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HomeMy WebLinkAbout0311 STARBOARD LANE - Health �311 Starboard T,ane � �� P '� ,� a 5 (, x�, a y � � A =. �Osterville �� �$�� �:�h � � A;��1a6.6 109�t � � .� 7i ..mil. Y .s... � �, ,`�..�� lss.°`" *pF,.�"T�K p4 .�y�N y yA' ,4 k i � w� i P ."p a, F-�f Sep 10 2019 12:46 HP Fax page 20 hh Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i� ' 311 Star Board Lane Property Address Barbara Dunn ; Owner Owner's Name - information is required for every Ostervllle MA 02655 9-5-19 page. CitylTown * State Zlp 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 and of the form. A OF Important:When A. Inspector Information �/ �� filling out forms #/gla8 3 2 s on the computer, #��:' JAMES use only the tab James D.Sears key to move your Name of Inspector :L): cursor-do not use the return Ca ewide Enterprises •, ^ �o key. Company Name 153 Commercial Streer CF 5 INSP�`\��`���` —I01 III 11l\0 Company Address Mashpee MA 02649 City/Town State Zip Code ; 508-477-8877 S 1623 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.346 of Title 5 (310 CM 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the Information reported below is true, accurate and complete as of the time of my inspection;and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails , f 9-6-19 actor's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform - In the future under the same or different conditions of use. 15inspboc-rev.7/2812D18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 1 or 1e - ` r 1 I Sep 1 C1 2019 12:46 HP Fax page 21 Commonwealth of Massachusetts Title 5 Official Inspection Form <I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 311 Star Board Lane Property Address , Barbara Dunn Owner Owner's Name information is required for every Osterville MA 02655 9-5-19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: 1!have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or-in 310 CMR 15.304 exist. Any failure_ criteria not evaluated are indicated below. Comments: The system is a 1500 Gal. Tank D Box and two its. Y P d _ 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. i The septic tank is metal and over 2b years old`or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 18 Sep 10 2019 12:46 HP Fax page 22 Commonwealth of Massachusetts 4 Title 5 Official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments VW 311 Star Board Lane Property Address Barbara Dunn Owner Owner's Name information is QSteNllle required for every MA 02655 9-5-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cant.) . 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or breakout or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain,below): ❑ obstruction is removed . ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): Elbroken pipe(s)are replaced ❑ Y ❑ N ❑ NO (Explain below): ❑ obstruction is.removed. ❑ Y ❑ N ❑ NO(Explain below): r 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. . - a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.tloc•rev.7/26M18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Sep 10 2019 12:47 HP Fax page 23 Commonwealth of Massachusetts jp Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -� 311 Star Board Lane Property Address Barbara Dunn Owner Owner's Name information is required for every Osterville MA 02655 9-5-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, If any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *•This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other; 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes: No ® 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 t6insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Sep 10 2019 12:47 HP Fax page 24 Commonwealth of Massachusetts , p Title 5 Official Inspection Form Vv') Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 311 Star Board Lane Property Address Barbara Dunn - Owner Owner's Name information is required for every Osterville MA. 02655 9-5-19 page. CitylTown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in is less than 6" below invert or available volume is less /z than' day flow ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s)• Number of times pumped: ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water.supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15,303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions In Section CA. Yes No ❑ ❑ the system is t within 400.feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply" ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone I I of a public water supply well t5insp.dos•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 V Sep 10 2019 12:47 HP Fax page 25 �L\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 311 Star Board Lane Property Address Barbara Dunn Owner Owner's Name information is k required for every Osterville MA 02655 9-5-19 page. CityfTown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes'to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no" for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® Were as built plans of the system obtained and examined?(If they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner)provided with information on the-proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information.For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is.at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-page 6 of 18 Sep 10 2019 12:48 HP Fax page 26 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 311 Star Board Lane Property Address Barbara Dunn Owner Owner's Name information is required for every osterville MA 02655 9-5-19 page. Citylfown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 440 gpd x#of bedrooms): Description: 1500 Gal. Tank D Box and two pit's. Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) _ Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2017-91,000Gais g ( y 9 (gP ��' 2018-126,000Gal's Detail Sum pump? ` P P P • El Yes ® No Last date of occupancy: Present Date t5irsp.doc-rev.7126018 Tltle 5 Official Inspecdon Form:Subsurface Sewage Disposal System•Page 7 of 18 4 Sep 10 2019 12:48 HP Fax page 27 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for VoluntaryAssessments ents 311 Star Board Lane Property Address Barbara Dunn Owner owner's Name inforrnaton is required for every Osterville MA 02655 9-5-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. CommerciaUlndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.), Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): s S 1 3. Pumping Records, Source of information: NA. z Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/2612016 Title 5 Official Inspection Foim:Subsurface Sewage Disposal System Page a of 18 Sep 10 2019 12:48 HP Fax page 28 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 311 Star Board Lane Property Address, Barbara Dunn Owner Owners Name information is (JSterVllle required for every MA 02655 9-5-19 page, City/Town state Zip Code Date of Inspection - D. System Information (cont.) 4. Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ InnovativelAiternative 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. Approximate age of all components, date installed (if known)and source of information:. 1976 Permit #76 -419 8- 17 New D Box. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 3011Feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints,venting, evidence of leakage, etc.): Pipeing is 4" PVC-.SCH -40. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Fam:Subsurface Sewage Qis_oose1 System•Page 9 of 18 . 7 Sep 10 2019 12:48 HP Fax page 29 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments V y 311 Star Board Lane V Property Address Barbara Dunn Owner Owners Name information is • required for every Osterville MA 02655 9-5-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): h Depth below grade: 18" feet Material of construction: ® concrete ❑metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal. Precast H-10 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 29 Scum thickness Oil Distance from top of scum to top of outlet tee or baffle 12' Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Tape asbuilt sludge judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc,): Tank at working level. Tank and outlet cover at 18" below grade w/Inlet cover at 10". Inlet old type wall baffle w/outlet baffle. No'sign of leakage or over loading - t5ins .dcc•rev.7126/2018 - p Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 10 of 18 Sep 10 2019 12:48 HP Fax page 30 ,t\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 311 Star Board Lane Property Address Barbara Dunn Owner Owner's Name egUir ed fo ati fo is every r Osterville MA 02655 9-5-19 requir page, City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan):, Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5lnsp.doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 i Sep 10* 2019 12:49 HP Fax page 31 Commonwealth of Massachusetts 1. Title 5 official Inspection Form i' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 311 Star Board Lane Property Address Barbara Dunn Owner Owner's Name information is required for every Osterville MA 02655 9-5-19 page. City/Town state Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ` ❑ No Alarm level: Alarm in working order. ❑ Yes No Date of last pumping: Date Comments(condition of alarm and float switches, etc.); 'Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.):. D Box is 16"x16"-2' below grade w/cover at 10". Box is clean and solid w/two lines out. No sign of over loading or solid carry over. t5insp.doc-rev.7/26/2016 TWO 5 OHldal Inspection Form:Subsurface Sewage Disposal System•page 12 of 1s f ,Sep 10' 2019 12:49 HP Fax page 32 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I 311 Star Board Lane Property Address Barbara Dunn Owner Owner's Name q ati isinformation ewired for every Osterville MA 02655 9-5-19 page. City/Town State Zip Code Daze of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): r I If pumps or alarms are not in working order, system is a conditional pass, 11. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: . 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: 15inWAoc•rev.712612016 Title 5 0`ficial In spection Form:Subsurface Sewage Disposal System•Pape 13 of 18 Sep 10 2019 12:49 HP Fax page 33 Commonwealth of Massachusetts Title 5 official Inspection Form qvi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 311 Star Board Lane Property Address Barbara Dunn Owner Owner's Name Information is OSterV lie required for every MA 02655 9-5-19 page. City/Tom State Zip Code Date of Inspection D. System Information (cont,) 11. Soil Absorption System (SAS)(cont,) Comments(note condition of soil,signs of hydraulic failure, level of pond ing,damp soil,condition of vegetation, etc.): Leaching is two 1000 Gal, Pits. Pits are 4'below grade wlcovers at 1'. Both pits are wet on bottom. No sign of over loading. 12. Cesspools (cesspool must be pumped as part of Inspection)(locate on site*plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc rev.7I28t2018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 14 of 18 f .Sep 10' 2019 12:49 HP Fax page 34 Commonwealth of Massachusetts Title 5 official Inspection Form j Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 311 Star Board Lane Property Address Barbara Dunn Owner Owner's Name information is required for every Osterville MA 02655 9-5-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction` Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t I t5insp.chc•rev.7/252018 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 r Sep 10 2019 12;49 HP Fax page 35 Commonwealth of Massachusetts ,� Title 5 Official Inspection Form "s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 311 Star Board Lane Property Address Barbara Dunn Owner -- Owner's Name--------"*-------**--"*.-- information is required for every Cisterville _ _MA 02655_ 9-5-19 page. CitylTown State Zip Code Date of Inspection D. System Information (cost.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system. including ties to at feast two permiar.-ent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate :•here pubk water supo#y er;ters the building. Check one of the boxes below,- ® hand-sketch in the area below , r drawing attached separately _ t /4 p i A,3, 3 8 -9r"p o 5, 3.3' i ��_�t yto -�o' y • 3' liliaSDl'IGahwoaAnFam:Sv�ece6ti.epoDiP�57w*".ye0tisa:; - . W'm.doc•per.yts - Z£ a6ed 'x?,J 4-1 2VZ2 LM 90 �S Sep 1d 2019 12:49 HP Fax page 36 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments F' r 311 Star Board Lane Property Address Barbara Dunn Owner Owner's Name information is required for every Osterville MA 02655 9-5-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam, ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells N° Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record if checked,date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers- (attach documentation) - ❑ Accessed USGS database-explain; You must describe,how you established the high ground water elevation: - Auger T.H.at 14'no G.W.. Bottom of pits at 10' below grade. Bottom of pits at 4'above T.H. Depth Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7262018 - Title 5 Official Inspection Form,SuOsurface Sewage Disposal System•Page 17 of 18 L Sep 10 2019 12:49 HP Fax page 37 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 311 Star Board Lane Property Address Barbara Dunn Owner Owner's Name informrequired fo is Osteryille MA 02655 9.5-19 required'for every page. Cityffown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3,or 5 completed as appropriate 4(Failure Criteria) and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch.of Sewage Disposal System drawn on pg. 15 or attached For 15: Explanation of estimated depth to high groundwater included CA4 D ry PIP t5insp,doc•rev.712612018 Title 5 Of ial Inspecion Form:Subsurface Sewage Disposal System•Page 18 of 18 i No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftplitation for 30isposar *pstem Cunstruttion Permit Application for a Permit to Construct( ) Repair X Upgrade( ) Abandon( ) ❑Complete System [Individual Components Location Address or Lot No. I ST,4k00A'kD (-Aj Onwner's NAame,Address and Tel No. Assessor's Map/Parcel jp(p f® 311 / ( LN d S r Installer's Name,Address,and Tel.No. S©9--f4'!Z.9 g 77 Designer's Name,Address,and Tel.No. CA06W 04; 1 NTqkP'WsE$ NIA Type of Building: Dwelling No.of Bedrooms NA'" Lot Size sq.ft. Garbage Grinder( Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) A)W gpd Design flow provided /ihl- gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil j Nature of Repairs or Alterations(Answer when applicable) N c.� H— t® D�c�jL CV LTA p(5ASR Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Healt S Date Application Approved by p Date ��— Application Disapproved by. r Date for the following reasons Permit No. �� Date Issued M"„,.^s»...-< <-..^, ..wb+>.- ;,� (�I�.•de`.•i,, �r-�t..»^�.t�...s' ..._.hn:Et�..i,.:�.. �! - ��.,_ ,.. .. k .,x No. �. �� f _... - Fee f-1,dt! THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: , PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 20pYication for 13isposal *pstem Construction permit Application for a Permit to Construct( ) Repair(X, Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. ST440.80Alb LAJ Owner's Name,Address and Tel.No. Assessor's Map/Parcel 166 l0 f j �Tfk� 7LZj L!� DST Installer's Name,Address,and Te1::No. S'O$•X f'1-t S 7*7 Designer's Name,Address,and Tel.No. CCAP6&j f 4,6 N/A Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) Aht gpd Design flow provided AIA_ gpd Plan Date Number of sheets Revision Date Title n Size of Septic Tank Type of S.A.S. • f Description of Soil t / , ` } _Nature of Repairs or Alterations(Answer when applicable) lELO �L«62 - rr Date last itispected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental'.Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Healtht Signed) ii Date c[-(/s,xQ Application Approved by �:�y - Date - Application Disapproved by 4! Date r for the following reasons i Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(X) Upgraded( ) Abandoned( )by—il AP6W 1 r - at. (( MMRB04P_A- 4-n/ O S 7—` - has been-constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N0,019--2-N dated Installer_ CAQ6 W 11)E: S&RIE Qj p� C Designer �j A �p � r #bedrooms Approved design flow ltd gpd The issuance of this permit shal not b construed as a guarantee that the system `iiI'•f�ttV--d'esigned. Date � b Inspector �� Fee �-�------ •---------- - - --------------- -- ----------------------------------------------------------------------------- -------- No. i � THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS 30isposal Opstem Construction 3dermit Permission is hereby granted to Construct( ) Repair(X) Upgrade( ) Abandon System located at �J 1 ''7�Q-� Q�:,�" CA tj 6 Q 9 mgDw C 1. and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with 5 Title 5 and the following local provisions or special conditions. fly Provided:Co truction must be completed within three years of the date of this permit. Date ) l � - Approved by � t T A, ION S G L 0 C A E PEl 1T %o. � t� VILLAGE INSTA LLERf'S NAME & ADDRESS �.f,.a�, �✓ ��i`Y. �...4 � �j C'��C�/� �� LIf a �.J it/1: .b/k�^'��' B Ut QV DATE t OR OWNER /)4°l DATE PERMIT ISSUED BAT E COMPLIANCE ISSUED a ���a �� �� ��� � �� �- `�� �� y �,�{ � ._ _�� - - - - - -- - /J f- M TOWN OF BARNSTABLE LOCATION311 VILLAGE-V-�,fW`LQ% ASSESSOR'S MAP 6z LOT�6!2/, =105 INSTALLER'S NAME & PHONE NO. WkCaC,A C°Qw&f SEPTIC TANK CAPACITY \I No LEACHING FACILITY:(type) tl"' (size) :Z t w NO. OF BEDROOMS PRIVATE WELL R PUBLIC WATER. BUILDER OR OWNER�:�k"INQ oub lz0S L ►� DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED- Yes No f a � • n� h yb �,9 0 JCr ' �I No.. - �f---- ( � 6 0 /p Fas/.lf.................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �._..... ..... ... .._..._......:OF......................................................................................... wiration -for Bh5psal orku owitrurtion{ rrutit Application is hereby made for a Permit'to Construct ( or Repair ( ) an Individual Sewage Disposal System at: --- ---- -------------------------- /y `� - ocatddress — o �L or/Iot�Noy�` ...../.�G/ ......................_ o a / [...... .....................................�o... � ..._...5.... .....5! �.... W �� .....fner // Ad ess .......... ._ Installer Address ���!C U Type of Buildin" po' �S feet yP g/' j/ Stze Lot .............. q. Dwelling No. of Bedrooms------- ...................................Expansion Attic ( ) Garbage Grinder pa, Other—Type of Building ____________________________ No. of persons.--------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtl W Design Flow................ ____-__--_--..gallons per person per day. Total daily flow...........�1��________---_-_..._.-..gallons. WSeptic Tank—Liquid capacity dw.gallons Length................ Vidth................ Diameter---------------- Depth..___-__.-._. Disposal Trench—No. .................... Widtll.._.. :__ _ to e th.................... Total leaching area_.__.__._____..__._.sq. ft. ,,�,�} c . Seepage Pit No----- .......... Diameter/�-_.-.v. Imp e ow nlet......... ......... Total leaching area._..._ ----------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) IZAA2 A _/ C/— 7e aPercolation Test Results Performed by------- •- •--------•-•------------- Date-----------------------_- ---------._.. Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water.........___--..--.--._ (4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-----.---_---__.--__.__. 04 -- /r---------- -- tc---u f- , ... O Description of Soil_.-�___.. __��--___ �'d1. . /� c.> e2.--- --- 1 --------- r .-- ' '---....................................................---------------------------------------- w x ----------------------------------- --------------------••••---•--•------------•---•----------•-----•-•----•---------•-----------•--•---••••-••••------------•---•--••--------------------. . U Nature of Repairs or Alterations—Answer when applicable.-------------------------------------------------------------------- -------------------------. --------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanit• C e—The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha be i sued by the boar f h Ith. Sigpd........ ............... --•- -•-- DattApplication Approved By...... /,� --- ---------- --------------- l - - - ------ Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------- .........•-•-----.-----.•---......•--•-•--------------------•----------••••-•-------•--•-.-•---••--•-----I------------------•-----------•---•---•---•---------------------------------------------------- Date PermitNo......................................................... Issued---------------------------------------•--•-----------• Date .................................................................................................................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1...........OF....... G ...................... Cirrtifirtttr of OwUntViiatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) by.......- -•-- •.-•----•-a_�--- ------------•-------••-•-••--------- ------- ------------------ - - -.4.1 ---r--- ---------- -4- I taller , - -_ R has been installed in accordance with the provisions of . c XI of The State Sanitary Code as described in the a lication for Disposal Works Construction Permit No. ........�� .._____ dated.._. `-^�__--7,�------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT TIME SYSTEM WILL FUNCTION SATISFACTORY. DATE-------/r.... -------- ................-- _..-•-•--•-----•-. Inspector- .. :'�- ---�"'-�,'•-•---------- No........... - FEs. Z&.............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....... ... ........OF.............................I............I................---.....-..-................. Appliratinn -fur Bhipviitt1 Works Tonmrurtion Perutit Application is hereby made for a Permit to Construct ( V) or Repair ( ) an Individual Sewage Disposal System at: ---------------------------- ------------------------------ /J ^t_ --_/,Zcatio ddress or Loot No. Owner �/ A/ddress a Installer� Address r. �_� d'G G o0 r5 feet Type of Building/ / Size Lot...... ............... q. Dwelling—No. of Bedrooms.---_-_`-_�____________________________--_--Expansion Attic ( ) Garbage Grinder aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixture-& ------------------------------ W Design Flow.................._. ...._.....__._gallons per person per day. Total daily flow............ �0... gallons. WSeptic Tunk—Liquid capacity_Cis_2�o_.gallons Length____ ___________ Width_.............. Diameter_-.--. -----___ Depth---------------- Disposal Trench—No. .................... Width........:: ____ .j��otta.11 er th--_--__-_-______---- Total leachingarea--------------------s ft. Seepage Pit No------ -.......... Diameter_lU` __ e`pth' elowtinlet_________ ______ Total leaching area.___________...sq. ft. z Other Distribution box ( ) Dosing tank ( ) QQ SQL - ,Z - / y '7(!� aPercolation Test Results Performed by------- -- -----------------------------=------------------------------- Date............... ----------------------- 1 Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water-..-_--..-._--.--_.----- �14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water.-_--.-..---__-._-__--_. 9 ---- --" /I f------...._......--------------•-.--------------- �; -- y� j r O Description of Soil---------- �' =�� -L, = �--------'� �� '��``'{� U -------- ---------------------z � '�� � ��-E --------_---------------------------------------------------------------------------------------- U W U Nature of Repairs or Alterations—Answer when applicable..-----------------------------------------------------------------------------------------_--. ---•--------------------------------------------- --••---•---••----------------------------••--•----------------------•--............._.......-----•----------------------------------=--------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has4bee his/sued by the board,of health. ` Sigd. '(--------------------------------- ----....------7.------------. Date Application Approved By � ....... _ ------- Date Application Disapproved for the following reasons-----------------------•-•--•-•--••-•--------.............--•-•----•-----.........---------._...------...._---•-- ................................................... ---------------------------•----•-•-•--••-•-----------------•--------------•------------------------•-•-•-----•---------------- ---------------•- Date PermitNo......................................................... issued.............................. ......................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �/ 1...........OF.......0 .................... Trrtifiratr of Tomphaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) b 1 .� �G � 1f__w I talle� �. . y............. -10 `... I has been installed in accordance with the provisions of A ticll XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No. .. 'r dated_... __- '.-_..;7.�----------------- THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE- � ....._... 440----Y----•-'74oK........ Inspector----- _VZ --------•------------•----- THE COMMONWEALTH OF MASSACHUSETTS ��� _ BOARD O HEALTH �- ......... ...... r -t/��.........OF_....... ......................................... No �'`C� G / No.------. /= FEE.../_-�� Bi paiial Norks ClIumitrurtion Vamit Permissionis hereby .granted--------------------------------------------------=-------------------------------------------------------------------------------•---.----- to Construct ( ) orsR.ep ( ) a Individual�S,wage Disposal System x at No._-�li '' -v�--C4 -1.�'Z � ....... �7�....v l GG•-t-k�1 -t-(l/.. ----- t Street as shown on the application for Disposal Works Construction Per �7No._____ ..__ _ Dted__.___. _ ......... DATE. Board of Iealth / 1 ram-•- �-�-•.................................. / FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS • 3 E t 1 ' 3 { i j `gyp 2 'o N Q� M ' jai 4,&L4tPTtc T 32 12do I-G Ltiocut�� nA,o 6 P-1T5 17 4To�l e "� _ Q ` ��i '1=vc�-j-r�_-_1_-_� 0 Q R�11 ::• 1.�5 �.c tz ES � � 14 4 -76 Z , r PLOT PLAN AND SEWAGE DISPOSAL PLAN Scales 1"= 40 FT. i SINGLE FAMILY RESIDENCE 4-BR--19.97 S.F. ¢ 498 S.F. (2nd Flr. Dates Sept. 1 176 r LOCATIONI LOT NO. 14 STARBOARD LANE OSTERVILLE , MASS. OWNER : MR. AND MRS. A. P. MacDONALQ. AMHERST , N . H.. �R.0 ARc REFERENCE-: LOT NO. 14 STARBOARD LANE . OSTERVILLE , MASS. y�T�� I certify that this plan is in accordance with ,� ayN0. 381c00 current zoning laws of the Town PP Be,:nstobll eozTON; ,C) o S I G N E D s G an�>:ta-- e- Per - _ F'{ TR�.. C y C0t 4L9 AsItAe 15 Y•�Ui p ,i�l•iid