continue in full force and
effect until such time that the Premises is connected
to Town sewer or the construction of a .residence with
greater than four (4) bedrooms is allowed as of right,
at which time this restriction shall become null and
void.
For title to the Premises refer 'to Barnstable County
Registry District of the Land Court Certificate of Title No.
164254 .
Executed a ealed instrument this
2003. " day of December,
l
Michael .Deeley Ruth Deeley
Commonwealth of Massachusetts Barnstable, ss:
On, this L' Iday of December, 2003, before me person.a.11y
appeared, Michael Deeley, to me known to be the person cribed
in and who executed the foregoing instrument, and a nowle .ged
that he executed the same as his free act and deed.
Notary Public
My Commission Exp:
Commonwealth of Mass,achuse'tts Barnstable, ss :
�jT
On. this 10 day of December, 2003, before me personally
appeared, Ruth. Deeley, to me known to be the person. described in
and who executed the foregoing instrument, and acknowledged that
she executed the same as her fre act and deed.
}
Notary PublicfS-
My Commission Exp: k.lr� �v�y
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION s
Property Address: 117 Starboard Lane
Osterville, MA 02655
Owner's Name: Alden Zieman 4
Owner's Address: Same
Date of Inspection: ',January 15, 2002
Name of Inspector: (Please Print) James M, Ford
Company Name: James M. Ford- Map: 165
Mailing Address: P.O. Box 49 Parcel: 77
1 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 they 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:
t ✓ . Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails ,
Inspector's Signature: Date: January 16, 2002
The system inspector shall submi copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be`sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority. ,
-
Notes and Comments "
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
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
_m CERTIFICATION :(continued).. .
Property Address: 117 Starboard Lane
Osterville, MA
Owner: Alden Zieman
Date of Inspection: January 15, 2002
Inspection Summary: Check A,B,C,D of E/ALWAYS complete all'of Section D
A. System Passes: 4
✓ 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.
t
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. t
*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. v
s
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' a
obstruction is removed
ND explain:
2 -
-
Page 3 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued) `
Property Address: 117 Starboard-Lane;
Osterville, MA
Owner: Alden Zieman
Date of Inspection: January 15, 2002 .
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 15.363(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 s -
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
: a
2. System will fail unless the Board of Health(and Public Water Supplier,if any)Aetermines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has 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: .ry
The system has a septic tank and SAS and the SAS is within a Zone'l;:of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a:,
private water supply well". Method used to determine distance
"This system passes if the well water`analysis,performed at'a DEP certified 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: , m
3
Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued) f `
Property Address: 117 Starboard Lane
Osterville, MA
Owner: Alden Zieman
Date of Inspection: January 15, 2002 ; 's
D. System Failure Criteria applicable to all systems: n
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 ''/z day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ 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 conform 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 I1 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 k
Page 5 of 11
OFFICIAL INSPECTION FORM-'NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 117 Starboard Lane
Osterville, MA
Owner: Alden Zieman
Date of Inspection: January 15, 2002
Check if the following have been done: You must indicate`eyes"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)].
I
5
Page 6 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 117 Starboard Lane
Osterville, MA
Owner: Alden Zieman
Date of Inspection: January 15, 2002 +
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): - 330
Number of current residents: 1
Does residence have a garbage grinder(yes or no): Yes
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): 2001 -100,000 gals.;2000- 73,000 gals.
Sump Pump(yes or no): No _
Last date of occupancy: - Currently occupied ,
CONEVIERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd r
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: None on file-per treatment plant
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: Qallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM _
✓ Septic tank,distribution box,soil absorption system -
Single cesspool t
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:
Sept. 23, 1991 -per as built card
Were sewage odors detected when arriving at the site(yes or no): No ,
6 ,
I
Page 7 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued).
Property Address: 117 Starboard Lane
Osterville, MA
Owner: Alden Zieman
Date of Inspection: January 15, 2002 a
BUILDING SEWER(locate on site plan)
Depth below grade: 3'
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: 2'
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: 1"
Distance from top of scum to top of outlet tee or baffle: . 10"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How were dimensions determined: Measuring 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 were no signs of leakage. Recommend installing
risers. -
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 bathe condition,structural integrity, liquid levels.
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 117 Starboard Lane
Osterville, MA
Owner: Alden Zieman
Date of Inspection: January 15, 2002
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: Qallons/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: ✓ (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.):
Unable to locate or find the D-box.
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: 117 Starboard Lane
Osterville, MA
Owner: Alden Zieman
Date of Inspection: January 15, 2002
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required),
If SAS not located explain why:
Type
✓ leaching pits,number: 6'x 6'with 2'stone
leaching chambers,number: ,
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number: -`
Innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
The pit had 6"of water on the bottom. The scum line was at the same level. There were no signs offailure. The bottom to grade
was approximately IT The cover was 4'6"below grade, Recommend installing risers.
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: e
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: 117 Starboard Lane
Osterville, MA
Owner: Alden Zieman
Date of Inspection: January 15, 2002
Map: 165
Parcel: 77
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.
ea
A
a
O a A3. q_7
{
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: 117 Starboard Lane - -
Osterville, MA
Owner: Alden Zieman
Date of Inspection: January 15, 2002
SITE EXAM ."
Slope M
Surface water '
Check cellar
Shallow wells
Estimated depth to ground water 20' +/- feet (Adjusted High Ground Water Level: 15.8)
Please indicate (check)all methods used to determine the high ground water elevation. Y
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:
The bottom of the leach pit to grade was approximately 12'. Using the Barnstable topographic map and the Cape Cod
Commission water contours map, the maps were showing approximately 20'+1-to ground water at this site. Using the Cape Cod
Commission Technical Bulletin, the high ground water adjustment for this site(MI W 29, Zone B, 12101)was 4.2'.
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.
• U
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I
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o�0. 0 roue C�wATE r 1 eve I
COMMONWEALTH OF.'MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE.5
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
r PART A
CERTIFICATION,
Property Address: 117 Spice Lane -
Osterville..MA 02655
Owner's Name: Richard Carvlei.
Owner's Address:`
Date of Inspection: OctobIor 26. 2012 .
Name of.,Inspector: (Please Print) Antes M. Ford
Company Name.: James M Foal
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 pwage'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 perfonned 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:
C i.l .Passes
Conditionally Passes
ds Further Evaluation liy the Local Approving Authority
F.:i s
Inspector's Signature: Date: November 5; 2012
The system inspector shall sub it 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 inspectorarid the sy'stetri 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. I:Ni 'r
Notes and Comments
_s
****Tliisn•eport only describe's 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 udder the same or different
conditions of,use: t :
` Title 5.Ilispection,Forni 6/15/200Q�j" la,. page 1
i
Page 2 of 11' rt
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
+j+: PART A
CERTIFICATION (continued)
Property Address: 117 Spice Lane
Osterville,MA
Owner: #, ;, Richard Cawlev
Date of Inspection: October 26, 2012
R,
Inspection Summary: Clieck 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
; t
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,staiements::If"not.determined",please
explain.
Jor
The septic tank is metal and'over 20 years old*or-the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltra.66 i 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. E;?,
- .: .,, . tit el.t�.tl •.. �'•,.:![ ,l� 'S'1�6, ;. . ,-
Page 3 of 11
i
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION`FORM
PART A
' t CERTIFICATION (continued) .
Property Address: 117 Spice Lane ;
Ostervdle,MA -
Owner: Richard Cawley
Date of Inspection: Octobe7-"26, 2012
C. Further Evaluation is Required by the'Board of Healthy
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.
l
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 liealth,safety and the'environment:
Cesspool or privy is withii150 feet of a surface water
Cesspool or privy is;withiri 50 feet of.a bordering vegetated wetland or a salt marsh
ul
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:,
![l The system liar a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or,t>>butaiy to a'surface water supply.
r c+j-•Hhe system has a septic tank and SAS and the SAS is within a:Zone 1 of a public water supply..
!!its as L ,:The system has aseptic tank and SAS and the SAS is within 50 feet of a-private water supply well.
The system,ha.s aseptic tank and'SAS.and the SAS is less than 100 feet but 50 feet or more from a
private Water'supply'well..1 Method used"to determine distance
*This system passes if,th6,well.water analysis,performed at a DEP certified laboratory, for coliform
bacterid,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.Acopy of the analysis must be attached.to-this form.
3. Other
1`r ter if t9:as: iit•.111h V t1'r1'
t. t 1'CI ltr.is"
3
,I
Page 4 of I
k;OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
t SUBSURFACE"SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
.CERTIFICATION (continued)
Property Address: "71 Z SyiceLae
'Osterville. MA
Owner: Richard Cawlev
Date of Inspection: October 26, 2012
D. System Failure Criteria applicableJo all systems:
You must indicate either"yes"or"no"to each of the following for,all inspections:
Yes No -
!1f 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
✓t rR . Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS1 or .
cesspool
✓' Liquid depth in cesspool*s less than 6"below invert or available volume is less than%z day flow
V Required.pumping more than 4 times in the last year NOT due to.clogged or obstructed,pipe(s). Number
of times.pumped
✓chi ;Any portion of the SAS,cesspool or privy is below high groundwater elevation.
✓ Any portion,o f 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
t`Idhr ``supply well with no`acceptable water quality analysis. [This system passes if the well-water analysis,
performed at;;wDEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates thaLilie..ii' 11,is free from'pollution from that facility and the presence of ammonia
' lnitrogen arid.nitrate';iiitrogen is equal to or less than 5 ppin,provided that no other fail ure.criteria
7 are triggered.,'A copy of the analysis must be attached to this form.]
No (Yes/No),Tlre.system fails I 1iave 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.whatwill 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 .M
You must indicate either"yes',?or no-tito each of the following:
(The following criteria apply,to;ldrgeisystems in addition to the,criteria above)
Yes No_.• ,t' tt: ` I�
_ the system is;.within,•400 feet of a surface drinking watersupply
the systern,iswithin 200 feet of a tributary to a surface drinking water supply
the system is.16cated`.in a;nitrogen sensitive area(Interim Wellhead Protection Area IWPA)or a mapped
Zone II of a public watersupply 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 l.arge)'sys;tein has Mailed. 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:
j. �41
Page5of.11
OFFICIAL INSPECTION'FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.B
CHECKLIST
Property Address: '117 Svice Lmie '
Osterville.MA`
Owner: , - Richard Cawlev
Date of Inspection: October'X 2'012 t
-
Check if the following have been done: You'inust indicate"yes"or"no as to each of the following:::
Yes No
✓ .is 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?
i v1I .. Have large volumes of writer been introduced to the system recently or as part of this inspection?
✓ I,} ;,Were as built plans o9helsystem obtained and examined? (If they were not available note as N/A)
Was the facility oildwelling inspected for signs.of sewage back up?
Was the site inspected for,signs of break out
✓ E�• `!1l 1"Were all system conip,onenis,excluding the SAS,located on site
✓ Were,the seitic tank manholes un'covered,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?
✓ i, r1.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 s
✓ Existing information•-1RFor example;a plan at the Board of Health.
✓ Determined in''the.field Gf anyof the failure criteria related to Part C is.at issue approximation of distance .
is unacceptable) [310 CMR 15.302(3)(v)]
f
HIV _ }9iGa lsl.�,.ti -
.. - NSF..
Page 6 of l l !:,
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE`SEA AGE DISPOSAL SYSTEM.INSPECTION FORM
PART'C
SYSTEM INFORMATION
Property Address: 117 Spice Lar{e_
Osterville, MA
Owner: 'Richard Cawley
Date of Inspection: October 26, 2012
FLOW CONDITIONS
RESIDENTIAL`. r `. :•
Number of bedrooms(design): 4 Number of bedrooms(actual):' 4
DESIGN flow based on 310 CMR 15.203 (for example' 110 gpdx#of bedrooms): 440
Number of current residents: 0
Does residence have a garbage grinder(.yes or,no):, N/a
Is laundry on a separate sewage system.(yes or no): . N/a [if yes separate inspection required]
Laundry system inspected(yes or no): 'uzo
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: Unknown
COMMERCIAL/INDUSTRIAL'Il
Type of establislunent:
Design flow(based on 310 CMR 15.20,3) „' gpd
Basis of design.tlow(seats/persons/sq/ftetc'):
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;(desciibe):
r e, tie. .c'+' ;�s: GENERAL INFORMATION
Pumphig Records.:: �t ', 1 4.
Source of information: Unavdilable dx
Was system pumped as part of the inspection(yes or no): Yes
- t
If yes,volume,puraped: r,.r gallons--,How was quantity pumped determined?
Reason for pumping; Maintenance r,
TYPE ,.OF;SYSTEM
Septic.aank;distribution,box,`soil absorption system
i-Single;cesspool :t?r n -
Overflow cesspool r
Shared system(yes of_no) (if,yes,attach previous inspection records,if any)
Innovative/Alternzttiveftechnology. Attach a copy of the current operation and maintenance contract,(to be
obtainedtfroin'sy'stem.owner)
.:Tight.Tank. .Attach a_copy of the e DEP approval
Other(describe)a:;,I` IF i•cJxr.i ,;;
t; a zl: ;'l Crs III ll, -
Approximate age of all co date] talled(if known)and source of information:
Date of:i»s't611ation.1130/99 per as-built curd
Were.sewage"odors detected when arriving at the site(yes or no): No
zJ
6.
a4 lay trign
T
1
Page 7 of 11 1 .:
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART_C
SYSTEM INFORMATION (continued)
Property Address: :117 Spice Laiie
OseJville.MA
,..+
Owner: Richard Cawlev .
Date of Inspections October 26, 2.012
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(6n condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade.;, 30" -
Material of construction: ✓, concrete; metal fiberglass -Polyethylene
-
_othe (explain),
If tank is metal list age: Is age confitined.by a Certificate of Compliance(yes or no (attach acopy-of
certificate) . a ;
Dimensions: 1500 gal.
Sludge depth11rs":,; 2't
Distance from top of sludge to bottW` f! utlet tee or baffle: 30"
5 - -
Scum thickness: 2"
Distance;fromatoplof scum to top;{o'f outlet„tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How were dimensions determined: Measuri.nQ stick
Comments (on'pun'ping recommendations,inlei and outlet tee or baffle condition,structural integrity;liquid levels
as related to outlet invert,evidence.of leakage etc.).
The teesuvere vi�esent..The liquid level was even with the outlet invert. Theme did not appear to be any signs of leakage
Tlie i'rzlet covet,,vvas 6"beloiv Qi'arle�.,}
GREASE- TRAP 1•':None (lo'cate o1i'site plan)
Depth below grade:
Material of construction: —concrete._metal _fiberglass; polyethylene :_other
(explain): ! fr i:-
Dimensions:
Scum thiekhess::..lc:: .
Distance fromitop,of scum to top:a outlet tee or baffle:
Distance from!bottom of scum.t.o:bottom of outlet tee or baffle:
Date of last:puiipilig:
Continents(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity liquid levels
as relatedito outlet invert;evidence of leakage,etc.):
tier
oi
! Yli(iW%,11 J.i, !l .ii' 1{6tjkjlI-! . 7
Idi COO.;96..Ilit'
Page 8 of 'I
OFFICIAL•INSPECTIQN FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
. t PART C
f'SYSTEM INFORMATION (continued)
Property Address: 117Spice-Lane
Osterville,AM
Owner: 'Richard Cawley
Date of Inspection: October 26;2012
TIGHT or HOLDING TANK: "Norie (tank must be pumped at time of inspection) (locate bn site plan)
y
Depth below grade:
Material of construction: _concrete ._metal _fiberglass '_polyethylene _other.(explain):
Dimensions
Capacity: •` t l
p ty: gallonsG
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alartri.in working.order(yes or no):
Date oflasf,humping:
Comments(condition of alarm and float switches,etc:):.
DISTRIBUTION BOX: ✓. (if present`must be opened)(locate on site plan)
Depth ofliquidtleuel above outlet inyett;;,.Even '
Comments(note if box is level aiid dtstriUurion to outlets equal, any evidence of solids carryover any evidence of
- leakage into or out of box,etc'),-.
The D-box.ivas n6ri ial. There wasp no.§,b �of failure fi-om leach•f eld
PUMP CHAMBER: None' _(locate`:on site plan)
Pumps in:.working,orde'r(yes cfiio)
Alarms in-working.order(yes,orno)
Comments(note condition of pump chamber;•condition of pumps and appurtenances,etc.):.
A.
j.
I'
4 l.:r 4 .i .. .. .. ...
Jos
8
V f.
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLU WARY ASSESSMENTS
SUBSURFACE,SE'".AGE DISPOSAL SYSTEM INSPECTION FORM
PART C`
SYSTEM INFORMATION (continued)
Property Address: 1.17 Spice Lane
Osterville,`~MA
Owner:, -Richard Cawley
Date of Inspection: October 26, 2012
SOIL ABSORPTION SYSTEM (SAS): ✓. (locate on site plan,excavation not required) .
a
If SAS not located explain why:
t
Type -
leaching pits,number:
✓ Teaching chambers,number: :3- inf ltrators with stone. Per as-built
leaching galleries,number:
-leaching trenches,number, length:
leachmg:fields,number�.dimerisions t;
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.),.
_77rere did not appear to be any signs of failcir•e from infiltrators
CESSPOOLS: None (ces5poolmust: e pumped as part of inspection)(locate on site plan)
17
Number and:configuration .
Depth- top of liquid to inlet invert
Depth oflsolids Payer; k .
Depth of scum layer.
Dimensions of cesspool:
Materials,o.flconstruction: tv.
Indication of groundwater inflow(yes or iio):
Comments (note condition of soil,sigp§of hydraulic failure,level of ponding,condition of vegetation, etc.)'
PRIVY: :.,.'None.; locate on site plan
Materialsfof construction:
Dimensions.*.:h }et 1r 713,z,: t l t.;ilS)'r
Depth of solids:-At
Commentst(note,.condition of soil;signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
K tYat`1..t' r St�f 1r
1'<dut�lt r: 9
7 Y
h
Page 10 of 11
OFFICIAQNSPECTION FORM:NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
_ SYSTEM-INFORMATION continued
Property Address: 17 Spice Lane
Osterville, MA '•
Owner: =Richard Cawley
Date of Inspection: 4 October26, 2012
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'l00 feet. Locate where public water supply enters the building.
e
O �
y �� rt� ;� -� ,� lt.'` ,�1,,� + �� ►y as
' d tr ar:� G
f1
LLfA i' , 10
T'
Page l l of 11
V � a
OFFICIAL INSPECTIbN.FORM=NOT FOR VOLUNTARY-ASSESSMENTS
<SUBSURFACE`SEWAGE DISPOSAL SYSTEM INSPECTION FORM
k PART C
{ SYSTEM INFORMATION (continued)
Property Address: 4 H7 Spice Lane.
Osterville;MA
Owner Richard Cdivler
Date of Inspection: October 26, 201:`?
SITE EXAM ; t
Slope
Surface water
Check cellar
t
Shallow.wells
Estimated•depth to?ground water 40+1- feet -
Please indicate (check) all methods used to" determine the high ground water elevation:
t .
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:_. Topoizraphic and water cohtours•maps
Checked with local excavators,'installers-(attach documentation)
Accessed USG$ database-explain:
You must describe how you establ>shedllthe high ground water elevation:
Using Barnstable W oer hi,cLund water contours inaps, the nia-ps were showing appr&61idtely 40 +/-to.grourid water at this..
site.. _::..tc l t I•_• .
•t,
Y.
This report has been prepared only for the septic system �iid components described he'rein. This septic system.has been.
inspected nird passed as of t/ie date of inspection. This report is not a tear ranty of guarantee that the system will.
f mction properly ire thg f qq el ,Thei,e hove been no warranties orguarawees, either e' ressed written'or�inIplied,. .
relatingtto t ire sepucdsysteln the rrxspection;this report andlor any compoiiehts of the:septic system.which have not
been located and.rnspected
1
t7yll.r_' tc t.�PY11
SMOKE DETECTORS ��'Oy1 NEW VAHIrr
NEH 48'.51' DRE991NG rADLe
• {/I/�[\/ ^ (/ FIG
S .REUSE IX.NDW FROM LIVING RM.
.. `• _ PE EX.--FROM LIVING
BARNSTABLE BUILDING G`�•P� RENOVATED
_ rl- BATH
EN BIDET•WC -CAT"CLG. _
i-
_------ —1 E EX.HOW
FM M M.BEDROOM
EfI ED
EC.CLOSET
II II _
. LAUNDRY CLOSET
RENOVATED TO BE Rn+O'vATm
KITCHEN PER ONNERSDIRECTIOL _
BY OTTERS
V
• R (ATF,t V
N. BEDRdd�1 IIIuF---V
NCW VAULTED CL:..U=
NF1M -I 5/4')111 710•LII i. FV 7/12 PITCA INSIDE F BwM ABOVE 33. 4.6 SOLID W Q
a TO FAD. Z REMOVE E%.
HDH-TO BE
REUSED
n .-J
L3�,q 7
M lOL DOOR9 TO.RE7INN
it-PLELOAR
NEID
lT
EX.FT r
/RENpyA= -+ N_E__
LIVID.R ��Z W G4s •O.
--1-7
NEW VAUC.TED CL., FIREPLACE yJ
_ FRAME*IN P �!ypENGn wlerl M
• 71�.MYCM IMSIDE ' MFR 9PCC9
4/y r I
It MA REpAL{EMENr DOORS
1 " G
v RErLACE EX. DOORS u✓
NEH FRENDL DOORS - MA REPALCEMENT DOORS
14-2 1/4'2 ..-,o I/2'S
A Z A 1$1 .. .. RETAINING WALL Tj
. C________Z INDICATES HALLS TO DE REMOVE
PROPOSED FLOOR PLAN suLE,v�•.r_o. �� INDICATES MEN HALL CCHSTItUCTIOI
® INDICATES OL.WALLS TO 8E RERENOyATED(EXTENTED TO FULL HT.)
0 INDICATES EXISTING WALLS TO REMAIN
/
TOWN OF BARNSTABLE - `
LOCATION T_rA/BOA/,J /4eJL SEWAGE # _'I 1" '401
VILLAGE O rrin, ASSESSOR'S MAP & LOT /6 S 0_71
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY /OTJb 6/a
LEACHING FACILITY: (type) (0 X(o ,(size) e1 SrO�
NO. OF BEDROOMS 3
BUILDER OR OWNER
PERMITDATE: 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 lea hi g facility) Feet
Furnished by -Ifcc�lbh '
st ORS-9
Via- a�
Oa
q3- ti-7
(33- 1-7
Ay- y6
GAfA ¢-
3
TOWN OF BARNSTABLE
LOCATION LA SEWAGE # T D
VILLAGE 5 -- '� ASSESSOR'S MAP Q LOT
INSTALLER'S NAME & PHONE NO. i-�1Qk )(—, Cam*
SEPTIC TANK.CAPACITY
LEACHING FACILITY:(type) P (size) 0t?-P�
NO. OF BEDROOMS_ PRIVATE WELL R PUBLIC WATER
BUILDER O O N
-- t
DATE PERMIT ISSUED: 'tp c
DATE COMPLIANCE ISSUED 1
VARIANCE GRANTED: Yes No lz
{ 3
♦ C
l
a
l
t
• �� • Y7 q 7
Nof ....::�2 7 Fms
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Applira#ion for Biipuaal Works Tnni#rnrtinn ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
Location-Address or Lot No.
...............� pz`..........:Z\�t��rJ................----------------. .............................................................................•....................
Owne Address
a k.lC\�t� ��v s� �'% S.l �- L= l!`Z ?� .
-•- •....-•-••--•--........•••..............•---...........-•-•--....... --.......
14 Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling No. of Bedrooms............................................Ex Expansion Attic a g— p ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures --------------------------------------------------------------•---•---•----------------- --------------•--•-••----•-•••-•-•-•---..................--••
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid'capacity............gallons Length............... Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
� Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water--_-____________-_-__.
4A Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................
9 ----•-•--•----------•-------------------•--------•••--••-- --•••-•-•-•-...••-•••-•----......................................•-•••--••--•--•--•-•...---....--
O Description of Soil...... = Z•...----•S v a =S�l ............ Z - •`-Y- C Lkq^) /-' t �
x ----• --..-•-- -•----
U •-••-•--••••----•------•-•-•------•-•-••••------•----•-•--------•-•--•-•---•--••--•....................••-••-•------••-•••-••-••---•---.........----------••......••...
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•- ZEu
U Nature of Repairs or Alterations—Answer when applicable---jF k�-____-w______--.- �`�s_1. t_._.____�g� Pao �,�
t'"STWt--�. VN
•-•-- .. .._ 3 ^' too ao P ..._.
Agreement: '
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been is ued bV the board of health.
Signed . ..........
Date
Application Approved By c - ................... z �'�
Application Disapproved for the following reasons- -------------- ----------------------- -------------------------- ------- - --------------------=-
...................... --- ----------------....-----................... ----------.....---........................----....................----- -----...-------------------------------- - ........................................
Permit No. ...c --
-I � ..��T] - �-----
_ Issued -- ------------------------ -------------------------to
.------------ ------
Date
i
r.
THE COMMONWEALTH'OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Disposal Works Tnnstriirtinn Permit
_ Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
4 ..._ �T..... o.f�. .-•----•-`.... ........................................'-=--•.......................... --........._ -.-_..------------...•.........-•-............
Location-Address or Lot No.
..•-•---•-•-•• ��----.....2 �M Iv-- -•---^--...-.•..........._.....
Owner.— Address
Installer Address
Type of Building - Size Lot............................Sq. feet
aDwelling—No. of Bedrooms....................._.......................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures --------------------------------------------------------------•---•---------•--------------••----•-•-•---------------------•-----------••....._--•-•-
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
W Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter-------------------- Depth below inlet....._.............. Total leaching area..................
sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) I,
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.-......................
RS ---------------------------•--------------------------------------•--- •---------------••--•••••---------•---•--------•-•-•-----••----•-••------•••---__---.
O Description of Soil...... = ............... =S-OI`' ......................-`_--- = '-�/- (I��^� /--7 -D �
x ----- ----------------
V --•----------------••--------•---••-•-•••---------------------•----------•-•----------------•-------------•-------------•------•-••-
UW Nature of Re airs or Alterations—Answer when a licable'_ \\..____�_w__.__--_---.�`�5.....W.---__--__�'
P PP. -=. .............................................a_.w..... � . ��` A^� . s°�0 P`� `��
...........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been Lisrued b the board of health.
Signed.... --P�, ........\. �........ ..........
Application Approved By ---- 5 u' _.._...............: ------------....---......... t vX/<�---------------
^i .
-
Application Disapproved for the following reasons- --------------------------------........ ------....--- --.............---........-- --..--....--- --------- ---------
-------------------------- ..-----------------------...............----------------------------------------------------.................................. ..............................
Date
PermitNo. 1.-f �.().7.................................. Issued -------------------................................... n
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
C�ez#ifira e of C�omyItttnxe
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired )
by ----- �c\ 4-------------Cb rJ Ste'
-
Installer
at .-- ........SRr y23o C��---..... -J tv -------------------- Q S
.................. .....................----------------------------------------------------------------------------------
a been installed in accordance with the provisions of TITLE �f Th��t Environmental Cod d cribed in
the application for Disposal Works Construction Permit No. .... ......��.�..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION S TISFACTORY. �
DATE �`I.'f � (.`-
....... ......... ---------.::.........-..-----------------------------------� v� ' - Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No.... �.-_�1�� TOWN OF BARNSTABLE FEE.... .D.........
Disposal Works Twonotrnrtioon "permit
Permission is hereby granted..._.._��0—.:_.`.f.......... ..................
to Construc or Repair an Individual Sewage Disposal System
P g P Y
at No...........P.3------ � ................._fi r.) OS�
Street qq
as shown on the application for Disposal Works Construction Permit No.__!.__f 92._ Dat�...9�J�9/
/ ---
2 c� / _
t G� -- --- Board of Health
DATE............. ------••--•--------- --••----`--
FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS
t . J TOWN OF BARNSTABLE
LOCATION 7 � ¢ (Z,Q (,,/� SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT/(a 5— 7�
INSTALLER'S NAME & PHONE NO.('ItAP) CpJ
r
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) MA-le-- C.P55F00L-(size)
':NO. OF BEDROOMS PRIVATE WELL O UBLIC WATER
BUILDER OR OWNER XLDe4\ / ?,lE-A44P,4
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
a
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ks
i
..s: ,fir:.-7`r34i,_' +tt; ... . ..,,.. „. .._ryt",-:::, M'r,rr=!Tp `�'"„+:h` -..;.� i F -it'.r ':K,., -k+:rtry4. "b .;..•y,t'-,C.+y. t .y-.,*1.- - +ra's,$ ,i.r.
TOWN OF BARNSTABLE — UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
OWNER AND .INSTALLER INFORMATION +i
v) -7
ADDRESS: MAP NO. PARCEL NO. a
OWNER NAME: etl, a)ld : llozd(r VILLAGE:
k /
INSTALLATION DATE: 1 f fA ire Y:
Se i N
0 ,+�rl�- r 1� �/J TANK INFORMATION
LOCATION OF TANK: f✓"ta/ r
CAPACI-TY .
,r/)^ 0A ' TYPE- Ttal t" AGE J2 a/ FUEL/CHEMICAL t a!!L
TESTING CERTIFICATION.5 C�,.] `'PASS C ] FAIL DATE
y.,. E 44+j n4.,11-31".:n m'R�tL t2 v a<qw�Y
LEAK DETECTION C)] CHECK>'NIF N®A TYPE/BRAND ! ® yo '
ZONE OF CONTRIBUTION C ] YES C NO 'DATE TO BE' REMOVED o
FIRE DEPT. PERMIT ISSUED C' ] YES C NO DATE -
LUNSERVATION , C}(] CHECK IF N/A DATE
BOARD OF HEALTH TAG NO.W& ]C ]C ]C ] DATE
e.-V
PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON T�E BACK OF THIS CARD
�Uv5e-
' F
X /v
mew '
ROOF—.. '"C(�N'r'R+DGE VEND
2.:; RIDGE
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