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HomeMy WebLinkAbout0128 STARBOARD LANE - Health (2) .28 STARBOARIP LANE, OSTERVILLE E, 'S, No. `g 7 /—[ � Fee Gov THE COMMONWEALTH OF MASSACHUSETTS ' ` Entered in computer: is Yes i PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS Application for Mi5poar *pgtem Con.5truction Permit Application for a Permit to Construct( )Repair(X4 Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ,2 Q� 5�Q��14 fL L A�`U f, Owner's Name,Address and Tel.No. V, cC1 Assessor's Map/Parcel ` i C(,A�£ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. es i 'Q AK,\Te4i'4'1G tr,4L 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 1 t Q gallons per day. Calculated daily flow i\ gallons. Plan Date J A&A 13 09�"7 Number of sheets 1 Revision Date Z 3 1,2 7 c_3 19/97 Title 1 i_ PL'A� y P 12 S i;t Ar2Y� L�G Size of Septic Tank i SX)C) Type of S.A.S. T 1'GVLY_L\ 1 v A x 4.0 Description of Soil b' 7,N,Z. i 5 S-r=JL-M 5, sCMA r= t LC_ C')- 3 \2.- A, 15r4U OK LCb4-\v-- 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 th Environme tal Code and not to place the system in operation until a Certifi- cate of Compliance has been isVby�_t_ois o a Signed Date Application Approved by Date 3" D 7 Application Disapproved for the following reasons Permit No. 9 7—133 Date Issued 7 97 7.5 No. / ,{, �:,y P Feed= / COMMONWEALTH OF MASSACHUSETTS "Entered in computer: PUBLIC HEALTH DIVISION'-TOWN OF BARNSTABLE, MASSACHUSETTS Ye / 1 l 2pprication for Migpogar\ipgtem Construction Permit Application for a Permit to Construct( )Repair(XUpgrade":.(,,-' Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. \2 ,S�����.2 J Lq� Owner's Name,Address and Tel.No. OSI `L E,, nj�)G cEZ Y,csr..Erc.. C Assessor's Map/Parcel- ..�w�P/ 5 5 °� C:l�t_JIF V Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. SAx ,2 )V1)CE NA L Type of Building: Dwelling No.of Bedrooms Lot Size k,9G sq.ft. Garbage Grinder(f� Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures /}. e� Design Flow gallons per day. Calculated daily flow gallons. Plan Date 7 Number of sheets Revision Date 2 13 19( ` Title Gate;' a c ai n5 c>F 12 93 5 74s e-W A\-L o LAYU ,. t Size of Septicfi'ank,. V 5-) Type of S.A.S. �'2 aAaL t.\ 1 X A X 4 O Description of Soil Z r. 1�3 EGJLE c ScwM Z tr Cl-5" 3'\"�„ 544YU ON( L6 Avg t Z 1b $ LOA"A C_ kM E3 5Ak)%D 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 a;in accordance with the provisions of Title 5 of the Environme,tal Code and not to place the system in operation until a Certifi- cate of Compliance has been iss by t 's of al // c Signed /J Date z9 - j Application Approved b Date_ Application Disapproved for the following reasons Permit No. 9 7—/3 3 Date Issued 3 _7 A- 97 - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ) Repaired( ) Upgraded( •° . 4. Abandoned( )by at rr S- w�.�a...J �a. _ U-��G�.�/i��' has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 9 7` (3 L dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date_ Inspectors No. 9 r 3 3 Fee �Uy THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Xigpogar *pgtem Conztruction vermit Permission is hereby granted to Construct( )Repair(X)U grade( )Abandon( ) System located at /2 �,� I�(y 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 be completed within three years of the date of this Date: c)- 9 7 Approved by l- r 't No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes G_ PUBLIC HEALTH DIVISION - TOWN Of BARNSTABLE, MASSACHUSETTS 4pliLation for MisposaY16pBtem Construction Vermit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. /02 8 S 7-c..-6 c- LAt/ Owner's Name Address,oq �d Tel.No. 4 `618l-,S`B a3 os7'e:n.."(la Sob.. L'b�glo,h Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address,ancTel.No. '$�c_c. Ctoc�l(,au! sae-3a6- Cq�� s; w s�,i�G sa8- `fdQ:3Q�f�f 8,1LTo d 1111�t_ O�T�+r.,��� 3Q6b ,?3 l.ucSTBc CST Type of Building: Dwelling No.of Bedrooms y��J Lot Size a�j IaO sq.ft. Garbage Grinder(X" Other Type of Building ,S,rlc,/IZf/o Q No.of Persons Showers( Cafeteria(+(rtl) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date /4ft(y,a0 Lb Number of sheets ( Revision Date Title Size of Septic Tank /PO O G41 Exf,%77 ,/ Type of S.A.S. Description of Soil / z Nature of Repairs or Alterations(Answer when applicable) =ilk/a- .np Scc_;cr ( 11 0-0 A^- ILt#-J '4tc *-or t-tL9—L,,&3 &q=L-_�� Co Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board f Health. Signed AjiDate JL Aec��,a�/©/ Application Approved by Date Fp Application Disapproved by Date for the following reasons Permit No. 0761�'l Z Date Issued No. t'/ Fee �V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: V r PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE,4NIASSACHUSETTS Yes �• 4plication for 0sposal 6pstem Construction Permit Application for a Permit to Construct Repair Upgrade Abandon pp ( ) p ( ) pg ( ) ( ) El Complete System 2 Individual Components Location Address or Lot No. 0 5 r`c�r ca. L n Owner's Name,Address,and Tel.No. 6. • E3(-5�� Assessor'sMap/Parcel W _ 5 S-^ $ crc•��n� [n, p ,`fir"(Ir Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. 1 r�Gc \Ac, CAP(. S"ry `.3??4t -BC Type of Building:_ Dwelling No.of Bedrooms ,,VIA Lot Size �7�f�[j sq.ft. Garbage Grinder(/-✓t) = Other Type of Building : jr,, `5 yo y No.of Persons .i Showers ` Cafeteria" --• .��� C�i�) (tip - , -- Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date 1''l 4-t 1 -Z G I Pa Number of sheets I Revision Date Title Size of Septic Tank /SG O CA/ e`r r si.. .,Type of S.A.S. i«nr��_ `/�S?�n r Y 416 Description of Soil Nature of Repairs-orAlterations(Answer when applicable) i rI S(���,, wti c r ( , . v v� R r 5J t 4 � \G C"'.c,-�'".�+t,�^.. �X\.0 i•I.�C-' Sc���F � .1,� 2`c:1 rYl�;., n C-C'_fC_c`r !7 C 4`�C CC" . Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on site sewage disposal system in r` „ accordance with the provisions of Title 5 of the Environmeirtal Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date ai.arc 9 K n?GfR ' Application Approved by .r►""'..« _ dl Date (�•-��'f -Application Disapproved by ; Date for the following reasons Permit NO. L1 ' t 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(1--)- 'Abandoned( )by S`m)p-r��; c Cu r1 S at . t -S'Tr, r�Ac�c_,4-1" ,�, lery Ir has been-constructedin-accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ,r2Of S-1 01'1 dated Installer r-O(�-�'IQ �'( , S i ( Designer C 0 r- 5 r y t ~ #bedrooms ll� Approved design flow N. gpd 'The issuance of this permit shalI not be construed as a guarantee that the system will function designed. ' � 1�, Date Inspector No.` D 1 Fee (5C) THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS ]Disposal 6pstem Construction Ver it Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) i I System located at 0 Q, Slf•ve,. J/rt C' •T�okl /1r�.S.�l /i 1SF/O/� /u L.XIf it 5�/rr� c !G✓th- and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. k Date " xs Approved by 'L''� V Commonwealth of Massachusetts, µ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not fo`r Voluntary Assessments 128 Starboard Lane(Main House Right Side) - Property Address Roger Kessel Owner Owner's Name information is y Osteryille MA 02655 Jul 15 2014 required for every , page. City/rown 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:out f rft A. General Information filling out forms A on the computer, use only the tab 1. Inspector: key to move your p cursor-do not Kevin J. Sullivan use the return key. Name of Inspector Ready Rooter, Inc. �y Company Name P.O. Box 371 Company Address Sandwich MA 02563 Cityrrown state Zip Code 508-888-6055 SI-13517 Telephone Number License Number, , B. Certification , I certify that l 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ' ® Passes ❑ Conditionally Passes - ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority .August 04,2014. Inspectors igna a 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. F I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 128 Starboard Lane(Main House Right Side) Property Address r Roger Kessel Owner Owner's Name information is Osterville MAY 02655 July 15 2014 required for every , page. Cityrrown 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"sec' need to be replaced or repaired. The system, upon completion of the replacement or pair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for.the foil ing statements. If"not determined,"please,explain. The septic tank is metal and over 20 yearn old*or the septic to (whether metal or not) is structurally unsound,.exhibits substantial infiltration or exfiltration or tan ilure is imminent. System will pass inspection if the existing tank is replaced with a complyin' eptic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is str turally sound,"not.leaking and if a Certificate of Compliance indicating that the tank is less tha 0 years old is available. El.Y ❑ N ❑,ND(Ex p n below): Commonwealth of Massachusetts U Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 128 Starboard Lane(Main House Right Side) Property Address Roger Kessel Owner Owners Name information is . required for every Osterville MA - 02655' July 15, 2014' page. Cityfrown state Zip Code Date of Inspection B. Certification (cont) B) System conditionally Passes(cont.): .. ❑ Observation of sewage backup or break out or high static water level in the distribution ox due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. ystem will pass in if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y, ❑ N ❑ ND(Expla' below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(E lain below): distribution box is leveled or replaced _❑, Y ❑ N = ❑ N Explain below): ❑ The system required pumping more than.4 times a ye due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the B rd of Health)' ❑ broken pipe(s)are replaced Y ❑ N ❑;ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ;❑. ND(Explain below): C) Further.Evaluation is Requ' ed by the Board of Health: ❑ .;Conditions exist'which re ire further evaluation by the Board of Health in order to determine if the system is failing to tect public health, safety or the environment. . 1. System will pass Mess Board of Health determines In accordance with 310 CMR 15.303(1)(b)that t system is not functioning in a manner which will protect public health, safety and the a ironment: ❑ Cessp of or privy is within 50 feet of a surface water ❑ Ce spool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 7 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 128 Starboard Lane(Main House Right Side) Property Address Roger Kessel Owner Owner's Name information is Osterville required for every MA 02655 July 15, 2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Z System will fail unless the Board of Health(and P/na er Supplier, if any) determines that the system is functioning in a mannetects the public hea ,safety and environment: ❑ The system has aseptic tank and soil absorptionSAS)and.the� S is within100 feet of a surface water supply or tributary to a surfacpply.The system has aseptic tank and SAS and the.Shin a Zon 1 of a public watersupply. ❑ The system has a septic tank and SAS and the Shin feet of a private watersupply well. ❑ The system has a septic tank and SAS and theSAS isle00 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, pert ed at a DEP certified laboratory,for fecal' coliform bacteria indicates absent and the presen of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other fai re criteria are triggered.A copy of the analysis must be attached to this form. . 3. Other: s . 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 El ® 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 Commonwealth of Massachusetts Title 5 Official Inspection .Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �< 128 Starboard Lane(Main House Right Side) Property Address Roger Kessel, Owner Owner's Name information is required for every Osterville MA 02655 July 15, 2014 page. Cityrrown State Zip Code` Date of Inspection B. Certification (cont:) Yes . No ElRequired pumping more than 4 timesiin 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- 101000gpd. E. ® 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 facil' 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 foll ing, in addition to the questions in Section D. Yes No 3 ❑ ❑ the system is within 40q feet of a surf a drinking water supply El El the system is within 200 feet o tributary to a surface drinking water supply El El 'Ahe"system is located in a itrogen sensitive area(Interim Wellhead Protection Area=IWPA)or a ma ed Zone II'of a public water supply well If you have answered"yes"to any que n in Section E the system is considered a significant threat, or answered"yes" in.Section D abo the large system has failed. The owner or operator of any large system considered a significant eat under Section E or failed under Section D shall upgrade the l system in accordance with 3 CMR 15.304. The system owner should contact the appropriate regional office of the De p ment. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 't 128 Starboard Lane(Main House Right Side) Property Address Roger Kessel Owner wnets Name information is e Osterville MA 02655 July 15, 2014 required for every 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 w. ® ❑ 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 backup?" ® ❑ Was the S- ite 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. I ❑ 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): 3 Number of bedrooms(actual): 3 DESIGN flow based on'310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 't 128 Starboard Lane(Main House Right Side) r Property Address Roger Kessel Owner owner's Name information is psterville required for every MA 02655 July 15, 2014 page. Cityrrown State _ Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Ye s ® No Is laundry on a separatelsewage system?[if yes separate inspection required] ❑.,Yes ®. No Laundry system inspected? ❑- Yes ❑ No Seasonal use? ' •Yes ® No Water meter readings, if available(last 2 years usage'(gpd)): Detail: Water meter readings for 2012 271 gallons per day 2013 271 gallons per day Sump pump? El Yes ® No Last date of occupancy: ' July 15, 2014 • .Date Commercial/Industrial Flow Conditions: ' Type of Establishment: Design flow(based on 310 CMR 15.203): canons p ay(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 stem? ❑ Yes ❑ No Water meter readings, if available: f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '( 128 Starboard Lane(Main House Right Side) Property Address Roger Kessel Owner Owner's Name information is required for every Osterville 'MA 02655 July 15, 2014 page. City/Town State Zip Code Date of Inspection D. System Information (cent.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Ready Rooter Pumped April 2013 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, distxaiietj-bax, soil absorption system El Single cesspool El Overflow cesspool El 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): r Commonwealth of Massachusetts. Title 5 Official Inspection dorm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 128 Starboard Lane(Main,House Right Side) Property Address Roger Kessel Owner Owner's Name information is - requiredforevery Osteryille - .MA 02655 July.15, 2014 _ page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)farad source of information: Sytem was installed in April of 1989 Certificate of,compliance on file at Board of Health Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.1' feet Material of construction: ❑cast iron 46 PVC El other(explain): Distance from private water supply well or suction liner N/A feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1.5' feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene El 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: 8.5'x 4.5'x 4.5' 1000 Gallons 2„ Sludge depth: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 128 Starboard Lane(Main House Right Side) Property,Address Roger Kessel Owner Owners Name information is Osterville required for every MA 02655 July 15, 2014 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 30" • Scum thickness _ . 211 Distance from top of scum to top of outlet tee or baffle 4 t Distance from bottom of scum to bottom of outlet tee or baffle 22" How were dimensions determined? Tape measure and dip tube. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity; liquid levels as related to outlet invert, evidence of leakage, etc.): PVC inlet Concrete outlet.baffle. Riser on inlet and outlet to bring covers within 6"of grade. Grease Trap(locate on site plan): Depth below grade: Zee Material of construction: 0 concrete El-metal ❑fiberglass° rne ❑other(explain): Dimensions: Scum thickness Distance from top of sX m outlet tee or baffle Distance from bottobottom of outlet tee or baffle Date of last pumg Date I Commonwealth of Massachusetts., Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 128 Starboard Lane(Main House Right Side) Property Address Roger Kessel Owner Owner's Name information is Osterville required for every MA 02655 July 15, 2014 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural ' tegrity, liquid levels as related to outlet in evidence of leakage, etc,): Tight or Holding Tank(tank must be pumped at time of inspection)y(lo to on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass y lene pol eth y y El other(explain): Dimensions: Capacity: r gallons Design Flow:, gallons per day. Alarm present: [I Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of ala at switches, etc.): "Attach co y of current pumping contract(required). Is copy attached? ❑ Yes ❑ No r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments '< 128 Starboard Lane(Main House Right Side) Property Address Roger Kessel Owner owners Name information isequired ore very OsteNllle 02655 July 15;2014 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 No Distribution Box Comments(note if box is level and distribution to outlets equal, any evidence of soli carryover, any evidence of leakage into or out of box,etc.): Pump Chamber.(locate on site plan): Pumps in working order: ❑ Yes 0 No Alarms in working order: El Yes 0 No Comments(note condition of pump cha er,condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan, excavation not required):, If SAS not located, explain why:. i f Commonwealth of Massachusetts Title 5 Official Inspection Form, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �t 128 Starboard Lane(Main House Right Side) Property Address Roger Kessel Owner Owner's Name information is required for every Osterville MA 02655 July 15, 2014 page. cityrrown State Zip Code Date of inspection D. System Information (cont.) Type: ❑ leaching pits number:' ❑ leaching chambers " number: ® leaching galleries number: (4) Flow Diffusers leaching trenches number, length: ❑ leaching fields number, dimensions: , 0 overflow cesspool number: ❑ innovative/alternative system F Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Inspection port on last flow,difusser shows'no signs of water and clean stone is visible at bottom of diffuser. Cesspools (cesspool must be pumped as part of inspection) (locate on sit an): ; Number and configuration Depth-top of liquid to inlet invert Depth of solids layer r Depth of scum layer Dimensions of cesspool Materials of construction Indication of ground er inflow ❑ Yes ❑ No r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary.Assessments 128 Starboard Lane(Main House Right Side) ' Property Address Roger Kessel Owner Owners Name information is OSterVllle required for every MA 02655 July 15, 2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding,_condition of.v getation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of h raulic failure, level of ponding, condition of vegetation, etc.): Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments UIV 128 Starboard Lane(Main House Right Side)` Property Address Roger Kessel Owner Owner's Name information is OSteNille required for every MA 02655 July 15,2014 page. Citylrown 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 A)=33� AQ A SOn G3 h RJVUAY S- r ' � f Commonwealth of Massachusetts Title 5 Official Inspection Form . ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1_28 Starboard Lane(Main House Ri'ht Side) Property Address Roger Kessel Owner Owner's Name information is required for every Osterville MA 02655 July 15, 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water. ® Check cellar ❑ .Shallow wells Estimated depth to high ground water: <13' feet , Please indicate all methods used to determine the high groundwater elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: June 25, 1984 Date ❑ Observed.site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with.local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: f. You must describe how you established the high groundwater elevation: Test hole done on June 25,1984 to 13'no water found. Before filing this Inspection Report, please see Report Completeness Checklist on next page. :. Commonwealth of Massachusetts v. Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form-Not for.Voluntary Assessments 128 Starboard Lane(Main House Right Side) Property Address Roger Kessel Owner Owner's Name information is required for every Osterville MA 02655 July 15, 2014 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 4 i _ T WN OF BARNSTABLE v fy LOCATION, SEWAGE # o VILLAGE �� ASSESSOR'S MAP & LOT O�S INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 16'0 LEACHING FACILITY: (type) teas . (size) ` NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: G Y R COMPLIANCE DATE: 7- -- 8 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) Feet Furnished by sC E7 6 - TOWN OF BARNSTABLE LOCATION 4 ,.04-W J-0 SEWAGE # T9 O VILLAGE C� �z`��i-vat ASSESSOR'S MAP Gz LOT J. CRAIG MEDEIROS 5644 INSTALLER'S NAME 6z PHONE NO. 78 LIN YANNIS, MA 0260 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) � a' (size) NO. OF BEDROOMS 7 PRIVATE WELL OR(PUBLIC WATER Bfflt;DER-9R OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No S � e A No......7.. .^�. Sr Fes$..r ?.......'..... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Appliration for Dispoo al Uorks Tonstrur#ion Permit Application is hereby made for a Permit to Construct ( ) or Repair (/an Individual Sewage Disposal System at: .........................................................d Lo ation-Address �r> or Lot N _.... ---------------------- ----- of � Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building No. of persons............................ Showers — Cafeteria 0.4 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. 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_-___-__-________.____.- Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-________-_-_____.______ a _ --------•---•• ------------------------------- --•------------------------------------------------------ Descriptionof Soil ---••-----•-----•-•----------------------------------•-----------------------------............................-- V -----------------------------------------------------------------•-••---•--•-----------.....------------_---- -- �' -1 W -----------------------------•-......_..-------•••--•--•••----------•-----------------•--•••-•......--•••-•--••-••.. �/ .. •i x 7;7/ �j ;t o h �d U Nature of Repairs or Alterations—Answer when applicable.___... _ __-_ -. --- ---------- �° - ,� ---------------.---------5 � ............ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with T�'14^ the provisions of T TTL of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed ._... ------•--- ......... ---� ' ... __ / Date Application Approved B . _.. ------......�_ --- Ss Date Application Disapproved for the following reasons-------------------------------------------------------------------------------------------------------•---_...._ -••----------------------------------------------------------------------------------•--•-----------...--••------...._.........-----•--••----•-•-•----•----------•-------•-----•------••--•-•--....---- Date PermitNo...... ........................ Issued....................................................... Date THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) IM ^�� C DATA �. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ........................ OF.:..:-...:.............................-.................................................. ApplirFatinn for Disposal Works Tonstrnrtiun jirrntit Application is hereby trade for a Permit to Construct ( ) or Repair (v ) an Individual Sewage Disposal System at — Location-Address - or Lot No. I Ow er _ Address 7"a _-- i (..........................................t•'47 `� ..............................................................` ' ' r--=----J-- '-----_^ --.----- i' Installer Address i 4 Type of Building Size Lot............................Sq. feet U Dwelling No. of Bedrooms.............................. .....Ex Expansion Attic� g— --------. p ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther 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. 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........................ (s, Test Pit No. 2............. per inch Depth of Test Pit.................... Depth to ground water------------------------ Pd ._.. ` - ---------------------------------" P ----•---•-•---------------------........................................................ A Descriptionof Soil =' ....................-................................................................................................................................ W = = r V Nature of Repairs or Alterations—Answer when applicable_____________________________ ______ .....................................................1 f ' ----= Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TT'I.E ':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. 1 .. Signed�_- ------••-- •----- --••--•- , ------- Date .> Application Approved By....... .....-- -`rt'"`"" -----------------•-------- -------------�- .................. Date Application Disapproved for the following reasons---------------------------------•----------------------•----------------------------------------..._...---.._... --•-------•-----------------••-----------------•---------.....-----------------•----........---...........---...--------••------•----------------....----------------------•-••-------•••--•---------•--- r, Date PermitNo.----. �------------------------ Issued....................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _ ,`.:..-" Tntif irFatr of Toutpli anrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (1.-') -,-- C-. �,<.�, Alt by = ,... ...= /' -• ,i Instal .,:.. _ ..._�,._._.......I�b_ ... Installer '^[ at_.2 has been installed in ackor ance with the provisions of T I T LE, 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No--------- �..... dated-............................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......................................•-------------.....--------.._...._..._.. Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOAR- D�tOF HEALTH No. - ........................................... ... Disposal Works Tagn#rnrtion rrtnit Permission is hereby granted "..............................w �....:: -*- to Construct (_-)..or,Repair G_)-an Individual Sewage Dis os d System at No r , Street as shown on the application for Disposal Works Construction Permit No...?_--- Dated.......................................... ...................................................... .................................................. Board of Health DATE............................................................................ .. FORM 1255 HOBBS & WARREN. INC., PUBLISHERS T WN OF BARNSTABLE LOCATION J., SEWAGE # — VILLAGE ASSESSOR'S MAP & LOT - S1sr, ��ii r INSTALLER'S NAME&PHONE NO. //'' ,CdVs`�'"ir v .(t d n� SEPTIC TANK CAPACITY LEACHING FACIL=: (type)eaui (size) NO.OF BEDROOMS BUILDER OR OWNER 4-0K/ V.LAnY, Ocy PERMUDATE: Y --II—COMPLIANCE DATE: '7 - 7_ 8 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) Feet Furnished by us 64 r R 157` : r Commonwealth of Massachusetts . Title 5 Official inspection Form Subsurface Sewage Disposal System Form-.Not for Voluntary Assessments , 128 Starboard Lane(Main House Back System) Property Address Roger Kessel Owner Owner's Name information is Osterville MA 02655 ' July 15, 2014 .required for every 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 f A. General Information .on the computer, use only the tab 1. Inspector: U key to move your cursor-do not Kevin J. Sullivan use the return Name of Inspector key. Ready Rooter, Inca �y Company Name P.O. Box 371 Company Address Sandwich MA. 02563 Citylrown State Zip Code 508-888-6055 SI 13517 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site, sewage disposal systems:.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ®Passes Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority - August 04; 2014 lnspecto Si a 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. LV gl IfD . 'J1 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 128 Starboard Lane(Main House Back System) Property Address . Roger Kessel Owner Owners Name information is Osterville MA 02655 Jul 15 2014 required for every = y , page. CityfTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E'J 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"s tion need to be replaced or repaired. The system, upon completion of the replacement repair, as approved by the Board of Health,will pass. Check the box for"yes",°no°or"not determined." (Y, N,,ND)for the lowing statements.if"not determined,"please explain. ` The septic tank is metal and cover 20 years old*or the septi ank(whether metal or not) is structurally unsound, exhibits substantial infiltration orexfiltration or t k failure is imminent. System will pass inspection if the existing tank is replaced with a compl ' g septic tank as approved by the Board of Health: "A metal septic tank will pass inspection if it is ructurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less t n 20 years old is available. ❑ Y 0 N ❑ ND(E lain below): t r Commonwealth of Massachusetts Title 5 Official lnspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 128 Starboard Lane(Main House Back System) Property Address Roger Kessel Owner Owners Name information is Osterville _ MA 02655 Jul 15 2014 required for every y , page. Cityrrown State Zip Code Date of Inspection . B. Certification (cont.) F /Eain B) System Conditionally Passes(cont.):❑ Observation of sewage backup or break out or high static w distr' ution box due to broken or obstructed pipe(s)or due to a broken, settled outi box. System will pass inspection if(with approval of Board of Health): broken pipe(s),are replaced ❑ Yg ❑ xplain.below):obstruction is removed ❑ Y ❑ xplain below):distribution box is leveled or replaced ❑.Y ❑ xplain,below): ❑ The system required pumping more than 4 ti es a year due to broken or obstructed pipe(s).The system will pass inspection if(with approv of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y .❑ N ElND(Explain below): C). Further Evaluatio s Required by the Board of Health: ❑ Conditions exist ich require further evaluation by the Board of Health in order to determine if the system is f i Ing to protect public health, safety or the environment. 1. System 11 pass unless Board of Health determines in accordance with 310 CMR 15.303(1)( that the system is not functioning in a manner.which will protect public health, safety an 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 Commonwealth of Massachusetts _ Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form-Not for Voluntary,Assessments 128 Starboard Lane(Main House Back System) Property Address Roger Kessel Owner Owner's Name information is Ostervill y e MA 02655 Jul 15 2014 required for every , 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 a determines that the system is functioning in a manner that protects the pub' health, safety and environment; El The system has a septic tank and soil absorption system (SAS)an he SA "is within 100 feet of.a surface water supply or tributary to a surface water supply. ❑ The system has aseptic tank and SAS and the SAS is within one 1 of a'public water supply. ❑ The system has a septic tank and SAS and the.SAS is w in 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less an 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, pe rmed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presen of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other fa' re 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 El ® 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 Commonwealth of Massachusetts Title 5 Official Inspection 1=orrr' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 128 Starboard Lane(Main House Back System) Property Address Roger Kessel Owner Owners Name information is y Osterville MA '02655, Jul 15 201.4. required for every , page. Cityrrown State Zip.Code Date'of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ` 0 ® 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 coliformbacteria 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. El ® 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 f ility with a design flow of 10,0.00 gpd to 15,000,gpd. For large systems, you must indicate either"yes or"no°to each of the owing, in addition to the questions in Section D. , Yes -, No ❑. El the system is within 400 feet of a s ace drinking water supply ❑ ❑ the system is within 200 feet a tributary to a surface drinking,water supply the system is located in itrogen sensitive.area(Interimr Wellhead Protection �' Area-IWPA)or a m ed Zone If of a public.watesupply well If you have answered"yes"to any que ion in Section E the system is considered a significant threat, or answered"yes" in Section D abo the large system has failed. The owner or-operator of any large system considered a significant eat under Section E or failed under Section D shall upgrade the system in accordance with 31 CMR 15.304. The system owner should contact the appropriate regional office of the Depa ent. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 128 Starboard Lane(Main House Back System) Property Address Roger Kessel Owner Owner's Name information is required for every Osterville MA 02655 July 15, 2014 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 F ❑ ® 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 ® El available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? [0 ❑ 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? ® El 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. ® 0 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):. 3_ Number of bedrooms,(actual): 3 DESIGN flow based on 310 CMR 15:203(for example: 110 gpd x#of bedrooms): 330 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 128 Starboard Lane(Main House Back System) Property Address Roger Kessel Owner Owner's Name information is required for every Osterville MA 02655 July 15, 2014 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 0 No Is laundry on a separate sewage system?[if,yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No. Water meter readings, if available(last 2 years usage(gpd)): Detail: Water meter readings for 2012 271 gallons per day 2013 271,gallons per day Sump pump? ❑ Yes ® No •Last date of occupancy: July,15,2014Date Commercial/Industrial Flow Conditions: Type of Establishment .,Design flow(based on 310 CMR 15.203): aeons 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 a Title 5 system? ❑ Yes ❑ No Water meter readings, if av 'able: Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments 128 Starboard Lane(Main House Back System) Property Address Roger Kessel Owner Owner's Name information is required for every Osterville MA •02655. July 15, 2014 - - page. City1rown State Zip.Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date - Other(describe below): General Information Pumping Records: s Source of information: Ready.Rooter Pumped Aphl 2013, 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) El .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): Commonwealth of Massachusetts Title 5 .Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 128 Starboard Lane(Main House Back System) Property Address Roger Kessel Owner Owner's Name information is required for every Osterville "MA 02655 July 15, 2014 page. City/rown State Zip Code Date of Inspection D. System Information(cont.) Approximate age of all components, date installed (if known)and source of information: Sytem was installed in April of 1989 Certificate of compliance on file at Board of Health Were sewage odors detected when arriving-at the site? E Yes r®. No Building Sewer,(locate'on site plan): .' Depth below grade: 2.1' feet Material of construction: ❑cast iron ®40 PVC 0 other,(explain): Distance from private.water supply well or suction?line: " N/A` feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate'on site plan): Depth below grade: k 1.25' feet Material of construction:. ® concrete ❑.metal ❑ fiberglass D polyethylene' El 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: 11'x 5.5'x 5' 1500 Gallons 21' Sludge depth: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-.Not for Voluntary Assessments. 128 Starboard Lane(Main House Back System) Property Address Roger Kessel Owner Owner's Name information is y Osterville . MA `' 02655 Jul 15 2014 required for every , 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 38" Scum thickness 6 Distance from top of scum to top of outlet tee or baffle Distance from bottom of.scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape measure and dip tube. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,,evidence of leakage;etc.): PVC inlet and outlet baffle. Riser on inlet and outlet to bring covers within 6"of grade Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑:fiberglass polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum /teeDistance from bottom of scaffle Date of last pumping: Date Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 128 Starboard Lane(Main House Back System) Property Address Roger Kessel Owner Owner's Name information is Ostervill Y e MA 02655 Jul 15 2014 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations,inlet'and outlet tee or baffle condition, stivctur integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) date on.site plan): Depth below grade: Material.of construction: ❑ concrete ❑'metal; ❑'fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: /. I llons Design Flow: llons,per day Alarm present: Yes El No Alarm level: larm'in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of arm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments "l 128 Starboard Lane(Main House Back System) - Property Address Roger Kessel Owner Owner's Name information is required for every Osterville MA 02655 July 15, N14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0.1 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.): One inlet and one outlet no signs of high water staining. r ` Pump Chamber(locate on site plan): - Pumps in working order: /and ❑ No Alarms in working order: . 0 No as Comments(note condition of pump chamber, condition nces, etc.): Soil Absorption System (SAS)-(I/ate on site plan, excavation not required): If SAS not.located, explain wh , - 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 128 Starboard Lane(Main House Back System) Property Address Roger Kessel: ., Owner Owner's Name information is y Osterville MA 02655 Jul' 15 required for every , 2014 page. Cityrrown State Zip Code Date of Inspection' D. System.Information (coot.) - Type: ❑ leaching pits number: leaching chambers number: ® leachinggalleries number. (4) Flow 9 Diffusers ❑ -leaching trenches - number, length: ❑ leaching fields number, dimensions:. ' . ❑ overflow cesspool number: El 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.): Video inspected line from d-box into floe diffusers no water present and no sign of.high water staining. Cesspools (cesspool must be pumped as part of inspection).(loc 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 in w ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for.Voluntary Assessments. 128 Starboard Lane(Main House Back System) Property Address Roger Kessel Owner Owner's Name information is Osteryille MA 02655 Jul 15 2014 required for every. y , page. Ci mown State Zip Code Date of Inspection D. System Information (cunt.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condi ' n of vegetation, etc.): P ' rivy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs f hydraulic.failure level of'ponding, condition of vegetation, etc:): Commonwealth of Massachusetts 0. Title 5 Official Inspection form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 128 Starboard Lane(Main House Back System) Property Address Roger Kessel Owner. Owner's Name information is erville - MA 02655 'Jul required for every Ost ;: y- 15 2014 page. CibRown State Zip Code Date of inspecd.on 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 30 © 01 .Q 3 w coy; �� LIMO,D40Ay Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-.Not for Voluntary Assessments 128 Starboard Lane(Main House Back System) Property Address Roger Kessel Owner Owner's Name information is Osterville MA 02655 Jul 15 2014 required for every Y , page. City/Town State 'Zip.Code Date of Inspection . D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells - <13, Estimated depth to high ground water. feet Please indicate all methods used to determine the high ground water elevation:' ® Obtained from system design plans.on record If checked, date of design plan.reviewed: June 25, 1984 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health,-explain: ❑ Checked with local excavators, installers (attach documentation). ❑ Accessed USGS database=explain: You must describe how you established the high ground water elevation:' Test hole done on June 251984 to 13'no Water found.. , Before filing this Inspection Report,please see Report Completeness Checklist on next page. _F , Al Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary.Assessments 128 Starboard Lane(Main House`Back System) Property Address Roger Kessel Owner Owner's Name information is + required for every Osterville MA % 02655," July 15, 2014 page, Citylrown = State, ' Zip Code Date of Inspection } E. Report Completeness Checklist E inspection Summary:A, B, C, D, or E clieeked ® Inspection Summary D (System Failure Criteria.Applicable to All Systems)completed lug E Systerri"Informationx—Estimated,depth,to high groundwater . E. Sketch of Sewage Disposal,System either drawn on page 15 or attached,in:separate file ' ` . t • , k - - F e III Commonwealth of Massachusetts Title 5 Official Inspection- Form Subsurface Sewage Disposal.System Form-Not for Voluntary Assessments 0 r 128 Starboard Lane(Cottage) Property Address - Roger Kessel Owner Owners Name information is Osteryille MA rc 02655 July 15 2014 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, use only the tab 1. Inspector. key to move your cursor-do not Kevin J.Sullivan . use the return key. Name of InspInspector. Ready Rooter, Inc. ICI Company Name P.O. Box 371 Company Address Sandwich MA 02563 Cityrrown State Zip Code 508-888-6055 SI 13517 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and thaf the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to.Section 15.340 of Title 5(310 CMR 15.000)..The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority August 04,2014 Inspectors Si atu Date • The system inspector shall.submit a copy of this inspection report to the Approving Authority(Board of Health orDEP)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. 1 ' Commonwealth of Massachusetts a lugTitle 5 Official Inspection . Form. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 128 Starboard Lane(Cottage) Property Address Roger Kessel Owner Owner's Name information is Osterville MA 02655 July 15i 2014 required for every page. Cityrrown 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" ction need to be replaced or repaired:The system, upon completion of.the replacement r repair, as approved by .the Board of Health, will pass. Check the box for"yes", "no or"not determined" (Y, N, ND)for the f owing statements. If"not determined,"please explain. The septic tank is metal and over 20 years old`or the septic t k(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tan failure is imminent. System will pass inspection if the existing tank is replaced with a complyin eptic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is s urally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than years old is available. Y ❑ N ❑ ND(Expla' below): i i Commonwealth of Massachusetts Title 5 Official Inspection Forme Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 128 Starboard Lane(Cottage) Property Address Roger Kessel Owner Owner's Name information is Osterville MA 02655 July 15; 2014.. required for every page, Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or'high static water level in the distribu ' n box due to broken or,obstructed pipes)or due to a broken,;settled or uneven distribution x. System will pass inspection if(with approval of Board of Health): #' ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (E lain below): ❑ obstruction is removed. ❑ Y ❑ N ❑ N (Explain below): ❑ distribution box is leveled or-replaced ❑ Y ❑ N ND (Explain below): ❑ The system required pumping more than 4 times year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of a 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 quired by the Board of Health:_ ' ❑ Conditions exist whic require further evaluation by the Board of Health in order to determine if the system is failin o protect public health,.safety or the environment. 1. System will ass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)t t the.system is not functioning in a manner which will protect public health, safety and a environment: ❑ esspool 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 Commonwealth of.Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 128 Starboard Lane(Cottage) Property Address Roger Kessel ' Owner, Owner's Name information. equir required is Osteryille MA 02655 Jul 15, 2014 required for every y page. City/town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fall unless the Board of Health.(and Public Water Supplier,if ny) determines that the system is functioning in a manner that protects the lic 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 su y. ❑ The system has aseptic tank and SAS and the SAS is w' in a Zone 1 of a public water supply. The system has a septic tank and SAS and the S is within 50 feet of a private water supply well. ❑ The system has'a septic tank and SAS and the SAS'* 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 a ysis, performed at a DEP certified'laboratory, for fecal coliform bacteria indicates absent and a presence of ammonia nitrogen and nitrate,nitrogen is equal to or less than 5 ppm, provided that o 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 128 Starboard Lane(Cottage) Property Address ` Roger Kessel Owner Owner's Name information is Osterville F` MA 02655 ;Jul 15, 2014 required.for every � y page. CitylTown State Zip Code Date of Inspection B. Certification (coat.),4 Yes No r Required pumping more than 4 times.in the last year NOT due to clogged or ® obstructed pipe(s):Number of times pumped: El E. ,­, Any portion of the SAS; cesspool or privy is below high groundwater 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- The system falls. 1 have determined that one or more of the above failure ` ® 1 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 mustserve a f ity with it design flow of:10,000 gpd to 15,000 gpd: For large systems, you must indicate'either'yes"or"no"'to,each of the.f owing, in addition to the questions in Section D. Yes No- El the system is within 400 feet of a s ace drinking water''supply ❑ the system is_within 200 feet a tributary to'a surface drinking water supply T the system,is located in' nitrogen sensitive area(Interim.Wellhead Protection Area=IWPA)or a d ped,Zone II of a public watersupply well If you have answered"yes"to any q tion in;Section E the system is considered a significant threat, or answered"yes" in Section D a e the large system has.failed. The owner or operator of any large system considered a significa hreat under Section E or failed under Section D shall upgrade the . system in accordance wit 10 CMR 15.304. The system owner should contact the appropriate regional office of the artment. v Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 128 Starboard Lane(Cottage) Property Address Roger Kessel Owner Owner's Name information is Osterville MA 02655. Jul 15, 2014 required for every Y 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? El N Have large volumes of water been introduced to the system recently or as part of this inspection? ® 0 Were'asbuilt: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 backup? ® ❑ Was the site inspected for signs of break out? El 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? ® El . 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 Cis at issue ® approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms'(design): Number of bedrooms(actual): 1 DESIGN flow based on 310 CMR 15.203.(for example: 110 gpd x#of bedrooms): 110 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System.Form-Not for Voluntary Assessments 128 Starboard Lane(Cottage) Property Address Roger Kessel Owner Owner's Name information is Osteryille MA 02655 . Jul 15,'2014 required for every y page. Cityrrown State Zip Code Date of Inspection D. System.Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a.separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? El Yes ❑ No Seasonal use? Z Yes ❑, No Water meter readings, if available(last 2 years usage(gpd)): Detail: Water meter readings for 2012 271 gallons per day 2013 2717gallons per day Water readings are for main house and cottage. Sump.pump? ❑ Yes ® No .Last date of occupancy: July 15, 2014 r: e Date ,. Commercial/lndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons r day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial.waste holding tank present? ❑ Yes El No Non-sanitary waste discharged to the Titl system? ❑ Yes. ❑ No- Water meter readings, if available: Commonwealth of Massachusetts Title 5 Official. Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 128 Starboard Lane(Cottage) Property Address Roger Kessel Owner Owner's Name information is required for every Osterville MA 02655 July 15, 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: bate Other(describe''below): General Information. Pumping Records: Source of information: Ready Rooter Pumped April 2013 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 . El Single cesspool ❑ Overflow cesspool El 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 El Tight tank.AAttach a copy of the DER approval. ❑ Other(describe): Commonwealth of Massachusetts Title 5 Official . Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Starboard Lane(Cottage) Property Address Roger Kessel Owner Owner's Name information is y Osterville MA 02655 Jul 15 2014 required for every , page. Citylrown State Zip Code . Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Sytem was installed in July of 1998 Certificate of compliance on file at Board of Health Were sewage odors detected when arriving:at the.site? ❑ Yes ® No Building Sewer(locate on site plan): 2' Depth below grade:' feet Material of construction: El cast iron '®40 PVC ❑ other(explain): Distance from.private water supply well or suction line: N/A feet Comments(on condition of joints, venting, evidence of leakage,.etc.): Septic Tank(locate on site plan)`. Depth below grade: 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 11'x 5.5'x 5'1500 Gallons Dimensions: lit Sludge depth: r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 128 Starboard Lane(Cottage) Property Address Roger Kessel ` Owner Owner's Name information is Ostervill Y e MA 02655 Jul 15 2014 required for every , 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 34" o;; Scum thickness Distance from top of scum to top of;outlet tee or baffle s 6 14„ Distance from bottom of scum to.bottom of outlet tee or baffle How were dimensions determined? Tape measure and dip tube. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): PVC inlet and outlet baffle. Riser on inlet and 'outlet to bring covers within 6"of grade. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: '❑ concrete. 0 metal. ❑fiberglass olyethylene 0 other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet to r baffle Distance from bottom of scum to botto of outlet tee or baffle Date of last pumping: Date Commonwealth of Massachusetts. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments- 128 Starboard Lane(Cottage)x ` Property Address Roger Kessel Owner Owner's Name information is Y-Osterville MA 02655 Jul 15 2014 required for every , page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or.baffle condition, struc ral integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Tight,or.Holding Tank(tank must be pumped at tim/inspecti]op cate on site plan): Depth below grade: Material of.construction: ❑ concrete ❑metal` ❑'fiberglthylene ❑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.ala and float switches, etc.)`. "Attach cop of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for.Voluntary Assessments 128 Starboard Lane(Cottage) Property Address Roger Kessel Owner Owner's Name information is Osteryille MA 02655 July 15 2014 required for every , 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 oil 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.): Concrete D-Box with one inlet and one outlet. D-Box 2'deep with riser to within 6"of grade no sign of high water staining. Pump Chamber(locate on site plan): Pumps in working-order: /urtenances, Alarms in working order:Comments(note condition of pump chamber, condition.of pumps an Soil Absorption System`(SAS) (locate on si plan, excavation not required), If SAS not located, explain why: Commonwealth of Massachusetts , Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form Not for Voluntary Assessments 128 Starboard Lane(Cottage) Property Address Roger Kessel Owner Owner's Name information is Osterville MA 02655 July 15 2014 required for every , page. Cityrrown State Zip Code , Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑. _ leaching galleries number:` ® leaching trenches number, length: (1)4'x 40'4" PVC w/stone ❑ '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.): b Cesspools s must be pumped as part of inspectio n)(Iod ate o i to 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 ground er inflow ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 Official inspection Form, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 128 Starboard Lane(Cottage) Property Address Roger Kessel Owner Owner's Name information is Osterville MA 02655 July 15 2014 'required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soili signs of hydraulic failure, level of ponding, con ' ion of vegetation,. etc.): Privy.(locate on site plan): Materials of construction: Dimensions Depth of solids Comments.(note condition of soil,'signs hydraulic failure,`level of ponding;condition of vegetation,. etc.): N , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 128 Starboard Lane(Cottage) Property Address Roger Kessel ' Owner Owner's Name Information is required for every Osteryille MA 02655 July.15, 2014 page. City/Town . State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage.Disposal System: Provide a view of the sewage disposal system, including ties to at least two.permanent reference landmarks or benchmarks. Locate all 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 - ------. A�= ' a� -�3-�r'G . 4VEwAy. Y . \. � Commonwealth of Massachusetts Title `5 Official s In ection Form _ p . Subsurface Sewage Disposal.System Form Not for Voluntary Assessments 128 Starboard Lane(Cottage) Property Address Roger Kessel Owner Owner's Name information is Osteryille MA 02655 Jul 15, 2014. required for every Y page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar , ❑ Shallow wells <81 Estimated depth to high ground water: ` feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record . March 18; 1997, If checked, date of design plan reviewed: pate ❑ Observed site(abutting property/observation hole within 150 feet of SAS) . ❑ Checked with Iocal'Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database explain: , You must describe how you established the high groundwater elevation: Test hole done on March 18,1997 to 96"no water found. Before filing this Inspection Report, please see Report Completeness Checklist on next page. Commonwealth of Massachusetts Title .5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 128 Starboard Lane(Cottage) Property Address Roger Kessel Owner Owners Name information is required for every Osterville MA 02655 July 15, 2014 page. CityrFown 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 TOWN OF BARNSTABLE UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS V ^E NO.,. PARCEL N0. 5. qq AS o S S ORS MAPS i ADDRESS: 9,rAef5oAep L&Nc- 160DC3p, VILLAGE' 0S T EPE'V qq CONTACT PERSON Q.4j4 IAYI—D PHONE NUMBER 42 19 3-l 1 LOCATION OF TANKS: . CAPACITY: ...TYPE- OF- FUEL AGE: TYPE: LEAK OR.CHEMICALS �� DETECTION l s S'TgF�=- SYSTEM DATE OF PURCHASE OF EACH: l O10-3 2. 3. 4. 5. DATE OF FIRE DEPARTMENT PERMIT: TESTING. CERTIFICATION SUBMITTED: PASSED DID NOT PASS PLEASE PROVIDE A SKETCH SHOWING THE LOCATION OF TANKS ON THE BACK OF THIS CARD. fa , r , �GIIF - g �v • k CENTERVILLE - OSTERVILLE FIRE DEPARTMENT PERMIT FOR STORAGE OF FUEL OIL In accordance with provisions of Chapter 148, d:L., and Regulations . j made under authority thereof. Name John..Taylor.... ..... Name ....C.eF...R. �. � ....... ......... ...... ... W _�^ (owner or occupant) (Installer) i Address128 Starboard L ,� , Address ......7.8 ...Ma ,x�..St...,. .oat# j Burner Storage j Make „Tank only Type of Tank round steel •••• I Manufacturer ...... Capacity 5100...... gals. (or) Size............ Model No. or Size .....5.c'.`:: � �............ Location left... Jd4B--.0X••h10US>a•- Type..K,,cf ` .... Mass. Approval No. ................... Q 1 Chief J M Farrin ton Permit issued .....��.......... ...................... ! g (Head of Fire Department ............................................................... By ..........................ZC�f'G J� (THIS PERMIT MUST BE CONSPICUOUSLY POSTED UPON THE PREMISES) j� JELEPHONE 428-6365 MASTER PLUMBER'S REG. No.4448 CARL F. RIEDELL & SON, INC. PLUMBING & HEATINGRS 778.MAIN STREET DK OSTERVILLE. MASS. 02655 CSR October 26, 198 3 SOLD TO John A. Taylor Box 337 Osterville, Ma. 02655 MATERIAL LABOR TOTAL Aug. 31 Investigate oil tank problem 280; 00 Sept. 7 Take out oil tank j 448100 Sept. 8 Labor on new oil tank 28000 Sept. 9 Complete new oil tank and oil lines 180; 00 1 500 Gallon Fuel Tank 500 �00 1 2 gals. plug 4 41 1 2"x1j" gals. bushing 4 71 1 2"x1j" gale. tee 13 50 1 2" galy. cap - 4 44 1 1i" gals. street 900 ell 12 48 � . 1_ . 1i" gale. 900 ell 5 21 - ! I _ 2 1g" galy. 90° ells 7 2 1i", galy. street 900 ells 10 �98 08 1 ill' vent cap 2 57 1 1l" #VS201 vent alarm 17170 1 21lx 4" galy. nipple 4 98 1 21Ix 6" galy. nipple 6 69 1 1j"x2j" gale. nipple 2 40 1 2"x1/2" od duplex bushing 7 19 1 1i"od x 3/8" male comp. adapter 1 90 i 1 1/211od x 3/811 male comp. 900 ell 3 56 2 50 feet coils 1/2" od copper tubing 102 00 10 lbs. cement mix 2 30 I 1 3/8" ips strt firomat.ic valve 8 72 f Sept. 13 Take pump to electric motor shop and i pick up later in the day 48100 Bill from Motor Shop: j i Repair Myers pump: Parts 34 11 Labor 48! 00 Sept. 14 Reconnect pump 481: 00 I 756 93 129 100 2090 7S Tax 37 85 1 ' i i i 1 I , 24' 5'-4" El.PT N T • - N N N U .f 4. 2x4 handrail&guardrai a; system 14r , 96 O i ' 3, 1B5Q4"Vanly r Exercise equipment 266E Door 6'9' - Water Meter �� •a HW Heeler 3' o . 2N16"Basement venting udndow Typ. Notes; 2x4 walls on PT sill plate Typ. ` John Hoagland 128 5tarboard Lane Ostervllle,MA02655 Date: 10/11/2015 Lower level floor plan Scale: 1/4"= 1'-0" CO aca s er u Ing, nc. Ebenezer Road mark.macallister@gmail.com Sheet no. 1sterville MA 02b55 50b-bbq-2441 N �EStC�ti.l �aT->o► S UDDER 1?Ea L�( BAY LNtao� 1 a. AfZEA ` LOCU$ 6 �. STD qNF pJ� UsE q x�0 l.c-Ar-H i czVE c-N g ' 0.2 u5C- (00jr ►� �SOp C�P,�I.w►.►s �� ��2 LOCUS MAP 5' 1' 1 c t ri0 LF_ • -( Fx�n >a Gs K3 t.,oG 1� t0 u N D.47j 0 A4 SCALE 15,000 lPAc ASSESSORS MAR 166 PARCEL 55 A,. 15poAoYLoaNn` 'a• I31 ISocCx. ZONE � ,-�--�} I ' B, sa►.,D _ marsh island ' RF-1 & A.P. -5.Lo&w► - ✓� 0.2 C . Mao 2.9 2.6 �O �_ �.l�•ram e Pa Ss v.,ti=� E K�t,/ 3.�o � � -0.2 �2.5 C.B. FND. .6 ly x -1.3 0.2 -Q x -0.3 x `.� 0.1 x -0.9 .. x 0.2 9 -0.1 1a1 Q - -0.3 x -0.4 { x -0.2 x 0.1 -0.3 2.2 C.-B. FND. --- --_-___:.� - 4 -r To Mq�,� l�S� x -0.1 �p 4.0 s 423 ' S 2.! ' 3 x - 3. ti5 .. -0.5 � p � ' ro 0.0 NID IL Xx �'''''' >�i =- - ____ -=--. ' •� ., �1l act S ,,, \, x -a1 x -0 4 ---_ y \ � �1 LLB `\X 14.7 ...>� , �\ 0. 2$.3 � x 21,a �` \ \� ti 3.9 \ `, 1 x 0.0 NI 13.1 0.1 IL gQ/"p �' �� �\ \ \ c.w \� 17.2� 1, �` \ `r ��X 4, .7 y `� \ ' •4 �27.8 AL 0 x -0.2 �. ox :---� 0.1 \ 24. , \. \ 1 1 \ l' \\ �� ��k �F 0.2 eANK -0.3 ... -0.5 _ �1" - e r -0.8 2 80.2 _.. d 28/6 )x 1. x 1 1 1 '.._ - ' �� N I �L 2 2 � i 1 �\ \ � ,, y 0.2 . la n 22.9 r , �,P. FNt�. \ 3.6 AL A �1Jlc '�!` 2 ./x 2 -8) x 3.6 29.1 27 SITE PLAN DE 128 STARBOARD LANE 28.5 1 I \ \ 3.4 \ LOT 23 27 28.2 28.1 / 1 ' r r x 1 6 I ( x 9.5\ `� \�� Ct1 N a ti o 28.1 / / ,/ f,' r I I - M \; ._ ,,� o.a 0 E R l L,C,C, 19 6 8 0 F l'� /� -' i' ; r �_ _- *�,. .....� , .__.._..__.... _ - marsh 5 CST v E) . / f �• ` � 2 LL / ` 85262 S,F, r `. .�x7. ALL BARNSTABLE , MASS .' '1,96 AC. 28.1 ' , I / / f . , ,. x �13:1 , � \ ' /gyp9 27. �, \\.. , r RGGE1 H. KESEL ET UX \ \ \ \ 3.3 __--- \ \ \ \x\ PLAN SCALE: AS NOTED DATE: JAN. 13 ,19G97 \ t x �.v• z- i,3 1� '48'E �' 'r ' ,r _ \ ti \ `z, 3.1 BAXTER & _NYE INC.(ZF_q 3-19-9-7 N61'1� �, \ REGISTERED LAND SURVEYORS 238. 6' r ��-- ia0.6 CIVIL ENGINEERS / \ SCALE: 1 Ax�i a.9 � � x->"9.2 \� \ benchmark ch rr�ark = 9. 6� N. G. V. D. � 20 0 S T E R V I L L E, MASS.- _ �•���F���s, arc x\19.5 0 20 PETE11 �+ p y e tK 3-374 Q; #96128 �I ' • w _ z ASSESSORS REF.. OVERLAY DISTRICT: ZONE: • �� # : Map 166 Parcel 055 o AP - Aquifer Protection District RF-1 o ° •y ,._ ° + Area (min.) 87,120 SF (RPOD) Bw ' - cQ FLOOD ZONE: Frontage (min) 20' - _ Width (min) 125 Zone X & o`� Setbacks: o_o T .: s• �° Zone AE (EL 13) ,S c Fron t 30' a ° u. .. Q•• . o .. 4> Map # 25001 CO563J ya1 ,�h°`Z�°'Q Side 15 fill - July 16, 2014 � o,0cFQh Rear 15 .�(�o� 1 0 ••• •t° • N ° �• ,� ,`O / Landing -zone Not M •t Q,t a r G\C� ................................................. C Eli c Approx Septic , /�/I / As Per BOH 1 Sty Locus Map / / // / CB/DH !/ As-Built Card Cottage Fnd Scale: 1"=2,000±' 83.5 / ��h \ �s` 00 i I % GI a9 #128 Paved 1 Sty W/f I Dwelling 17- Drive g w I I R 28.0 zc') \ 25 —26 \ / 34.1 Q L i {p \ :Proposed ` —28— � — Fnd x �Fnd � - - — — / oh O - - - -37 O \ •. Z .� N °\ BRB .\ \ ` \Fn` oh ° \ I s `6i• O e, \ 5ro O .y \ ° �6 � 9 •�� Le end: 1 1.) The property line information shown was ° h n��\ ® Catch Basin compiled from available record information. ( rl Guy B/D !, 2.) The topographic information was obtained — — �38/ �� O utility Pole from on on the ground survey performed on OHw— overhead wires 221MAY/18. -25— — Elevation Contour S Underground Utility Line 3.) The datum used is NAVD '88, a fixed mean sea level datum. ,� `moo i %P� Title: PREPARED FOR: PREPARED BY. Plan Showing apeSury Proposed Garage at John H. Hoagland 128 Starboard Lane 23 West Bay Rd, Suite G 128 Starboard Lane In Osterville, MA. 02655 Osterville MA 02655 Barnstable (Osterv►lle) Mass. (508) 420-3994 / 420 surv.c m 0 -,, www.capesurv.com 20 0 10 20 40 60 Date: Scale: Field: WHK/ASK Review RRL May 14, 2018 1 '=201 Com Draft: WHK Drawing p/ g # C275_6G1