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HomeMy WebLinkAbout0011 TEA LANE - Health 11 TEA LANE OSTERVILLE A = /f l I i u u TOWN OF BA INSTABLE t/ LOCATION �r ��'� SEWAGE # VILLAGE / ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. �/J�-�S SEPTIC TANK CAPACITY �LG"tJ LEACHING FACILITY: (type) ��cS"9"off (size) NO.OF BEDROOMS BUILDER OR OWNER L.4 i PERMIT DATE: S /a"9 $ COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to th ottom of Leaching Facility Feet Private Water Supply Well and Leach, Facility (If any wells exist on site or within 200 feet of lea ng facility) Feet Edge of Wetland and Leach,n acility(If any wetlands exist within 300 feet of leac 'ng facility) Feet Furnished by W Ate` a i c xL 0 No. Fee $5 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZIpprtcation for �Dtgpos%al *pztem Congtructfon permit Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 11 Tea Lane , Osterville , MA Joseph and Lillian Eid. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service PO Box 1089, Centerville , MA Type of Building: Dwelling No.of Bedrooms 3 Z 5 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand. Nature of Repairs or Alterations(Answer when applicable) new Title-5 septic system. 1 , 500 gal. tank, D-box and. stonepacked. ieachchambers. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Bpard Oealth. , Signed � Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued �61'Lum t. N FeeSO o q. N Entered in computer: v w THE COMMONWEALTH OF MASSACHUSETTS Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZIpprication for ;Dizpaar *pztem Cortgtructiou Permit i Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components ocation Address or Lot No. Owner's Name,Address and Tel.No. Tea Lane, Osterville, MA Joseph and. Lillian Eid. ' Assessor's Map/Parcel Installer's Name,Address.,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service PO Box 1089, Centerville, MA ; Type of Building: Dwelling No.of Bedrooms 3 / 5 Lot Size sq.ft. Garbage Grinder( ) ' Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures ; Design Flow - gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank' Type of S.A.S. Descr.:iption of Soil Sand Nature j4 Repairs orAlterationsa(Answer when applicable) new Title-5 septic system. 1 ,500 gal. tank, D- ox and, stonepacked leachchambers. Date last inspected: t 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 until­a1Ceitifi- cate of Compl" has been is edlbLis, } and ;`ealth. Signed tDate��� Application A�pro ed by Date -r Application Disapproved for the following reasons I Permit?V Date Issued THE COMMONWEALTH OF MASSACHUSETTS Eid f"! BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired (X )Upgraded( ) Aband ed Wm. E. Robinson Septic Service at Iggqq ( by Tea Lane , Osterville, ^ . e' co structed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ate InstallerWm. E- Rob ins on S r. Designer Cl The issuance of this,p" t sha 1 t'be c nstrued as a guarantee that the t will function a desi/ Date Inspector _ -•---1 �` ---- ----- ---- -_- -_- No. > Fee- - $5 0 - - - THE COMMONWEALTH OF MASSACHUSETTS _ PUBLIC HEA&A 61VIS4ft-- RNSTABLEs MASSACHUS _iye��r - E id dg ool * 5tem CowAructiou Permit Permission is hereby granted to Construct( )Repair� )Upgrade( )Abandon( ) System located at 11 Tea Lane , Osterville, MA 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. // O c Provided: Construction must e c 9npl/t ,,W in three years of the date of s e t. Date: Approved by / l� i I ti 1 1/6/99 . NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WTTHOUT DESIGNED PLANS) I William E . ' ft obinson,S,rnereby certify that the application for disposal works Q construction permit signed by me dated /6 -Qf ef concerning the property located at 11 Tea 7 nP , Cis+Ariri!I@,--r:rn meets all of the following criteria: • The failed system is connected to a residential dwelling only.-There are no commercial or business uses associated with the dwelling. 6 he soil is classified as CLASS I and the percolation rate is less than or equal io S minutes per,inch. ' There are no wetlands within 100 feet of the proposed septic systeni — 1 /There are no private wells within 150 feet of the proposed septic system V- There is no increase in flow.and/or change in use proposed no/There are no variances requested or needed. ��The bottom of the proposed leaching facility will not be located less than five feet above the mammurn adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable) a If the S.A.S.,wilI be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(l l) feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) u, B) G.W. Elevation +the MAX. High G.W. Adjustment DIFFERENCE BETWEEN A and B SIGNED : d a, t DATE: 07 [Sketch proposed plan of system on back]. q:health folder:cert ., • ' �� i J� �v . �� ---� y ��� , . TOWN OF BARNSTABLE LOCATION %� �`'n �• .4 _ SEWAGE # VILLAGE__ �,�' E ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. y�.i•'�-� N 2 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) + /t� NO. OF BEDROOMS BUILDER OR OWNER ''t � PERMTTDATE: S—/D-7 COMPLIANCE DATE: F-atS Separation Distance Between the: Maximum Adjusted Groundwater Table to th ottom of Leaching Facility Feet Private Water Supply Well and Leachi Facility (If any wells exist on site or within 200 feet of lea ng facility) Feet Edge of Wetland and Leachin acility(If any wetlands exist within 300 feet of leac 'ng facility) Feet Furnished by V P-A 'O rt r _ \\` -5 ( ..'a ze j a a TITLE V CALCULATION CHART COMPONENT 3 BEDROOMS 4 BEDROOMS 5 BEDROOMS 6 BEDROOMS SEPTIC TANK 1500 Gallons 1500 Gallons 1500 Gallons 1500 Gallons DISTRIBUTION BOX Distribution Box Distribution Box Distribution Box Distribution Box SOIL ABSORPTION SYSTEM: �1 Cultec Recharger 330's 4 (334 GPD) 6 (471 GPD) 8 (606 GPD, 9 (674 GPD [NOTE:5 are not enough [NOTE:7 arse not C Cultec Recharger 330's(with 2'stone surrounding SAS) -provides only 401 GPD] enough-provides only 538 GPD] Cultec Recharger 330's(with 3'stone surrounding SAS) 3 (332 GPDI) 5 (490 GPD) [NOTE:4 6 (569 GPD) 8 (728 GPD) are not enough-provides [NOTE:7 are not enough only 411 GPD] -Only provides 650 GPD] High Capacity Infiltrators 4(394 GPD) 5(461 GPD) 7(598 GPD) K! 8(667 GPD) NOTE:6 are not enough,only H.C.Infiltrators(with 4'stone and 14 inches underneath) [NOTE: 4'stone is not recommendeed,more infiltrator units are recommended] provides 530 GPD 1 Infiltrator Maximizers 5(342 GPD) 7(457 GPD) [NOTE: 6 9(573 GPD) [NOTE:8 11(689 GPD)[NOTE:10 Infiltrators Maximizers(with 2 ft.stone surrounding SAS) are not enough,only 399 are not enough)only 515 are not enough,only 631 GPD capacity] GPD capacity] 1 GPD capacity] Infiltrators Maximizers(with 3 ft.stone surrounding SAS) 4(357 GPD) 6(494 GPD) 7 (563 GPD) 1 9(700 GPD) [NOTE:5 are not enough, [NOTE:8 are not enough, only 426 GPD] only 632 GPD] Infiltrators Maximizers(with 4 ft.stone surrounding S.A.S.) 3(357 GPD) 5 (516 GPD) 6 (595 GPD) + 7 (675 GPD) [NOTE: 4'stone is not recommended,more infiltrator units are recommended] [NOTE:4 are not enough,only provides438 GPD] 500 Gallon Chambers 4 (395 GPD) 5 (477 GPD) 6 (560 GPD) 8 (724 GPD) [NOTE:7 500 Gallon Chambers/Drywells(with 2'Stone) [NOTE:3 are not enough, are not enough,only 642 only 312 GPD capacity] GPD capacity] 500 Gallon Chambers/Drywells(with 3'stone) 3 (384 GPDI) 4 (477 GPD) 5 (574 GPD) L 6(669 GPD) 500 Gallon Chambers/Drywells(with 4'stone) - _2(355 GPD) 3(462 GPD) �ry+4—(590•GPD)- j5(677 GPD) [NOTE: 4'stone is NOT RECOMMENDED,more chambers are recommended] —Flow Diffusors(wft62'stone surrounding SAS and 12"deep 4(343 GPD) 6(485 GPD) [NOTE:5 —7(556-GPD) ~ 9(698 GPD) [NOTE:8 stone on bottom) are not enough,only are not enough,only 627 provides 414 GPD] GPD] Flow Diffusors(with 3'stone surrounding SAS and 12"deep 3(340 GPD) 5(506 GPD) [Note:4 are 6(589 GPD) 7(671 GPD) stone on bottom) not enough,only provide 423 GPD capacity) Leaching Trench 60' X 4' X 2' or(2) 80'X 4' X 2' or(2) (2)48'X 4'X 2' or (2)57'X 4'X 2' or 30' X4' X2' 40'X4' X2' (4)24'X4'X2' (4)28'X4'X2' Leaching Field 446 S.F. (330GPD) 595 S.F. 743 S.F. 892 S.F. ALL MINIMUM S.A.S.SIZE REQUIREMENTS LISTED ABOVE ARE BASED UPON THREE ASSUMPTIONS (1) No garbage grinder,(2)Class I Soil(0.74 GPD/S.F.),(3)No wetlands within 250 feet of S.A.S.and groundwater is greater than 14'below SAS J:CHARTITV riw Northern Trust Gonilmny- f1 SO Sonlh La Salle SII'el't Chicago. Illinois 60675 (3 12)444-3677 Northern Trust Steen J.Appell Senior Vice President September 12, 2000 Mr. Ed Jenkins Town of Barnstable Building Inspection Department 367 Main Street Barnstable, MA 02601 Ms. Donna Miorandi Town of Barnstable Health Department 367 Main Street Barnstable, MA 02601 Dear Donna and Ed: Thank you for taking the time to review my questions regarding the septic and plumbing replacement work at 11 Tea Lane in Osterville. For background, I have enclosed previous correspondence, plot plan and contract estimates from William. E. Robinson, Sr. - Septic Service. My concerns are as follows: 1. Is the house no 4 certified for a 5-bedroom system? 2. Is the replacement installed at the correct pitch for outflow to the system? Ed, as discussed, I will plan,to meet you at the house on Tuesday, October 3 at 2:00 p.m. to review the basement plumbing. I have also tried to contact William Robinson numerous times during the past 30 days, but did not receive a return phone call. Ultimately, I was informed by the receptionist/secretary to call the Board of Health, "if I had any questions." Please feel free to call my office directly should you have any additional questions, 1-800/621- 1911 ext. 43677. Also, I have never received any copies of Inspection Certificates for the plumbing or septic system. Please let me know if either of you can provide those copies. Sincerely, Enclosures Northern Trust Th; \orthern Tn;st Company 5o�o,:uh LaSatle Street Chicago, Illinois 60675 i ri.i. ;;_,.630.6000 D Steven J.Appell Semor Vice President August 11, 1999 William E. Robinson, Sr. Septic Service P.O. Box 1089 Centerville, MA 02632 Sent Via Fax: 508/790-1694— 1 Page Dear William: My wife and I are the prospective buyers of Joseph and Lillian Eid's home on 11 Tea Lane in Osterville, MA. We are aware of the septic system failure and seller's agreement to pay for Title 5 compliance prior to our closing date of September 3, 1999. We have also agreed with the sellers to pay for the incremental cost of upgrading the system from a 3 bedroom to a 5 bedroom capacity. I am in receipt of both of your estimates and will forward the difference to Mr. and Mrs. Eid upon completion of the work. I will be in Osterville on Friday,August 13, and would like to speak with you regarding additional questions. Specifically,will all fees and permits cover the 5 bedroom system at the time of installation? Similarly,will the inspection by the Town Board of Health and Certificate of Inspection reflect the enlarged system? During construction, I will be in Chicago. However, my brother-in-law, Joseph Brown, is a resident of Marstons Mills and is available to stop by the site at any time. He can be reached at 508/420-2882. ! We look forward to our new home and contracting with you for the ongoing service. F Sincerely, t f i LOT 8 (j, L.O T ' y Q A. rb ikTIO In J . "(ST f� On 63- PA RSL R Y" LANE RES ZONE "RC" FLOOD ZONE "C" THIS mc)R rC;ACE x NSPEC:-F x C:)N PLAN IS FOR TOWN:' E3ANK 'USE ONLY REGISTRY OWNER: DOROTHEA COCHRAN DEED REF: a BUYER:J'OSEPH AND LILLTAN"'8ID DATE: • JULY 14 1988 PLAN REF: 233/81_ SCALE: ere y Cert y that t o u_ ing "�-- shown on t,,his plan is located on c `j"IoFit YAhStC� SUFZVEV the ground as shown and it y �CDNSU _ -rjnf NT'S position does confore to the ° F 70 RASPBERRY.LANE zoning law setback requirebent of MEFis7HEW MARSTONS MILLS No.32098 and does not; lie within the special �°� �'f� QEd �ti'Q MASS 02648 C Sd hazard area as shown on to, .u_ d. flood trap dated - _ ' is P an hot ;ad c "roa an itistrumcnt Paul A. Merithew, PLS survey, not to be used for fence c AUG-04-1999 13:24 COTTON REAL ESTATE T 508 420 3161 P.03 Ly _ P.O. Box 1089 `I Centerville,MA 02632 Plhoneg(508)775-8776 Fax#(508)740-1694 SUBMITTED TO:Joy h and f illian Ei.d _ PHONE:420-2142 DATE; STREET: 11 Tea Lane _..,n.._, _..,_, r_ jOU NAME: CITY,BT,ZIP:Qsterville,MA 026.55 JOB LOCATION:same --._.—._.._............. .,,.,_.... .. ARCHITECT: DATE OF PLANS: �_. JOB PHONE: Dcucripttorn: 1: We wily.turnplumbinIZto left side of houSe a><zd install„new Title=5 septic systezu Consistir of _—_____ _ .� w _ 2: _a 1,500 gal tank. D--box And 4 concrete_. stone asked leaC]I Chambers. _ w— 3: Remove all necessary_trees. _..... .----4- All All ices And Emits. S. All materials and labor. _.,.__.._..._._.__._.__. .,... -6- All All lambing 7: Rake clean, loam,and seed work.area.. 8: I! ecL=on by the Town otBart�stable Board of Health. w_ _ 9: Certificate of Inspection. ' *Not responsible for utilities not marked by Dig,Safe. *Newly installed Title 5 Septic Systems guaranteed for 10 years under the conditions of nmintainenee pumping performed by its every other year. We Propose hereby to furnish material and labor-complete in accordance with the above specifications for the SUM OF: $6 500 Six thousand five himdred dollars. ---------._-.—•- PA'YMENT METHOD., Deposit of$3,800 due with signed contract. Balance Due:Upon da of com letiotx, ._..._....,.�.,....-., -.___.------___--- .._:.............__----M. All mnteon]is gntwanlat!to be as specified All Wrn3:i6�eutPtontini tvorlonanGka ru ma occordipg to speci$eldom%1braitt4 per standard peaclivkx. Ally dttmtion or deviation firm above a cWoation�involving e.tra COO Wa b<e only upon wtittez or ts,and will txcnma an etara Clmtko Authorized cecuted m•Crurdaboveduestatmm.rWap=catstnrttingmlilpanRiktr. aoadenu of detnye beyond ouraontrot Owner to C AY W,m¢nodo and nther necessatyu,sa,anoe. Now This proposal imyhewididrawo 'Our uvrkaa are fully Covered by Travels Property Casual{y, by tis if not vuxpted within days. Acceptance of Propogtd: -the above pried, spocificatims and oWditiotns are sati:rfu=rY And life liercby accepted.You are authorized to do the wotk as -Tecified.Payment will be made as outlined above. Signature Date of acceptance: Signature i Papa: r t I Vropolat I va "� Wm,E. Ra incon Sr Sgotic Srrvice P.O.Boa 1089 Centerville,NIA 02632 Phone#(508)775-8776 Fax#(508)790-1694 SUBMITTED TO;Joseph and Lillian Eid -_------ ---_.._......._. PIIONE:420_2142 -- DATE: Y 7/26/99 STRZET: 1 I Tea Lane _- JOR NANTE:Sop6o syStent CITY,ST,7AP:OStcrville,MA 02655 JOB LOCATION:salve ARCIIITECT: DATL,OIL PLANS: JOB PRONE: Dcacription: _ 1. Left side of house and install a new Title-5 septic-SS ystM, conkstin of a �f 2: 1,500 gal. tank, D-box and 2 concrete,stonepacked leach chambers. _ — --� 3:Remove all 4: All fees aitd permits- _` 5: All materials aind labor, 6: All plc inbh!_g costs, _ _ Alb 7: k1cE,Olean, loam and seed work area.. � 8: Ins on by the Town of Barnstable Board of Health. g: Certificate of 1i1sectioix.ry ,,.....,, 10: 11: *Not responsible for utilities riot marked by big Safe. *Newly installed Title S Septic Systems guaranteed for.10 years under the conditions of maintairlence puking performed by us every other year. We Propose biereby to furnish material and labor-complete in accordance with the alcove specifications for the SUM OF:$5,000 Fivc thousand ninety dollars. PAYMENT METHOD:Deposit of.$3,500 due with signed oontract._ Balance Due:Upon day of completion_ _ _ rW material i,guaranteed to be a,xpcei5ed AU.+erk is a substantial worknwnLl;e •manna eecotdins to spai6a,6ons Kbndttv],pa inwidud praaian. Any dM-ation or deviation from above:pedfimtions invoking exam costa hill be e:eecuted only upon atitlen order,and will become mn e,Ctin 0wpc Autho riz over and above the eabmatea.All agr=etti con4ngatt upon acnt:ea, f mojdeRa or delays beyond rnrr control Qwittt b CAt[y are,toatado and ether . naWacvinaaranx• Note:This proposal maybe withdra-Am "Our xwrke rs are fjLL5i covered by Travelers Property Casualty. by us if not accepted within^, �days. Acceptance of Proposal. he above pdce, specifications and miditions are satisfac oiy and ate hereby accgAod.You arc audjorrzed to dotliework as spocified Payinadivill he niade as outlined above. Signature Date oPAcccptancc: ._ Signature RaRti- . TOTAL P.05 Y CO NI'ION-WEALTH OF MASSACHUSETTS _ 1 EXECUTIVE OFFICE OF EN-viRO"INMENTAL AFFAIRS �' �•• -:rtr.— DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE 'WINTER STREET. BOSTON MA 0210S (617) 292.550o TRUDY CORE, Secretan ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Conurussioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 11 T1ea Lane , Osterville Name of owner Joseph and Lillian Eid. Address of Owner:S 9 M e Date of Inspection: Name of Inspector:(Please Print)Wm. E . Robinson Sr. I am a DEP approved systerrl inspector rsuant to Section 15.340 of Trde 5(310 CMR 15.000) Company Name: Wm. E . Robinsoneptic Service MaBingAddress: PO Box 0 9, Centerville , MA Telephone Number: 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 sew a disposal systems. The system: Passes Conditionally Passes µ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: W ' Date: / 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 t . 0 RECOVE0 SEA 8 1999 � TOWNOFDARNSTggLE HEALNDEPr revised 5/2/98 PagcIofll ti ✓n^red on Recyclyd Paper I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued)- Iroperty Address: 11 Tea Lane , Osterville Jwner: Joseph E i d. Date of Inspection: INSPECTION SUMMARY: Check (OBI C, or D: A. SYSTEM PASSES: �.J 74 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. ENTS: i B. S STEM CONDITIONALLY PASSES: i 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. j 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). i 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 { r •i. ti U I revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A .CERTIFICATION (continued) Property Address: 11 Tea Lane, Osterville Owner: Joseph E i d t Date of Inspection: C. FU ER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: C ditions exist which require further evaluation by the Board of Heilth in order to determine if the system is failing to protect the pu lic health;safety and the environment. 1) SYS WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS N 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) SYS M WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUN TIONING 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 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) 0 HER i . r s t revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 11 Tea Lane , Osterville Owner: Joseph E'id. Date of Inspection: 7 p-`^ D. SYSTEM FAILS: You At indicate either "Yes" or "No" to each of the following: .have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this etermination is identified below.. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes 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 1l2 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 STEM FAILS: You must indi ate either "Yes" or "No" to each of the following: The ollowing criteria apply to large systems in addition to the criteria above: The ystem serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public healt 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 perator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the apartment for further information. i revised 9/2/98 Page 4of11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property ddres. 11 Tea Lane , 0 s t e ry i l le Owner: J o s e ph E'i d. Date of Inspection: Check if the following have been done: You must indicate either "Yes or "No" as to each of the following: Yes i 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 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. _ The site was inspected for signs of breakout. ✓/ _ All system components,excluding the Soil Absorption System, have been located on the site. V _ 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)] The facility owner (and occupants,if differerg from owner) were provided with information on the proper;maintanaaC4"f SubSurface Disposal Systems. revised 9/2/98 Page 5ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION tiopertyAddress: 11 Tea Lane , Osterville owner:J o s e ph Bid. Date of Inspection: S�G� t9 g FLOW CONDITIONS RESIDENTIAL: Design flow:- .7 6g.p.d./bedroom" Number of bedrooms(design►: Number of bedrooms(actual):_ Total DESIGN flow' 8 Number of current residents:_ Garbage grinder(yes or no):.Ae IS Laundry(separate system) (yes or no):&.0 If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):Al—b Water meter readings, if available (last two year's usage(gpd): 1998 129, 000 gal. Sump Pump(yes or no):_z J 1997 141 , 000 gal. Last date of occupancy: �4 COMMERCIAL/INDUSTRIAL: Type of stablishment: Design fl w: gpd ( Based on 15.203) Basis of) f esign flow Grease tr p present: (yes or no)_ Industria Waste Holding Tank present: (yes or no)_ Non-san ary waste discharged to the Title 5 system: (yes or no)_ Water eter readings, if available: Last a of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS andjjource of information: //4 System pumped as part of inspection: (yes or no) �t/D If yes, volume pumped: gallons Reason for pumping: TYPE O 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:�i g� •f`9 Sewage odors detected when arriving at the site: (yes or no) /- ys revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icontinued) *ropertyAddress: 11 Tea Lane , Osterville t Owner: Joseph E i d. Date of Inspection: BUILTG SEWER: (Localon site plan) Depth b low grade:_ Material f construction:_cast iron_40 PVC other(explain) Distanc from private water supply well or suction line Diamete Comme ts: (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: 4 Dt f!i Sludge depth: Distance from top of sludge to bottom of outlet tee or-baffle: Scum thickness: r 1 Distance from top of scum to top of outlet tee or baffle:_ t I Distance from bottom of scum to bottom of outlet tee or baff}l : How dimensions were determined: 11lat✓ . 1� L. IC ;omments: (recommendation for pumping, con ition of inlet.and outlet tees or baffles, depth of liquid level iti re lion to,outlet invert, structural integrity, evidence of leakage, etc..) ` 'yit J� L IV TL{ Le cC. GR ON E TRAP: s (locate on site plan) Depth b ow grade:_ Material f construction:_concrete metal . Fiberglass _Polyethylene_other(explain) Dimensi s: Scum th' kness: Distanc from top of scum to top of outlet tee or baffle: Distanc from bottom of scum to bottom of outlet tee or baffle: Date o last pumping: Com ants: (recl mmendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evid nce of leakage,etc.) i revised 9/2/98 Page 7of.11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART C SYSTEM INFORMATION Icorrtinued) Arop"Address: 11 Tea Zane , Osterville Owner: Joseph E i d. Date of Inspection:' TIGH OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate n site plan) Depth b ow grade:_ Material f construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensi s: Capacity gallons Design ow: gallons/day Alarm p esent Alarm I vel: Alarm in working order: Yes_ No Date previous pumping: Corn ents: (condi ion of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: V Comments: Inote if level and distribution is equal, evidence of solids carryover, evi ence of leakage into or out of box, etc.) - 0& 44 � �� PUMP CH MBER:_ (locate on ite plan) Pumps in orking order: (Yes or No) Alarms in orking order(Yes or No) Comments (note con tion of pump chamber, condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'ropertyAddress: 11 Tea Lane, Osterville Owner: Joseph Lid. Date of Inspection: j-_'p,4_9ej^ SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: " Type- leaching pits, number:_ leaching chambers,number:T Z-f 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, damp sd'iLcondiPn of v etation, etc.) CESSPOOLS:_ (locate on site plan) r Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer. )epth of scum layer: Dimensions of cesspool Materials of construction: Indication of groundwater: ,4� inflow (cesspool must be pumped as part of inspection) Comme Is -. 4 Inote co dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) r • PRIVY: (locate o site plan) Materials of construction: Dimensions: Depth of olids: .Commen s: (note co dition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) h revised 9/2//9C Page 9ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) "ropertyAddress: 11 Tea Lane , Osterville )caner: Joseph Eid. 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) i ti i i n6ti r �L"G� revised 9/2/98 Page 10of11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) rope►tyAddress�l Tea Lane , Osterville owner: Joseph E i d Date of Inspection: �. O 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) V revised 9/2/98 Page 11of11 I.F.S.5-621.1013C V SEP12'0o 50 South La Salle Street i "» Chicago,Illinois 60675 f pp U METER a Northern Trust 7022104 U.S. POSTAGE , :a FIRST CLASS MAIL W 7: S 11 �a r 0 16 rck i'1 C� ©r., , ✓t P `7a a �� '� � � ' .� i _ -. 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