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HomeMy WebLinkAbout0047 SUNSET POINT - Health (2) 4 74#0 sunset Point ll a o Ostervi e P I a a 051 015 , o . � e a N A o ° i c a - a f 0 a ° ° a o ° y ° , ° TOWN OF BARNSTABLE LOCATION ZZ SEWAGE# _�'0/3 VILLAGE OS7�e/lrii%lE ASSESSOR'S MAP&LOT ,e.S"/ INSTALLER'S NAME&PHONE NO. i�a�fa�lise�/ SEPTIC TANK CAPACITY LEACHING FACILITY:(type) �1� C 6.��,1' (size) NO.OF BEDROOMS 3 BUILDER OR OWNER /�ruc-e cl�`s�1 7�oro PERMIT DATE: COMPLIANCE DATE: Separaiion Distance Between the: Maximum Adjusted Groundwater Table and 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 ^ /� .� ,. s, �q-/- 0 ., `a o ,z 3 li ,, ,�_ y � 3 3 "9� '� ��-Y= y� f-,s�� 3 3 /3-s% a7� '� '� ��.���� No. �0 1 � ' l ! / Fee L THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:_ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 21pplitation for bisposal 6pstem Construrtiun Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. O is N e Address an4Tj As se' ap/Parcel l ,$" /✓� ,� ld S% NIMNC 5 '� Installer's Name,Address,and Tel.No. Designer's N�pe� dress,and Tel.No. wo Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Natu a of Repairs or Alterations(Answer when applicable) Q 2I�. am 1 1 v ,�7l C . Date last inspected: �J fl dn/�`` S ev141 —7}z4-, 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 Bo f Health. Signed Date 3 Application Approved by Date Application Disapproved by Date for the following reasons Permit No.ao �j �' M / Date Issued No. a U I -22 111 / Fee - THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 9pplication for Vsposal 6pstem Construction permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or L No. Ow er's Name Address,and T �l-/� UrlSr `mil J� 6 S7 '/VI . �,�yili il' C.C��9 £ Ass ssor's ap/Parcel o �'" /l9 p Jr )'j/ Installer's Name,Address,and Tel.No. 6r Designer's Name/dress,and Tel.No. /V�.rfl yL GAUD (�j47� �l!// ao Type of Building: Dwelling No.of Bedrooms ,:;� Lot Size sq.ft. Garbage Grinder( ) Other Type of Buildinw*4/ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title R Size of Septic Tank Type of S.A.S. ' —Description of Soil Nature of Repairs or Alterations(Answer when applicable) )9 -�� Z ,G - l- Z Date last inspected: �/D Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in V:-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 Bo f Health. � L)� L✓ziv/ Signed I Date 3 _ �- Application Approved by Date L / " _ Application Disapproved by Date ;n for the following reasons �,•, - Permit No. O i?i r (9—7 Date Issued ----------- �1 (s ty f TIC N COMMONWEALTH OF MASSACHUSETTS I`�V BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired/ Upgraded( ) Abandoned( )by�N4�U e�44 i4�,y— �S �71:K at [p'/" N V has been constructed in ac)c/oo d ce with the provisions of Title 5 and the fo isposal System Construction Permit N . j% dated Installer /��//✓(iyL�U!/ 5 Designer #bedrooms Approved design flow / / gpd The issuance of this pe Mit shall of be construed as a guarantee that the system w�Iftinction as dejsiigJned, /�Date .' Inspector � ✓ 1�1 /il� �� p No. (� I J ` / `/� Fee •--- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Bisposal *pete /Construction permit Permission is hereby granted to Construct( ') Repair( Upgrade( ). Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. I Provided:Construction must be completed within three years of the date of this permit. Date /t/ Approved by L' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments G M . 47 Sunset Point (SYSTEM 2) Property Address Jennifer Walske 2118 Vallejo St San Francisco,CA 94123 Owner Owner's Name information is required for Osterville MA 02655 4/20/13' 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: A. General Information When filling out R� forms on the computer,use 1. Inspector: only the tab key I fI✓�to move your David Burnie Sr cursor-do not Name of Inspector use the return Q key. Neighborhood Waste Water Company Name -r • 350 Main St < C3 Company Address W.Yarmouth MA 02673 City/Town State Zip Code-7;:7 =:_� , 508-775-2820 SI386 " Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Sect 1p, ;' t, 40 of Title 5(310 CMR 15.000).The system: �1,Cr F<, ® Passes El Conditionally Passes El �• C•�`,• ; ` J. ❑ Needs Further Evaluation by the Local Approving Authority 4120/13 ��%>aa 1 N S P'�����0� Insp s Signaturl 4111 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. I � t5ins•3/13 Title 5 0ffidal Inspecti F :Subsurface Sewage Disposal System•Page 1 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments:. 47 Sunset Point (SYSTEM 2) Property Address Jennifer Walske 2118 Vallejo St San Francisco,CA 94123 Owner Owner's Name information is required for Osterville MA 02655 4/20113 . � - , every page. Cityfrown 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 16.304 exist. Any,failure criteria not evaluated are indicated below. Comments: The system was found in good.working order. B) System Conditionally Passes:, One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon'completion of the replacement or repair,as,approved by the Board of Health,will pass: Check the box for yes "no"or no determined"(Y, N, ND)for the following statements. If"not, determined," please explain: The septic tank is metal and over 20 yeais old*or the septic tank(whether metal or not) is structurally unsound,:exhibits substantial infiltration orexfiltration'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 *A metal septic tank will pass inspection if it'is structurally sound, not.leaking and if a Certificate of Compliance indicating that thetank,is less than 20 years old.is available. ❑ Y ❑ N., ❑`ND(Explain.below): 4 t5ins 3/13 "Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2,of 17 Commonwealth of Massachusetts - Title 5 Official- Inspection form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Sunset Point (SYSTEM 2) Property Address . Jennifer Walske 2118 Vallejo St San Francisco,CA 94123 Owner Owner's Name information is required for Osterville MA 02655 4/20/13 - every page. City/town State Zip Code Date of Inspection B. Certification (cont.j ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if,(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ ry ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form,- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 47 Sunset Point (SYSTEM 2) Property Address P _ Jennifer Walske 2118 Vallejo St San Francisco,CA 94123, Owner Owner's Name information is required for Osterville MA 02655 4/20/13 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont:) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of,a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank.and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and,SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *'This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded_ or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 r Commonwealth of Massachusetts Title 5 Official '!nspectio' n Form Subsurface Sewage Disposal System Form--Not for Voluntary Assessments M 47 Sunset Point (SYSTEM 2) Property Address Jennifer Walske 2118 Vallejo St San Francisco,CA 94123 Owner Owner's Name information is required for Osterville MA 02655 4/20/13 _ _ C' frown State Zip Code bate of Inspection eve page. �Y P pest every P 9 B. Certification (coat.) Yes No El 0 Required pumping more than 4 times in the last year NOT due to clogged or obstructed i e s . Number of times um ed: PpO P P ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. E] ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.' ❑ ® Any portion of'a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [this system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria.exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure.- E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ the system is within 400 feet of a surface drinking water supply ❑ the system is within 200 feet of a tributary.to a surface drinking water supply- ❑ El Area system is located in.a nitrogen sensitive area(Interim Wellhead Protection Area—1WPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large' system considered,a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17 I ' Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form-Not for-Voluntary Assessments ' 47 Sunset Point (SYSTEM 2) Property Address Jennifer Walske 2118 Vallejo St San Francisco,CA 94123 Owner Owner's Name information is required for Osterville ' MA 02655 4/20/13 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? El ® Have large volumes of water been introduced to the system recently or as part of -this inspection? ❑ ® Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? Z ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? - ® ❑ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® . ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information..For example, a plan at the Board of Health. ❑ ® Determined.in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System. Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): SAS@425 gpd t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 47 Sunset Point. (SYSTEM 2) Property Address Jennifer Walske 2.118 Vallejo St San Francisco,CA 94123 Owner owner's Name information is required for Osterville MA •02655 4/20/13 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description:' This system contains a septic tank, d-box and leach pit and only handles part of the house. Number of current residents: 0 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry.system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 12= 1175gpd 9 ( Y 9 (gP ))� 11= 1043gpd Detail: Customer has irrigation. Sump pump? ❑ Yes ® No Seasonal Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft.,:etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal.System-Page 7 of 17 I Commonwealth of Massachusetts Tale 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 47 Sunset Point (SYSTEM 2) Property Address R Jennifer Walske 2118 Vallejo,St San Francisco,CA 94123 Owner Owner's Name information is required for OsterVille MA 02655 4/20/13 every page. City/Town State- Zip Code Date of Inspection' D. System Information,(cont) ; Last date of occupancy/use: Date Other(describe below); ' General Information Pumping Records Source of information: -Neighborhood Waste Water Was system pumped as part of the inspection? ® Yes ❑ No ` If yes, volume pumped: 1000 gallons gallons How was quantity pumped determined? Site glass on truck Reason for pumping: Maintenance Type of System: ® Septic tank; distribution box, soil absorption system Single cesspool ❑ Overflow cesspool" ❑ Privy ❑ Shared system(yes or no) (if yes, attach-previous inspection records,if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system�owner)and a copy of latest - inspection of the.I/A system by.system operator under contract Tight tank.Attach-a copy of the DEP approval. Other(describe): t5ins•3/13 Title 5 Official Inspection Form'Subsurface Sewage Disposal System Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Sunset Point (SYSTEM 2) Property Address Jennifer Walske 2118 Vallejo St. San Francisco,CA 94123 Owner Owner's Name information is required for Osteryille MA 02665 4/20/13 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: 1982 per plan on file at the Barnstable BOH q - Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑cast iron 0 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): We ran a camera up the line and it was ok at the time of inspection. Septic Tank(locate on site plan): Depth below grade: Cover is 6"deck is 21" feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) The inlet and outlet covers are within 6"of grade. If tank is metal; list age: yearn Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions:, 1000ga1 Sludge depth: 0 t5ins-3113 Title 5 Official Inspection Form:.Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � 47 Sunset Point (SYSTEM 2) Property Address Jennifer Walske 2118 Vallejo St San Francisco,CA 94123 Owner Owner's Name information is required for Cisterville MA 02655 4/20/13 every page. CityfTown 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 Q Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 0 Distance from bottom of scum to bottom of outlet tee or baffle 0 How were dimensions determined? 0 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 was pumped out for maintenance. Grease Trap(locate on site plan): Depth below grade:. feet Material of construction: ❑ concrete ❑ metal - ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping'. Date t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage,Disposal System-.Page 10 of 17 r Commonwealth of Massachusetts Title 5 Official_ Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 47 Sunset Point (SYSTEM 2) Property Address Jennifer Walske 2118 Vallejo St San Francisco,CA 94123 , Owner Owner's Name information is required for Osterville MA 02655 4/20/13 every page. Cityrrown State Zip Code Date of Inspection D: System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)..(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity_ gallons Design Flow: gallons per day Alarm present: ❑ Yes- ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and.float switches, etc.): *Attach copy of current pumping contract(required).,Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' M 47 Sunset Point (SYSTEM 2)k Property Address Jennifer Walske 2118 Vallejo.St San Francisco,CA 94123 Owner Owner's Name information is required for Osterville MA 02655 4/20/13 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) . Distribution Box(if present must be opened) (locate on site plan): 0il Depth of liquid level above outlet invert Comments(note if box is,level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box, etc.): The box was found in good working order and it is 6"from grade to cover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: The SAS was found to be dry. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage-Disposal System Form-Not for Voluntary Assessments w 47 Sunset Point (SYSTEM 2) Property Address Jennifer Walske 2118 Vallejo St San Francisco,CA 94123 Owner Owner's Name information is required for Osterville MA 02655 4/20/13 every page. CitylTown State Zip Code Date of Inspection D. System Information (cunt.) Type: ® leaching pits number: 1-6x6 El leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length:, ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level.of ponding, damp soil, condition of vegetation, etc.): The SAS was found to be dry at the time of inspection. It-is under the driveway and viewed using a sewer camera. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer. Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Orrn Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 47 Sunset Point (SYSTEM 2) Property Address Jennifer Walske 2118 Vallejo St San Francisco,CA 94123 Owner Ownees Name information is required for Osterville MA 02655 4/20/13 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, . etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-all Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Sunset Point (SYSTEM 1) Property Address Jennifer Walske 2118 Vallejo St San Francisco CA 94123 Owner Owner's Name information is Osterville MA 02655 4/20/13 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately FRoN T 3�' o 614kA6E y 0 3 � a �- 1 - 30 f6 it 3 a 33 '6" y 5 6 04 3 : q3,6„ S Y S"!>� 1. a - ac 3 3f' t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Sunset Point (SYSTEM 2) Property Address Jennifer Walske 2118 Vallejo St San Francisco,CA 94123 Owner Owner's Name information is required for Osterville MA 02655 4/20/13 every 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: 11'+ per plan dated 1982 feet Please indicate all methods used to.determine the high ground water elevation: ® Obtained from system design plans on record 1982 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: MIW-29 Zone A water level 6.9 .8xl2= 10"adjustment You must describe how you established the high ground water elevation: Per previous report dated 2004 and available at the Barnstable BOH it shows approximetly 24 to ° groundwater. From grade to bottom of pit is 8'9". If you add to that a required seperation of 4' plus the adjustment of 10"you have a total of 137". You are out of groundwater by at least 10'. Before filing this Inspection Report,please see Report Completeness Checklist on next page: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inispecti®n Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 47 Sunset Point (SYSTEM 2) Property Address Jennifer Walske 2118 Vallejo St. San Francisco,CA 94123 Owner Ownees Name information is required for Osterville MA 026.55 4/20/13 every page. CitylTown State Zip Code Date of Inspedion 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 f P t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 I O Town of J ar nsta•ble. ,• P# - Department of Regulatory Services 41f �/('/ Public Health Division Date_' wse - 1 7 _ 16Jq �s$ 20o Man Street,Hyannis h4A 02601 • SEED IntA'I�' ' Fee Pd. Date Scheduled These ; Ulf i Soil,, uatabilaty Assess�ne ct fog- S.ewac a Dtsp sal o Performed By ��-. 6`� Witnessed By: 1 90 LOCATION&GENERAL INFORMATION . O I:ocation Address l�7 �u n S Q f- Vol d ` 1 T Owner's Name �/ll'fELS�-�_.. Q T. ,Ann l J I Address slY� IF C o4 r+. - `E 2 3 Assessor'sMap/P4rcch ►`Q� Q�"�"� i Engineer's Name, De rre•, NEW CONSIRU0TION REPAQt X Telephone# Sv 3to o- > Surface Stones Land Use Slopes(96) ' �" / C Distances from: Open Water Body 60 y ft<.Possible Wet Area ft Drinking Water Well�l .1V ft : U _ft Other ft t)reinage Way ft Props:.,y lane _. SKETCH:'($treet name,dimensions of 1ot,exact locations of test holes&We tests,locate wetlands in proximity to holes) I ' Parent material(geologic) k a N)A1A £�t' Depth to Bedrock Depth to GroundwaWr. Standing Water in Hole• "' i Weeping ft'om PIt Face cn a [/ Estimated Seasonal Vgh Groundwater /I a i' DtTERMINATION FOR SEASONAL HIGH WATER TADLA, Method Used: . in. Depth dbserved standing in obs.hole: _in. Depth td sgli ti99tt13: Depth toiweeping from side of obs.hole: I it1. Groundwater Adjustment ! _ A .Actor..,..�.� Adj.0roundwaterl.evel— Index Well# — Reading Date index Well lev6i --- di ; PERCOLATION, TEST . D�tp xl�_ Observation I. Tune at 9 -- Hole# ,. ��i Time�at 6" ..... - Depth of Perc :-�- ' Time(9"-6") --� --- ' Start Pre-soak Time.@ -- � � i End Presoak Rate MinJlnch Site Suitability Asscosmeut: Site Passed Site Failed; Additional Testing Needed(YIN) Original:.Public kleith Division' Observation Hole Data To Be Completed on Back--------- ***If percolafi�ion test is to•be conducted within 100' of wetland,you must fia'st notify,the Barnstable C44servatiou Division at least one(1) week prior to beginning. _ , , DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other .Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.3fi Gravel) A- Lx4104114 6-1 k3t' DEEP OBSERVATION HOLE LOG Hole# �Y Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistent %Gravel) ,io-3q 9, u om'<a Y" 1,0$% - 12 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Cons istency.%Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from S ' Horizon Soil Texture Soil Color Ul Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsisten F Flood Insurance Rate Maw. Above 500 year flood boundary No— "es Within 500 year boundary No— Yes Within 100 year flood boundary No` Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist.in all areas observed throughout the area proposed for the soil absorption system? i If not,,what is the depth of naturally occurring pervious material? Certification I certify that on 0 q (date)I have passed the soil evaluator examination approved by the Department of Enviro ental Protection and that the above analysis was performed by me consistent with the require ' i ,expe 'se and experience described in 3,10 CMR 15.01 . Signature v Date Q:\.SEPTIC\PERCFORM.DOC a:0o� V No. ^ � � i'_ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for TMpo$af *p5tem Construction permit Application for a Permit to Construct( ) Repair( ) Upgrade(/Abandon( ) ❑.Complete System ❑Individual Components Location Address or Lot NfLo Sih"X PO®^t'f O5}��h�l� Owner's Name,Address,and Tel.No. 6"Sl�e OYs�r Q4S Assessor'sMap/Parcel S'� _ �� �xc✓� f�(1\\e v'AA 0z632 ~ Installer's Name,Address,and Tel.No. 1�<*tC4\ Po.V�^9- a C Designer's Name,Address and Tel.No. ROxKe Aye LD Gcan&e� Co 4-ci-\J%- (Sd 9) 3 9 T-9 L114 -72 gov*, SA'Ce e r W-JCA, �1S.AkA 026ot A02- 3 Jo8 3 9 q-o rs4 Sa -rr -�)So'L Type of Building: ay Ca�e,,�/�1� Dwelling No.of Bedrooms A Lot Size %igZC) sq.ft. Garbage Grinder ( ) Other Type of Building ?'oak \NWTe No.of Persons Showers( ) Cafeteria( ) Other Fixtures p� Design Flow(min.required) /y gpd Design flow provided gpd .� Plan Date Number of sheets Revision Date Title Size of.Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) wain -20 000 be C C,0,%A t t- o esi i k Date last inspected: Agreement: d The undersigned agrees to ensure the constructio maint ' e of the afore described on-site sewage disposal system in accordance with the provisions of Title-1 0 nviron and not to place the system in operation until a Certificate of Compliance has been issued by thi and of He lth �n- Date 117 Jos Application Approved by Date ^ 1 7— Application Disapproved by: Date for the following reasons Permit No. 0G �6 Date Issued �— !7—6 No. O '� F Fee �j ,. ;'Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS p4ration for a g,pogal 6pgtem Construction Permit s Application for a Permit to Construct O Repair O Upgrade(Abandon O ❑ Complete System ❑Individual Components Location Address or Lot No�L17 S ASCJ Ppi A'( 01- e(V'Mt Owner's Name,Address;and Tel.No. 6"s4e. gvlli"A� Oys•4•Ar H�,.�dors �.t7_4pK �S Assessor's Map/Parcel r O } C-A\-t-rYM(-,v AA 02.j/�i A' Installer's Name,Address,and Tel.No. 1�<#\eC4\ V,3 mj�r— Designer's Name;Address and Tel.No�lS X+ 'e - AY e 2_0 (_QA&CVJcyo6 Lci�na._ (5Oe) 39g'9L1'T41 78 t4oC•-\t�, S-Vtee-\' �a�.v.�StAA 02-60% t o n,c r� t 1 A (SO,? '3 4-O SS -cam. : I-75 02 Type of Building: Cv.�e,,� no Dwelling No.of Bedrooms /V � Lot Size R119Z-0 4 / sq.ft. Garbage Grinder ( ) Other Type of Building Po,a k kNojSe No.of Persons Showers( ) Cafeteria( . Other Fixtures ' Design Flow(min.required) gpd Design flow provided N gpd } Plan Date Number of sheets Revision Date Size of.Septic Tank Type of S.A.S. Description of Soil t r Nature of Repairs or Alterations(Answer when applicable) A Z L.;,� 000 p M A 6ka,r•.1oA C. G0,%0QC_A w C, q0 .r ( ,A Date last inspected: � $�����G f�,4,�}��� Agreement: C The undersigned agrees to ensure the construction andmains enance of the afore described on-site sewage disposal system in accordance with the provisions of Title.,5 of the-Environmer(fad�Code and!not to place the system in operation until a Certificate of Compliance has been issued by this -oard of HPn�-a,-NACAV64M4?� Signed r'AE11K' � Date ? 1-7 10,3 Application Approved by / f Date / - 17- 06 Application Disapproved by: Date for the following reasons ' Permit No. �D G ^ 13 6T ,...-Date Issued �� 1 7— d THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( )I Abandoned( )by- �t\/I TtiAc, at &OrS P' tllQ has been constructed in accordance vn. with the provisions of Title 5 and the for Disposal/System onstruction Permit No. �U 'dated 7_�-7 Installer Designers #bedrooms Approved design flow a _ gpd The issuance of this permit shall not be construed as a guarantee that the system i-1 func�ttiiionn"ass°designed. 00 Date / // / Inspector / �/// I/! / �1�i ��'l��✓/ -------------------------------- No. 00 JC 30 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS 1=i.5po5a1 6pgtem Construction Permit Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) _ --Systern located at--11-Q- 5Z,--3 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 p�ertit. Date �� ir?^ Approved by .VLAV. 015. 20C,5 (yAI? g ::� :ENTER":LLE FIRE 506790258•5 ?AaF. (,�d:: --� MaJ(U appiiCaticn to fac;ai Tire Department. Fire Department retains original application and issues duplicate as permit, D Is d -S e<rrrx� xenCc�C: %tee Pays � ,'rx ' 111 + t i '`�... T N and PERMITi Fee: for stcroge tars( remo�ral and transportation tee approved tank disposal yard in accord rice with t-he provisions Of M.U.L. Chapter 148, Section 38A, 527 CMR 9.QD application 15 ...�..._ hereby made by: Tank Cvwner dame(pieese prirytl x Address set Pc i n - — _ b,urJ,q a, �� t Ater ti J- - - -- s�•�, afy --� , - Campa-iyName Ei.,viro-Safe Cor-porati.on i CO.Or Individual L<'nvi.rc?- afe Corporation Address 143 jan Sebastian Drive. S a.n 'a 1,r., n , Address Signature 9 (if apNlyiny far erm't P i Signature(if vi g for p Itj 1 U IFCIp Certified! 0 IFCI"Certili , i c ed .,P# OtherEll L i -- -� _J Yank Location -o—:�� L)ri5� t .iG1I11� Oyster Hdr1Jors , mA Tank Capacity tI "-.�IaefAddresz Gc•'i.tG�� --- .-�-••--•-C�- �...----- -_..,.�_.wo„_-___--...� I gailcns) _ Substanep Last stt red i i Tank Dimensions(diametor x lon th) Tloq Firm transporting waste En C - ,I 1?Cam 1 :rJ r Slate Lic.4 329 l Hazarco'�s waste roard fast# M AM 8 3 77 8 2 MAD 9 r . # 8526J323 fApprr+ved tank disposel andp- y Tank yarc! a 002 I Type of inert gas �- ankyardaddress _ G ,.,_ C�rnmcl�1 Stree" L� nn M 01=_(CaQ6ervP_tjoh Dept, -- GityorTown Gentervid.l: Date;M100 _ j Gate of;ssU�—May 4. 2Ut) � - rate of axpiration _May 1E, 2005 'CNgsafeapwl'OV21number, 1' 3 o.iy toil BrtC 32m i. Number i 5'rpnature!Title or 7lfiCer granting permit Aker rerjova!isj GnS1lrnpi V3 lief?°f M1; -- _.__ -- r •- — i St.; Fire Marsh€cl,t'SY uel .,!tnnk., exempted)sand Forrr; Ff'-�9f;1�slgrtrt by Lo+v i , c:, Atc�ry C`,omplianc:e Vnrit, P.O. acx 102", Stow, MA 01775. a Fire Cer,a�ro7ent is C,tri-e of t!e 'Intem360r:31 Fire CQUPy Institute JUL-30-2008 01:24P FROM: T0:815083940955 P.2 Town of Barnstable SINE Regulatory Services Q, Thomas F. Geiler,Director ,AARMN L Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601' Office: 508-862-4644 Fax: 508-790-6304 Date: 15- 10 c�r6 Sewage Permit#;Z00g.. _30Z Assessor's Map/Parcel Installer &Designer Certification Form Designer: - t OAtE -w-w - Installer: n( b► TJk Rhl Address: �� �ao�S t �T , SA61--U0o, Address: jb CA hipLtt°Wcst.,�S.-LA/ - l�yl s i 1�1� n16o1 P.v.t>-bx r9s �ennrs�o , M On ' 1—i ' Og r'1L [ ii n� was issued a permit to install a Lt")p �,JU KAP (date) (installer) V Glna ,A(wr ,septic- Ykem at 4';� S qnS e--'4• 05V01Y L VHFr based on a design drawn by (address) c`►2 P ;►,'QQ„�� -dated ( esigrier� ec . cg .r ryt} n '�i �..' t 'tl" i i 9 t a e[ a ' a. .....:: r�J.. A_ I certify that the septic system referenced above was installed•substantially acco Aing to the design, which may include minor approved changes such as.lateral'relocation"of the'. distribution box and/or septic tank. Stripout (if required) was inspeci<e_d and tl soils; were found satisfactory. l 0 I certify that the septic system referenced above was installed with ma o chang s (i.e_. greater than 10' lateral relocation of the.SAS or any vertical relocation of y coi7n$?onen�t�' of the septic system) but in accordance with State & L ons. P an revigbn . certified as-built by°designer to follow.. Stripout.(if ecte and the soils were found'satisfactory. moo`' STEPHEN °yG� D. MCIVIL vi • CIVIL Al.- staller's Signature) P No 46345 a �� °�F O/S r sS/ONAL ENG ((Designer's Signature). (Affix Designer's Stamp-Hefe) � .4` t -- •.,-, .. .+ r...,z r:w�. sz.. . i tJ z. ., ,•... 'p ': .. ,b. .J r . s .i-k�� ,i.X PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE 'OF COMPLIANCE-.WILL NOT BE ISSUED -UNTIL BOTH-THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC]HEALTH DIVISION. THANK YOU: q:\office form0designercertification form.doc ': r JUL-30-2008 01:24P FROM: T0:815083940955 P.2 Town of Barnstable Regulatory Services Thomas F. Geiler,Director ,AJUWABL& i Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508=790-6304 Date: 15-- a 0;6 Sewage Permit#Z00g' _Z- Assessor's Map/Parcel Installer&Designer Certification Form Designer: �C� t — 61wlt t�i K G- Installer: r►l�— Address: �-� k4o0.T �T SAo�000, Address: ?o �hlD l.6 v�/od� ot6ot �.v.�b�xi9s 17�nn�s0o(�, ✓1'1A oz�3� On 1-1 A hip&Tqt:'1LW (M A was issued a permit to install a L%")p �Vu"^P (date) (installer) e-V\4 wt(W'r I �y 4egtic4*effi at y "Syn5 e L VA Pr based on a design drawn.by (address) cyL ' dated o c'$ ( esigner3 I certify that the septic system referenced,above was+installed-substantially according to. the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that:.the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordancc with State & L ons. Plan revision or certified as-built by designer to follow. Stripout (if ected and he soils.: were found satisfactory. o? �y STEPHEN r- D. c, MATSON, En CIVIL N '(I staller's Signature) No.as3a5 0 �� sTEa� -- �SS�ONAL ECG\ (Designer's Signature) - (Affix Designer's Stamp Here) - PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. q:\office forms\designercertification form.doc yy M_. p T�jO`4�1.� OF uDARNST�aBLE LOCATION L � ��� i®►K-k (o-o �c, rg� sEWAGE# 302 VILLAGE 03+e c ale- ASSESSOR'S MAP&PARCEL 0® � INSTALLERS NAIVLE& )?7IIONE NO. l ' A u�� Q,4•� �" $�P C9°d7 SEPTIC TANK CAPACITY Vpjrc,�-,e /000 Gam,. �� .��•g,✓ LEACHING FACILITY.- (type) (size) Ns&N NO. OF BEDROOMS VVe A OWNER 9,tis;6-k PERMIT DATE: -7//`T�� COMPLIANCE DATE: Separation Distance Between the.- Maximum Adjusted Groundwalec Table to the Bottom of Leaching Facility NIA )Feet Private dilater Supply Well and Leaching Facility(If any wells exist ev/ on site or within 200 feel of leaching facility) Feet Edge of Wetland and Leach aty y wetlands exist within 300 feet of le rng faci ' t"/A Feet a FURNISHED � � } o _ Kw P- id is I ca Owl J I � M 00 COMMONWEALTH OF MASSACHUSETTS ul EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENT �� IVIAP PARCEL 5 2004 LOTu�` AUG 2 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 47 Sunset Point(System#1) Osterville,MA 02655 Owner's Name: Roger&Kathleen Stoll Owner's Address: Date of Inspection: August 10, 2004 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-6049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority . 4Falls Inspector's Signature: Date: August 14, 2004 The system inspector shall subint copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 47 Sunset Point(System 41) Osterville,MA Owner: Roger&Kathleen Stoll Date of Inspection: August 10, 2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)-in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 r Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 47 Sunset Point(System #1) Osterville, M4 Owner: Roger&Kathleen Stoll Date of Inspection: August 10, 2004 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR.15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health;safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis;performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 r Page 4 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 47 Sunset Point(System#1) Osterville.MA Owner: Roger&Kathleen Stoll Date of Inspection: August 10, 2004 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than'/h day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. _ ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000gpd to 15,000 gPd- You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 r Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 47 Sunset Point(System#1) Osterville, MA Owner: Roger&Kathleen Stoll Date of Inspection: August 10, 2004 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ _ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS,located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)]. 5 r Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 47 Sunset Point(System#1) Osterville.MA Owner: Roger&Kathleen Stoll Date of Inspection: August 10, 2004 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed approximately in 1982 Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 47 Sunset Point(System#1) Osterville,MA Owner: Roger&Kathleen Stoll Date of Inspection: August 10,2004 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 2' Material of construction: ✓ concrete _metal _fiberglass polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30 Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle: 6 Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Cement tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs o leakage. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 r Page 8 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGEDISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued), Property Address: 47 Sunset Point(System #1) Osterville, MA Owner: Roger&Kathleen Stoll Date of Inspection: August 10, 2004 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: - gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-box was level and clean. No solids were present. PUMP CHAMBER: None (locate on:site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 r Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 47 Sunset Point(System#1) Osterville,MA Owner: Roger&Kathleen Stoll Date of Inspection: August 10, 2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: I-6'x 6'with 1'stone(per design plans) leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The leach pit had 1'ofwater on the bottom. The scum line was approximately 2'up from the bottom. There did not appear to be any signs of failure. The pit was under a driveway. A video camera was used to inspect the pit. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 r Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 47 Sunset Point(System#1) Osterville. AM Owner: Roger&Kathleen Stoll Date of Inspection: Agmt 10, 2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. SySrc,r" 1 Sy sr ., a FrOnT 8 A Q \ I ac) 3o 1000 Soo a 3-33y \ C 3 3 y3 ya aL _ a 6,4(A6L 3 - Q e a� as 3 a 33 aq6 y y 3 yY 3� ys� 3o 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 47 Sunset Point(System#1) Osterville.MA Owner: Roger&Kathleen Stoll Date of Inspection: August 10, 2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 12'+/- feet Please indicate(check)all methods used to determine the high groundwater elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: Topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: . Using Barnstable topographic maps and water contours maps, the maps were showing approximately 12'+/-to ground water at this site. The system is within 300'of a tidal bay and no high ground water adjustment needs to be taken. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees,either expressed, written or implied,relating to the system,the inspection and/or this report 11 Z31 COMMONWEALTH OF MASSACHUSETTS " EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROOTE ON MAP RECEIVED r PARCEL 0, ,.� AUG 2 5 2004 LOT ' SyS Z TOWN OF BARNSTABLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 47 Sunset Point(System #2) Osterville, MA 02655 Owner's Name: Roger&Kathleen Stoll Owner's Address: Date of Inspection: August 10, 2004 Name of Inspector: (Please Print) James M Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs er Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: August 14, 2004 The system inspector shall sub 't a copy of this inspection report to the Approving Authority(Board of Health or The system inspector shall subz DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 F % . Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 47 Sunset Point(System #2) Osterville, MA Owner: Roger&Kathleen Stoll Date of Inspection: August 10, 2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due'to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken`pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 1 r F Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property arty Address: 47 Sunset Point(System #2 Osterville, MA Owner: Roger&Kathleen Stoll Date of Inspection: Aufust 10, 2004 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the.Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: I 3 Page 4 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 47 Sunset Point(System #2) Osterville, MA Owner: Roger&Kathleen Stoll Date of Inspection: August 10,2004 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all.inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or,privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this forma No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 r Page 5 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 47 Sunset Point(System #2) Osterville. AM Owner: Roger&Kathleen Stoll Date of Inspection: August 10, 2004 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ _ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ _ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection ? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS,located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge-and depth of scum ? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 47 Sunset Point(System #2) Osterville, MA Owner: Roger&Kathleen Stoll Date of Inspection: August 10, 2004 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 2 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes_or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIALANDUSTRIAL. Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the•Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How,was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy'of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed approximately in 1982 Were sewage odors detected when arriving at the site(yes or no): No 6 +J Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 47 Sunset Point(System 42) Osterville, MA Owner: Roger&Kathleen Stoll Date of Inspection: August 10, 2004 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line:_ Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 22" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1500 gal. Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 29" Scum thickness: 5" Distance from top of scum to top of outlet tee or baffle: 4 Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: concrete _metal _fiberglass ,.__polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or.baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): h 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 47 Sunset Point(System#2) Osterville. MA Owner: Roger&Kathleen Stoll Date of Inspection: August 10, 2004 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-box was level and clean. No solids were present. The D-box was under a driveway. A video camera was used to inspect the D-box.. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 i + Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 47 Sunset Point(System #2) Osterville, MA Owner: Roger&Kathleen Stoll Date of Inspection: Auizust 10, 2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 -6'x 6'with 3'stone(per design plans) leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The leach pit had 6"of water on the bottom. The scum line was approximately ]'up from the bottom There did not appear to be any signs of failure. The pit was under a driveway. A video camera was used to inspect the pit CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction:, Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 • Page 10 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 47 Sunset Point(System #2) Osterville, MA Owner: Roger&Kathleen Stoll Date of Inspection: August 10, 2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A F�o�T g aC 30 1000 /Soo a 33 31 0 / \ C 3 ti3 ya Q a Q a G,q(A6L c s 3 a 33 aq� - yS� 3o 10 J Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 47 Sunset Point(System #2) Osterville, MA Owner: Roger&Kathleen Stoll Date of Inspection: August 10, 2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 12 +/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: Topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic maps and water contours maps the maps were showing approximately 12'+/-to Around water at this site. The system is within 300'of a tidal bay and no high Around water adjustment needs to be taken This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied,relating to the system, the inspection and/or this report. 11 C) COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL P J LRIVED PARCEL ®� AUG 2 5 2004 LOTaa � TowH O FBH DEPTABLE TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 47 Sunset Point(Guest House) Osterville, AM 02655 Owner's Name: Roger&Kathleen Stoll Owner's Address: Date of Inspection: August 10, 2004 Name of Inspector: (Please Print) James M Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Osterville,MA 02655-0049 Telephone Number: (508)862-9400. CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs Plurther Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: August 14, 2064 The system inspector shall subm copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 47 Sunset Point(Guest House) Osterville, MA Owner: Royer&Kathleen Stoll Date of Inspection: August 10, 2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 47 Sunset Point(Guest House) Osterville, MA Owner: Roger&Kathleen Stoll Date of Inspection: August 10, 2004 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 47 Sunset Point(Guest House) Osterville, MA Owner: Roger&Kathleen Stoll Date of Inspection: August 10, 2004 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_: ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary,to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section_ E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 47 Sunset Point(Guest House) Osterville, MA Owner: Roger&Kathleen Stoll Date of Inspection: umt 10, 2004 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection ? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ — Was the facility or dwelling inspected for signs of sewage back up? ✓ — Was the site inspected for signs of break out? ✓ — Were all system components,excluding the SAS, located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? ' The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes No ✓ — Existing information. For example,a plan at the Board of Health. ✓ — Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)]. N 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 47 Sunset Point(Guest House) Osterville, MA Owner: Roger&Kathleen Stoll Date of Inspection: August 10, 2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): a 3 DESIGN flow based on 310 CM_ R 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown-guest house COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gad Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Age unknown Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of I 1 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 47 Sunset Point(Guest House) Osterville, MA Owner: Roger&Kathleen Stoll Date of Inspection: Aukwt 10, 2004 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 20" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 5" Distance from top of scum to top of outlet tee or baffle: 4" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs ofleakajze. A tree was growing over the top of the tank. Recommend removing the tree. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: ' Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): I 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 47 Sunset Point(Guest House) Osterville, MA Owner: Roger& Kathleen Stoll Date of Inspection: August 10, 2004 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete _metal fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None (if presentmust be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): I 8 7 Page 9 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 47 Sunset Point(Guest House) Osterville, MA Owner: Roger&Kathleen Stoll Date of Inspection: August 10, 2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: ✓ overflow cesspool,number: / Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): The overflow cesspool was S'W x 6'T x 9'bottom to grade. The cesspool was dry and clean. There did not appear to be any signs of failure. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 e Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 47 Sunset Point(Guest House) Osterville, MA Owner: Roger&Kathleen Stoll Date of Inspection: August 10, 2004 , SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A 3AJ) Q � Q 38 3 to Page 11 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 47 Sunset Point(Guest House) Osterville, MA Owner: Roger&Kathleen Stoll Date of Inspection: August 10, 2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 12 +/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: Topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic maps and water contours maps, the maps were showing approximately 12'+/-to ground water at this site. The system is within 300'of a tidal bay and no high ground water adiustment needs to be taken. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. it COVIVIOtiTWEALTH OF ivWSACH�.;SETTS EXECUTIVE OFFICE OF ENVIRONMENT L 'FAIRS 1� DEPARTMENT OF ENVIRONMENTAL PR r ECTIO cc t ONE WINTER STREET, BOSTON MA 02108 (617) 29 -5 0 W` O 0 1999 lad IOF Y COXE � �un,o Secretary ARGEO PAUL CELLUCCI A STRUHS Governor Commissioner SUBSURFACE§EWAGE DISPOSAL SYSTEM INSPECTION FORM E PART A �) , 0 CERTIFICATION Propeqy Address: 1 7 S ll t r (y Name of Owner TI M W 1 1 t SySrG 'ONE Address of Owner: Sf��1t Date of Inspec7don -. ` Name of Inspector- ease trt) 6DW4120 C, 130USF(Ee-0 1 am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000) Company Name: FDWAQD C. QO(JSF/ECp Marring Address: WUt9D RvE S A) N<<N M a, o�S63 Telephone Number: TM 92S 32 3 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported,below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Jl Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Kinsp.ction Inspector's Signature Date:The System Inspector shall submit a copy o report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving authority. NOTES AND COMMENTS / 00 614LLOlU Se p7/C -7-;j NK /000 6AR-01V L EAC/-1 P I T revised 9/2/98 Pagel of11 i�Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART (continued)/� �r^CERTIFICATION(continued) Property Address:`-17 solos ET f L S:G P i IC S YS/tiC M -7* 04)67 . ownerT wHITE Date of Inspection:/_'_19_I G q INSPECTION SUMMARY: CheckO B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health, will pass. r Indicate yes, no, or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank, whether or not metal,is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. . Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced ' The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2of11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A cCERT/IIFICATION(continued) Property Address:YT s (INS Pt, J�r/ 'C S` sr6-M -Auve Owner: �',uJ H Date of Irsspection:/ 1_19�S'I 1p C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3of11 w .. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: y7 SvtiSCr aL< <SEPTI�- SvSTEM 40/v&: Owner. Tr WKr TE Date of Inspection:(j—' D. SYSTEM FAILS: You must indicate either"Yes" or"No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an 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 1/2.day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either"Yes" or"No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPEC ON FORM PART B CHECKLIST Property des::,�{ 7 SuAjSG-T- PC Se p �- SVSTEM Owner: Date of Inspection: Check if the following have been done:You must indicate either"Yes"or"No" as to each of the following: Yes No — Pumping information was provided by the owner,occupant,or Board of Health. A — None of the system components have been pumped for at least two weeks and the system has been receivingnormaf flow rates during that period. Large volumes of water have not.been introduced into the system recently or as part of this / inspection. AJ A As built plans have been obtained and examined. Note if they are not available with N/A. — The facility or dwelling was inspected for signs of sewage back-up. — The system does not receive non-sanitary or industrial waste flow. — The site was inspected for signs of breakout. — All system components, excluding the Soil Absorption System,have been located on the site. 4- — The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.H. _ Determined in the field(if any of the failure criteria related to Pan;C is at issue,approximation of distance is unacceptable) y (I 5.302(3)(b)) The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYST'EM,INISPECTION FORM PART C SYSTEM INFORMATION - Property Addr q7 N.SET Pt, SYSTE/h Owner: H Date of Inspection:/-- -65q ii�' 1 FLOW CONDITIONS RESIDENTIAL: Design g.p.d./bedroom. Number of bedrooms(design):S Number of bedrooms(actual): S Total DESIGN flow 5-50 Number of current residents: Garbage grinder(yes or(9 Laundry(separate system) (yes or®1111(�; If yes,separate inspection required Laundry system inspected (yes or no) Seasonal use(yes or no):_ Water meter readings,if available(last two year's usage(gpd): Sump Pump(yes or no): N0 Last date of occupancy: STIlt-(:xCUplap COMMERCIALIINDUS TRIAL: Type of establishment: Design flow: qpd ( Based on 15.203) Basis of design flow Grease trap present:(yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system:(yes or no)_ Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS a94 source of mf mation: - HAS rvo'r 1�£EN PvM E b �aW N ER� System pumped as part of inspection: (yes ordv6LO If yes, volume pumped: gallons Reason for pumping: e TYPE OF SYSTEM �4 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other ll APPROXIMATE AGE of all components,date installed(if known)and source of information: Sewage odors detected when arriving at the site: (yes o i&�. revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:147 SO Ns CT P(.. SEPTIC S YS rcm ory E' Owner. T—.W l4 (TC Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade:_ Material of construction:_cast iron_40 PVC_other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints,venting, evidence of leakage,etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade:`(M145 Material of construction:/concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ Is age co/nfi(rfined by Certificate of Compliance_(Yes/No) Dimensions: �1b',�X y to",W X 5' 'I Sludge depth:l/NC -� b Distance from top of sludge to bottom of outlet tee or baffle:W1pj6KS Scum thickness:2,I/UcH Distance from top of scum to top of outlet tee or baffle: 31 $ Distance from bottom of scum to bottom of outlet tee or baffle: 51IV045 How dimensions were determined: TRPE M154SY06 Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, . evidence of leakage,etc.) (/ek Goo O Colo row PCRSr/C. PVC TIES .C-I QV I D R7' B077&1,1 OF 0(11T- €T 7� . GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass Polyethylene_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) revised 9/2/98 Page 7or11 L �; • .. ... .. ` .-� _. _ �'.t`.: �-. ..fir.. y�4v, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(condriued) Property Address: Y7 S-U/ S ET Pt, S6 pVc SY SIEM -4 6N E Owner:T, W 14M6 Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX:J�, (locate on site plan) , Depth of liquid level above outlet invert: 4 r-&776M Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box, etc.) ONE PIPE fN — ORI Ply OUT; ft SOURS PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 Page 8of11 L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) - Property Add►ess:q 7 SvNSC l Pr:. S€PT/C SYS-r6-M Owner: T—, W N M5 Date of Inspection: -�_��J.��. SOIL ABSORPTION SYSTEM(SAS) (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, ex,.� lain: Pp NAS RE . OxXtCp , f?[/r NOT CAC-4yATED , 04)0 k f,9UE/n6/VT Type: CNE SO FbaT /000 6A(.00/U CE'AG�/ P/T leaching pits, number: leaching chambers,number:_ leaching galleries,number:_ leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number._ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, d p soil,condition of vegetation, etc.) No POruoIN& /pit Q6NS 01� t'DRRuCiC ¢,gi�v2E CESSPOOLS:_ (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.) PRIVY _ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.) revised 9/2/98 Page 9of11 rZ- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FARM PART C • SYSTEM INFORMATION(continued) Property Address: SVIvSer PL. p—l(L .Sf's7E/►-I QNF Owner: T.W H 177 Date of Inspection. '''19q� SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) .rn�i,� HoUsE t�R t �y 39 - 30 C. � revised 9 2 Page10of11 Ise / /98 t 4; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM NFORMATION(con*weM - TE Prop"Addlrew:97 S-m-56-t PL, SE PT(C sy5 M lowner: T-,vJ(4 ITC Date of Inspection:/ NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) OWNE HAS /A)FOR A7-/OrL) 0 Aj "4'rEk 7-A Ge-(g revised 9/2/98 Page 11 of 11 COVIIMONWEALTH OF 1JASSACH'�SETTS EXECUTIVE OFFICE OF ENVIRONMENTAL FAIRS ` DEPARTMENT OF ENVIRONMENTAL PRO AC; ON �ECEIVEQ 'I ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 J N p 1999 IHD XE y tar9 ARGEO PAUL CELLUCCI B TRUHS Governor � otnntissioner SUBSURFACES GE DISPOSAL SYSTEM INSPECTION FORM DUES_ ILI DU.S� � � i-� PART A 5 _ S CERTIFICATION Property Address: 1 7 sos T PT Name of OwnerT_ W �I Address of owner• SAME Date of Inspection: 6-1-iy�9 �Di�1ARD�. Name of Inspector:(Please Print) QO(.sF/C j_D 1 am.a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) _ Company Name: E0W4RL-) Cr Marring Address: Qwnw Aur 94AjdwC�1 Telephone Number: S g S�Q CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature:e Date: C7 The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page Iof11 , i�Printed on Recycled Paper _ — vz 1Yr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A . , CER�TI�FIICAAT�IIO'N(continued) Property Address: y7 soivsc-T PT; �j l/C-�/ f7 iV ownerT w#1 rc Date of Inspection: _//p INSPECTION SUMMARY:? Check(p B, C, or D: A. SYSTEM PASSES: m XI have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health, will pass. Indicate yes, no, or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined",explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of. Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection:or the septic tank,whether or not metal,is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health), broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2of11 Rr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERT//I-'FICAATIO/N(continued) Property Address:y 7 5wc-r Pr, G UCJ/ A/o(6 E Owner:T,law/w Date of Inspection: C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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. v- The system has a septic tank and soil absorption system and the SAS is_within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3of11 r VW r" SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM gr. PART A r CERTIFICATION(continued) G oEST Ilovs C-- Property Address: SuNSET PT, Owner:or; Date of Inspection:6_I-M9 D. SYSTEM FAILS: You must indicate either"Yes" or"No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is-less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either"Yes" or"No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 9�aaY�B.�p" -":'� ...}. ...._. r. �T..."-S'-. .. •-we Aim�6' 9 «.,,. .. - - .. _m SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 5. PART B CHECKLIST Gv s� �0 o Property Address: y 7 SuIUSPr SIF Owner: 'F W NrW pp Date of kspection:/ Check if the following have been done:You must indicate either"Yes"or"No" as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health. _ - /► None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this Jn inspection. As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. X _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. -A _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)] x _ The facility owner (and occupants,if different from owner) were provided with information on the proper maintenance of Subsurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM a . PART C SYSTEM INFORMATION Property Address: -7 6V&d,4..r P7, GVCs Owner: Date of Inspection:,(_�_��yY vv FLOW CONDITIONS RESIDENTIAL Design flow: /10 g.p.d./bedroom. Number of bedrooms(design): Number of bedrooms(actual): Total DESIGN flow VV o Number of current residents:_ Garbage grinder(yes or f1�9:-,&v Laundry(separate system) (yes or(g):A&: If yes,separate inspection required Laundry system inspected (yes or no) Seasonal use(yes or no):_ Water meter readings,if available(last two year's usage(gpd): Sump Pump(yes or�:ALI) Last date of occupancy: COMMERCIALIINDUSTRIAL: Type of establishment: " > Design flow: qpd ( Based on 15.203) Basis of design flow Grease trap present:(yes or no)_ Industrial Waste Holding Tank present:(yes or no)_ Non-sanitary waste discharged to the Title 5 system:(yes or no)_ Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: — — GENERAL INFORMATION PUMPING RECORDS and source of information: MY /4107- RC641 10y1*70PC0 System pumped as part of inspection: (yes or gy�t If yes, volume pumped: gallons " 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known)and source of information: Aaemx -3S vrf Sewage odors detected when arriving at the site:(yes or& / revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM %.` PART C SYSTEM INFORMATION(continued) GUEST f-/ousc Property Address: �7 SUNS6T PTr, owner::011rc Date of Inspection:6+1g9_I BUILDING SEWER: (Locate on site plan) Depth below grade:_ . Material of construction:_cast iron_40 PVC_other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints,venting, evidence of leakage,etc.) SEPTIC TANK:,`, (locate on site plan) Depth below grade: Material of construction: concrete_metal_Fiberglass Polyethylene_other(explain) If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: Sludge depth: IIVC14 Distance from top of sludge to bottom of outlet tee or baffle: �At I'Vo4s Scum thickness:3)IUCHS Distance from top of scum to top of outlet tee or baffle: 1 SINUS Distance from bottom of scum to bottom of outlet tee or baffle: R 18&9f How dimensions were determined: 'TRPE ftASURF Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) 7 ko,!tcolnmelyo Pump 1N7AC4-1V6XT V 04'e' C.4sr ,-.Rmj TEES GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain). Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) revised 9/2/98 Page 7of11 CI +v✓k.'e"' .. y.hw �'�'+!"P�Y"'�i�~ �a'f _a4 +, t1'4aw'A'�'•(- i.s?;.--I�Y -a. _ . _t SUBSURFACE SEWAGE DEPOSAL SYSTEM INSPECTION FORM SYSTEM INFORMATION ,( )continued - Property Address: ! 7 SUNSET PT �(f�� -10 /SF ' Owner:'T.I(IN//7(Z7 Date of Inspection:� TIGHT OR HOLDING TANK:7 (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) ' DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: _ Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ ►locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 Page 9of11 aY'�- + . - - _ w:.k.i..xGi.. �aY -„✓..r_-f.s-• .. �•-.w...r: ... .e:-vat ...:'.e .-, wr..4.m':w. v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t PART C SYSTEM INFORMATION(condmieM Property Address:9-7. 50S67 Pr. G UE S i yASE owner:T.(ACE{1M Date of Inspection:+Igyl v SOIL ABSORPTION SYSTEM(SAS). (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explai �AVC Nor 10,, A Q 5/4,S 47"FE0 Nyu(ZS OF SEARCHING Type: leaching pits,number: LEAD!-( pIT OR Po55tB�Y LEl3�H T�E/L'C/�S leaching chambers,number:_ leaching galleries,number:_ leaching trenches,number,length: leaching fields, number,dimensions: overflow cesspool,number:_ Alternative system: _ Name of Technology: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, dam soil,condition of vegetation, etc.) NO s��NS OF DAMP Soli PcN0i2'G i0e damp F!1LwY-E tV Y161-1 VEGEr ry&', CESSPOOLS:_ (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) revised 9/2./98 Page 9of11 ..,. .. ,....�,.tr B..i.�.7s-G �,pt.�w�-� .•.0 ea K.:.."t .T.y�'�'.gr,y+.d sb,s:..ht ._ ..,. � ..... J,.,,., $''.Y. - _. .. 'pry :. .a _ .. .{ ?4 •w.�+ t n °y4'vh "�i'1i`i ] 9�E # a j H_. .. - —' •. �A,�r�t..,... � y�,A:.•^.ti'h�'ua.s�:b-� a�. xf ea + A) 'iY'.^'4-r�'+ •,'h �.�. }'� _., . SUBSURFACE SEWAGE DISPOSAL�SYSTEM INSPECTION FORM PART SYSTEM INFORMATION(continued) h � ) Property Address: 17 SUNSET pr; 6(/ES7 yDUSE Owner: 7, W y(Te Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 1 D 5 5' ,w M o5S18CE ��afiioN ►NG W f1"N SoME�yN� ��Ea UP REROt) DOw'U t pgoae revised 9/2/98 Page 10or11 - ` f ..ti.- +...,.,�,�-� ...,».. s :. .<.�' a .: . .. - —�-•.^ .,az -s _ �.�. r _ .:. b,_ „e y��, .;r. -.r, �..SCk�e.�, _.• .. ,«"� .,C, —n�.,°Wa+rf3y'i=a".i t. _ ... , ., ... , -,t. ....». ^.:..ii:... .fin:._ y. 4 r 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM!INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner'T,(A a Date of Inspection: NRCS Report name 1 ' Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) OLUAJEK WAS YyFO ON W,11V)e 7r466C revised 9/2/98 Page 11of11 010 No.C;-Q �L Fee / Lj 6 THE COMM WEALTH OF MASSACHUSETTS Entered in computer: yet,— PUBLIC (; HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS application for ]Disph8al 6pstrm Construction permit �V Application for a Permit to Construct( ) Repair(-�<pgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.tq SUCI`.�,� �OQt1} Owner's Name,Address,and Tel.No. Assessor's Map/Parcel (n 5 —a (DrUGe �)d"M�CD Installer's Name,Address,and Tel.No. 7'7�-a Designer's Name,Address,and Tel.No. 3(pa- agao7 ��iC��ll�C`tl V.�O a �C. CCU t Type oo`f�lBuilding: ry� Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided ��d gpd Plan Date 1a Number of sheets Revision Date Title Size of Septic Tank I Type of S.A.S. Lr MS 0�,7� - Description of Soil Nature of Repairs or Alterations(Answer when applicable) �4'c�E y C("v C Ce cbQ t`S 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 t e Envir ental Code and not tQ,06ce the system in operation until a Certificate of Compliance has been issued by this Board of exalt f !!! - l igne ;i'-�' ,� ._. Date ) / Application Approved by Date � ` ,3 Application Disapproved by Date for the following reasons Permit No. �—© � R Date Issued ------_ — - ---------- ------ - - -- —— — - �� r Fee /0 THE COMMONWEALTH C�aF MASSACHUSETTS Entered in computer. Y PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS � ..s.. �J�IYItat1DTY for �ISpD��I Mop8te11I COIIStCULtIOtI 'Permit ! GL6 0 Application for a Permit to Construct( ) Repair(14111Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot.No.yI �U(1`. � Ocic*t Owner's Name;Address,and Tel.No. l '`,Assessor's Map/Parcel Q 5 ) ®C r 7 Installer's Name,Address,and Tel.No. 75—d Designer's Name,Address,and Tel.No. �jtpa- aC�o1p7�_nw. e;c�thc u.�,Vie. ors Mt eGTN ass �� 4, t _ uer Type of Building: k11 /), -I 't , J 1 f +� Dwelling No.of Bedrooms ``,,� Lot Size sq.ft. Garbage"Grinder LAW.�1PShowers( ( ) Other Type of Building ./ 1�1�it 1t f1 No.of Persons Showers( _) Cafeteria( ) Other Fixtures Design Flow(min.required) _021)0 gpd Design flow provided 31s o gpd Plan Date �a Number of sheets Revision Date Title Size of Septic Tank 1 Type of S.A.S. L\ m os OF 5 - 10 6 c-r•( 9\�O Description of Soil ��/ j MS /� :tr►� l � � Nature of Repairs or Alterations(Answer when applicable) —\ �2 y ECG ,s 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 t Enviro ental Code and not top ce the system in operation until a Certificate of Compliance has been issued by this Board of alth I/ igned (� �„- •• Date Application Approved by Date Application Disapproved by - t'. . `'I Date 3 for the followiing_-rreasons •` ! _- - �' o I , / Permit No. �• Date Issued (� THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewagee Disposal system l`+Constructed( ) . Repaired( ) Upgraded cJC ( ) Abandoned( )by 1J2�:Q.�C1�C�1C�(1h(X� ,L�CLSI�, I. + , m at �� �JyC1.�E',°C {;(�t , C)&V`kA)�\\E has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No-,%/ t dated Installer Designer #bedrooms Approved des' n flower " . :rN -'.'gpd j ,. The issuance of this permit hallf of b/e ��c nsty d as a guarantee that the system %etJion as designed.�J .: 11v4 V Date / // Inspector I/.� �` kLx �� �f^ f'l t7�o-`1:(I%( ;{• t r---f - ; No. 4 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE MASSACHUSETTS -Misposal 6pstem Construction Vermit ` Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) System located at Lo 5�� �4 � �(\�s dy�e �nwz 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. Date :-,w Approved I I J14/21i2013/FRI 02: 19 FM - FAX No, -P. 001 Town of Barnstable Regulatory Services Thomas F. Gezler,Director RARNRrAA7 9 VAft Public Health Division Thomas McKean,Director -' 200*Main Street.Hyannis 1VLA 02601 Office: j03-962-464 Fax: 508-790-6304 Installer&Desi Iter Certification Form Date- Sewage Permit;r � Assessor's iVYa �v ` 01 5 1'parcel Designer: Installer: Address: 'BOX j�. Address: y S&AQ u - On was issued a permit to iuistal a {date) (installer) septic system at J ►+�5 T based on a design drawn by j _, (address), _� (desigS V��l dated ner) l certify that the septic system referenced above was installed substantially according to the design, which may include minor approved cb ees such as lateral relocation of the distribut',on box andlor septic tank. 4.c'V�k.IEVA Kat V-. 10 WrV 4_2�o p016TQ W-1 . &610� �-- 3 P-r BELOW AA00 M000 IDILNP—V+N I certify that tl a septic systern referenced above was installed with major Changes (i.e. greater than 1 Q' lateral relocation of the SAS or any vertical relocation cf any component of he septic system) but in accordance with.State& Vocal Regulations. Plan revision or certified as-built by designer to follow. OF .,ilgss��d •R � `�'�T`'y� � D R N M. (installer's Signature) S1 -A S�NITAIt�P �L (Designer's Sianamm) (Affix Designer's Stamp Here) PLEASE RETURN TO STABLE PUBLIC HEALTH DIVISION CERTIFICATE OF CONIPLLUNCE WILL NOT BE ISSUED UNTIL BOTH THIS FORNI AND AS-BUILT CARD ARE RECEIVED BY THE BARR\STAYM, PUBLIC HEALTH DIVISION. THANK YOU. Q:HealttUSepcic!Designer Certification Form 3=164.doc r I � IN 2 716 tin 5.92 - :w. i OSTERVILLE _. U) a� .. InGO I � I : 30' C 6v OYSTER I HARBORS N \ PARCEL ID: 2 '.. OTUIT a 51/011 I 5 BAY LO US. I 00 _. N 1G, DOE C= J \ SOT UNE 15.5 16.6' Bulk-ONBulk-ONSETB� ' i pROP.. _ ti /GARAGE 1 �� LOCUS MAP 2 27.6' 28.T� 4 6 (oN StAB)u ] �/ TITLE REF: CTFp2002 2 Ct PLAN REF.' LC 22528A OBS. 10' S PARCEL ID: MAP 51 PAR. 15 1 / ZONING: "RF-1' SETBACKS: 30'F-15'S-15'R C.0.5p3+ WITHIN 1 MILE FROM COAST: EXPOS. 8 (� m 0 - � �C TTAES � -N 10' 1 01 S.6 EL:�25001CO756J NDATED:07/16/14 HAZARD/ / / FLOOD ANNUAL ' COMMUNITY PAN /� / / xO. 9y \ J\ oBs.bg: / / ' / CERTIFIED .PLOT PLAN (SHOWING PROPOSED ADDITION) 79.4' 1 LOCATED AT: 47 SUNSET POINT OSTERVILLE, MA. PARCEL ID: y " 51/015 �� SPHALTI \ l 1 If PREPARED FOR Z S RIVE 1 G y . AREA= 1.97 ACRES Tp� _J o 4.. jl o THE JOHNSTON FAMILY 122.T / I 1/ v O� AUGUST 3, 2015, REVISED: AUGUST:19, 2016 1 / REVISED: OCTOBER 28, 2016 0. A � � \ � x��' E or weD��yG STONE CB/DH No.28 Poo' r_ LpO�F o S A Sib .1� ------ __� --- BUILDING 1 LOT LINE MEYER & SONS, INC. CB/DH PARCEL ID: GRAPHIC SCALE P.O. BOX 981 51/008 30 U 15 3 B0 126 EAST SANDWICH, MA. 02537 (508)362-2922 ( IN FEET 1 inch = 30 ft SHEET 1 OF 1 J 1541CP3 qll W-, Klils SEWAGE PERMIT NO. VLLLAGI VISTA LILER'S 04AME ADDRESS 1B U 1 L D,E OR OWNER DATE P F R N I T ISSUED DATE COMPLIANCE ISSUED � ifJ? J� __ _ _ �. r� //' � �i � � a � , � �� � .� �� ; � � �� � . F ^� 1 . R , ............................ THE COMMONWEALTH OF MASSACHUSETTS BOARD 9F HEALTH ----­--­--­OF......10.A e I).CS j.W� w 4E................1:............. Appliratiou for Uhipoiial Workii Totutrur6ou-11amit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: _/ 44, /6'__ ---------------- .... .................................................................. tion-Ad VS ore No., ------------------ ­ ---------------------------------- ...................... ................. ...:,4oca ..... .. ... ................. . ....... ... Owner Address .................................................................................................. ....................................Ig............................................ Installer Address Type of Building Size Lot...12!ic------- L�5o. of Bedrooms.......................61...............Expansion Attic (L�p Garbage Grinder U Dwelling Other—Type of Building ............................ No. of persons._....._.._..........__.___. Showers Cafeteria Otherfixtures ..................................................................:...................................... ------ ..7 ..Design Flow................ S-5- �75�%ailo,,.. ailo s,per person per day. Total daily flow................. ------------i-----E 6, CZ 9 Septic Tanl5--Liquid capacit W V11.376---gallons Length................ Width....._..._...___ Diameter---------------- Depth........... Disposal Trench—No..................... i�thgy------_----- Total Length................v... Total leaching area....................sq. ft. Seepage Pit No-----C;7......... Diameter./,.4. .. ...... Depth below inlet....Z.......... Total leaching area..15.V4...sq. ft. Z Other Distribution box Dosing t k Percolation Test Results Performed by 3.1 Date........_ r Test Pit No. 1.........I-----minutes per inch Depth of Test Pit k -V .......... Depth to ground wat I............... r--- Test Pit No. 2...........1_...minutes per inch Depth of Test Pit" Depth to ground water_ ,tr7. . ..... -------------- ......... .... ............. ;........;0........................................ .0 Description of Soil--.-. L>-m. ,... ............................................. U ......................................................................................................................................................................................................... ........................................................................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable................................................................................................ .........................................1­........................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with State the provisions of L 5 of the Sta' Sanitary-Code— The undersigned further agrees not to place the system iri operation until a Certificate of Compliance has bee issue he board of I I Signed...... ..... .................... ....... ......................klei%J7...... ApplicationApproved By......................................................................... --- ------------------ ---------------------------------------- Date Application Disapproved for the following reasons:................................................................................................................ ....................................................................�m................................................................................................................................... Date PermitNo......................................................... IssuedL....................................................... Date .............. tt THE COMMONWEALTH OF MASSACHUSETTS BOAR® PF HEALTH �- cJ,tJ................OF.............A..ft- ---S. 4t Applirdtinn for Disposal Works Toustrnrthin ramit Application is hereby made for a Permit to Construct ( or Repair-( ) an Individual Sewage Disposal System at ocaf n-Ad s ,/ e� (}°mot.� /.��[ •-- u-f�r_x-/'l•...1-- ------•-••-••----..1..1..-1..�---------------•----- --•- ----------•- •or Jett No.�...��!vhJ----- W Owner Address ' --------------------------------------------•------•----....................................••••.. ..................................... --•---••••••--•---•-..................••••....•• Installer Address i- Type of Building // Size Lot____ ,I5.._._______ a Dwelling . of Bedrooms______________________S _.._....__.__..Expansion Attic (� Garbage Grinder (� 5 aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures -------- , 7 Design Flow.......................`J5.k 5 ._ allons per person per day. Total daily flow................. .'I.. ......._..gallons. a, Septic Tank{--Liquid capacitYi.. lions Length................ Width................ Diameter................ Depth................ Disposal Trench—No..._.....�.... Veialth-�/............. Total Length.............../--- Total leaching area....................sq. ft. Seepage Pit No.....0?-__-.__-- Diameter.- ..t _j Depth below inlet_............. Total leaching area.�r�- ._...sq. ft. Z Other Distribution box (LL� Dosing tF k ( ) ' ` \ _,-- '-' Percolation Test Results Performed by.._.....t-�-_4-�4...... .-__ :.G� �Date.......... � lP ---------Test Pit No. 1.._..._.._I.._._minutes per inch Depth of Test Pit.�._�........_._ Depth to ground water_.___G>~ Test Pit No. 2.._.._.....i..._minutes per inch Depth of Test Pit-_lk._IZ.. Depth to ground water.._ .....___.. a l �� h .may' --------------- _ _ __ _ D Description of Soil---- .F L .:5 (1__.e�.�/�." !!' 4�JIA... x U -------------------------------------------------------------••-------•-------...------=•-...-----••-•-•-- W UNature of Repairs or Alterations—Answer when applicable------------------------------- -- -•--•-•---------------------------------------------•----------.........------..--------•-•---------•-•-....----•--•-----•-•-----•----------•-••-••-•-........................_. ; A eement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with %7 the provisions of TITIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue he board of h 1 t Signed....... ------ ---------------------------• •-------•-•---------•- - ---•--(J7 7 Date Application Approved By........................................................... Date - Application Disapproved for the following reasons:--•••-•-----••---•---•---•-----•••-•---•----•--•---•-••-•-••••--••------•--••-•---•---•••--•••---• w -............. F. ...................•.................................._......................................................................_.....................-.......----...........•---......----................. e. Date Permit No.......,.......--.. ..------••--••-• Issued------------------ .............•----•---- •- ---•--•--•-•----•- -------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......................OF....' .......................................................................... Qrrtifiratr of Tompliam THIS IS TO CERTIFY, Thy the Individual Sew/age Disposal System constructed ( ) or Repaired ( ) - Sol* Inst ller has been installed in accordance with tt-le provisions of TITLE r of .her�tate Sanitary Code as described in the application for Disposal Works Construction Permit No..__.......IIA-_ .7 7-•--• dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTR AS A GUARANTEE THAT THE SYSTEM W1 F NCTION SATISFACTORY. DATE....../.z .>.�....................................................... Inspector.... ... •••---------•....•••---......•----------•......-----•..........-••....-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH env No..... -........ FEE.. ................ Permission is hereby granted......... -? ?• --------•---•------ ...................................- to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at No ----------- >...............•..••. Street " as shown on the application for Disposal Works Construction Permit No.._....... ..`?��. Datedr.__.____._._ `..L....: .......... _, / + DATE. /` `�" r (/ Board of Health - 4 ` -fk FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS t, ,, ,: . , .� " , z. : , b d ,.'r - ll� _ _ .. ,e A I: (a.xP.xP �X1511NG - - t' :�: ,� .. yRv G c.�I _ 11 WaCI1NG e/oxe/9 - ^maexxi •. x - - :f�X1Jl IN� . � - " - n,ap a .> ., e - ,sc I z 15 a ;,. z 11. % ------- -------- ---- - ' '-- _ ------- ------ ------- --=i'., +; � t� a . wrote .O - 1 .. . . r„ l C.) U C" S} P . ' �: h fD-N VTI%! fD-N~v- - (D-N,/Tx%f ,a ' 1 i ,a W 9,Y'.., �. MAf ROOM ; �,,N 1 i - ' , C�: dd QVf VOOM 0 :O a� " NEW w �, . t DEtY00M#I , ' ex• r• --- ----- ----- #2------- --- -- -- '1 u O vwrorx: . ---- ---- it. 's �i 0 pj W.I.C. 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