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HomeMy WebLinkAbout0204 WASHINGTON AVENUE UNIT #A - Health 204 Washington Avenue Osterville P A = 139 083 z ,. a _ q �_ -- �4 .� -.�.--.��_ 9,...-�-��.�.6—mow-; �-n�;��-��-��•:�. r ° o e oc a 0 c c k n -✓1 1 TOWN OF BARNSTABLE Li7CATION OyLJAsy,,�6T� �.L. SEWAGE# o� VILLAGE ©S%criyi/lc ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO.Z-tC.ccJ J_.S- SEPTIC TANK CAPACITY 2�000 69t 1 LEACHING FACILITY.(type)?_k ?jZ T- &67-,.rt (size) NO.OF BEDROOMS OWNER �-r n/ PERMIT DATE. COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY L1_ �x�sl • ( . 3 1 CA 1^ U C1"A o Jr 6 a x ' CH•r`'•nC, Lis _ _ No. CT v < Fee OO THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MAS9ACA0SETTS Yes application for misposar 6pstem Construction i3ermit Application for a Permit to Construct(tU Repair(K) Upgrade( ) Abandon( ) ❑Complete System A Individual Components Location Address or Lot No. 2C>4\44ASK1 t 3GjZ>"AVL Owner's Name,Address,and Tel.No. (xTee,!«LL Ao�.1 Cutz-Zs ' GAlt� C Assessor's Map/Parcel i pg l'"WO /fit IP'IS V 0211 Installer's Name,Address,and Tel„No. $, p Designer's Name,Address,and Tel.No. Gb$-4,2$,S-34, 13ruCC �La�ca-t`•Sly Lro1� SSdr/ 5V L.L,"m..v E&Z VQvG a ruc (AiG Z l�o�� o j aL���• q PA2k.E-e- )P-04,fl OSTE4 ll LCt, Type of Building: Dwelling No.of Bedrooms Lot Size 10) sq.ft. Garbage Grinder(4 Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) �� gpd Design flow provided ?LU S gpd Plan Date V U to 6A Z012 Number of sheets -1/ 1 Revision Date K�0,.,3 h Title S, TG '?LAry . 21J 01059D 1 v,&f9jN J6�e NT 5 & 7-0,0�li f OJ6-Mcu Au IF 0%-aeyL Size of Septic Tank 02 7 oa) Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) �Q Q 2 - co V,&e,&a 1 M fc II�T 2 0 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board f Health. d� 7' Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. / l p T Date Issued f No. �•• ' /C / Fee CCU 00 THE COMMONWEALTH OF MASSACHUSETTS } Entered in computer: PUBLIQ,,R_-AL�H DIVISION - TOWN OF BA RNSTABLE, MASSACHUSETTS Yes 2ppfication for is osaY p t t; Construction Permit Application for a Permit to Construct(() Repair(X) Upgrade( ) `Abandon( ) ❑Complete System [X Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. 2b-334� Assessor's Map/Parcel t3 oS3 lU ruip,U'�I��Z>C 1$ 'a 1�JpS-NZxU V`-t A dam\t Installer's Name,Address,and Tel-No. 'v Designer's Name,Address,and Tel.No. �R>� Type of Building: Dwelling No.of Bedrooms Lot Size 10)�C�S sq.ft. Garbage Grinder(� Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) S gpd Design flow provided `7 J�O 1'LU S gpd Plan Date J U to&A wl`Z t y Number of sheets r�' � Revision Date K� Title �J T ��N��! 20{�OSG� V,A e�V awl NT`j Z �l�KIS fil !1U 1Z�YU �U L' �Si i Ve Size of Septic Tank '2 Type of S.A.S. K�.5 Description of Soil Nature of Repairs or Alterations(Answer when applicable) ,k D{) Co A L LO tii j i o ' r, r Date last inspected: Agreement: - The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. gn d ✓ A; f ,r Date 0/- /,2 Application Approved by Date 7 f Ca., Application Disapproved byr,� Date r s` for-the following reasons Permit No. pQ/ Date Issued f a, THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Swage Disposal system Constructed( ) Repaired(k) Upgraded(�) Abandoned.( )by', S�w •�( �-t e cw\ at 'Z 04 ,VJ N(,rNu A y has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.90)a )24 dated �o /7 �/ ► Installers .,CCe�CC_1 \� s `cf Designer �u��-1V ramiti(� nj£uL,tVG h #bedrooms � Approved design flow gpd The issuance of this p rmit sha I not be-construed as a guarantee that the systemTwillun `on d sig ed.Date p ,� v• Inspecto No. Fee ------- - -----��--------- — i�'y -�- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposat 6pstem Construction 311errnit Permission is hereby granted to Construct( ) Repair(V) Upgrade(�O Abandon ` ( ) System located at 209 tkskS (tyc,-\T)" 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 co pleted within three years of the date of this pe it. Date � )7 � Approved by • a 9 Y i ♦ - 'Die'r .6.,//} Ce 14 1-r IJAP z Mil s A 177 �+ i 1 t A. VO s Installer A Dedow Cerd$caAm Farm Dane: TvuK Sao(Se,agePer" a%AsstmesblapWarxl Lag— 083 Deslgaer: �]�. 'vani .�i atS In�taHeri � c ✓/ Address: 1.0.'33, 499 Address: �ST hfA �a /cry./� tP. pnSuN� a 3"x" issued a permit to install a {date) {installer) septic system at 020,y A/ o - %d / based on a design drawn by ) En�101ccrteL.2 dated. I ccr*that the septic system raced above was installed snbstandaUy according to the design, which may awhile minor approved chafes such as lateral relocation of the - distribution box an&or septic tank_ I certify that the septic system referenced above was installed with elms(L-e- greaw than IO2 lateral relocation of the Srti.S or any vertical relocation of any component of the septic system)but in accordaaw with State&local Reg,tatkm Plan revisiLon or certified as-built by designer to follow (Installer's Sigunu e) (Designer's Si*atwe} (Affix Here} PLEASE RETURN TO BARKSTARU PUBLIC HEALTH 1YbSI0A��CE1Z171.7CATE OF ,OQMPLjA= WILL NOT W ISSUED MUM BOTH THL4 FORM AND As-suu.T CM-Au, RECEIVED BY THE BARMST_ABLE PUBLIC HEALTH DIVISION. THAM-K YOU Q: _ Caat Pam3.1&0&= I 3 p THE Town of Barnstable Barnstable Ep Tp� Board of HealthAff-AmedcaCfty �""`Ns`A°L NASE' A. � 200 Main Street, Hyannis MA 02601039. � D Q opArfo MAt 2007 Office: 508-862-4644 Wayne Miller,M.D. FAX: 508-790-6304 Paul Canniff,D.M.D. Junichi Sawayanagi CERTIFIED MAIL # 70110470 0001 4525 5327 September 30, 2011 Alan B. Curtis and Gail Eagan 9 Union Park, # 1 Boston, MA 02118 RE: 204 Washington Avenue, Osterville, MA=Front House YOU ARE SCHEDULED TO APPEAR BEFORE THE BOARD OF HEALTH on Tuesday, October 11, 2011 at 3pm in the Town Hall, Hearing Room, 2nd Floor, 367 Main Street, Hyannis, MA due to your failure to repair or replace the failed ' septic system,at 204 Washington Avenue, Osterville, MA 02655. The State Environmental Code Title V requires all failed septic systems to be repaired or replaced within two years. The Town of Barnstable Board of Health has more stringent deadlines dependent upon the type of failure identified. In this case, the septic system has been in failure beyond the established deadline. You will be given the opportunity to testify, present witnesses, documentary evidence, and other official information regarding this case. PER ORDER OF THE BOARD OF HEALTH Wayne Miller, M.D. Chairman Q:\SEPTIC\Letters Septic Inspection Failures\204 Washington Ave Ost BOH Oct201 I.doc `',Excerpt from Board of Health Meeting Minutes 10/11/11 A. Alan Curtis and Gail Eagan, owners -204 Washington Avenue, Osterville, past deadline repair date. No one was present. The owner had emailed that they were unaware of any failed report until they received our letter to appear before the Board. They asked for an extension to research the issue. They had bought the house in 2005 and were only aware of one septic inspection, which had passed, and it was their understanding that both houses were connected to the same septic system. „ Mr. McKean explained that there was an earlier inspection done in 2004 which was for the front house and which showed it in failure. There are some questions to be answered. It's unclear whether the front house is hooked up to the rear, since the water was turned off to the property at the time of inspection in 2005 (the rear house passed).jhe water was turned back on'in April 2011_according to Water..Dept./ Upon a motion duly made by Dr. Canniff, seconded by Mr.Sawayanagi, the Board voted to continue this to the November 8, 2011 meeting. The owner wili`be notified as soon as possible. (Unanimously, voted in favor.) Excerpt from Board of Health Meeting Minutes 11/08/11. B. Alan Curtis and Gail Eagan, owners- 204 Washington Avenue, Osterville, past deadline.repair,date. t Mr. Curtis corresponded that,he was unable to attend the meeting and that he was unaware of a septic failure. -At the time of purchase, he was given the septic inspection which passed and had thought both houses were on the same system. The Health Division received_ one septic inspection for each house and one is in failure. .Mr. Curtis asked-for-a two month extension-to research"thesituation.--The!_ house is unoccupied ' Upon a motion duly made by Dr. Canniff, seconded by Mr. Sawayanagi, the Board voted to approve a two month extension on the deadline and return to the Board on January 10, 2012. (Unanimously, voted in favor.) Q:\MINUTES\EXCERPT OF MINUTES\Excerpt BOH Oct Nov 2011 204 Washington Ost.doc Crocker, Sharon From: Alan Curtis [alan@curtisllc.com] Sent: Monday, November 07, 2011 1:22 PM To: 'Crocker, Sharon - —1 Subject: Re: 204 Washington Ave in Osterville Sharon, Thank you for the update. As we discussed, my understanding is that both houses are tied into the septic system to the back of the property and that system was. in compliance. I was surprised when I received the boards letter stating that the houses were on separate systems and one was not in compliance. Unfortunately I haven't been able to meet with anyone who can inspect the septic system so I cannot clarify the matter for the board. The house• is currently unoccupied.and I am living in Boston AI would ask the board to 1 extend the hearing- for at least 2 months to-give me time--to-.clear up^the confusion: Thank you, Alan Curtis a On Oct 31, '2011, at 3:57 PM, Crocker, Sharon wrote: > Alan > I am writing to make sure.,-you are aware.. the Board of Health did > postpone the hearing for one month, until our next meeting - which is to > be held on Tuesday, November 8, 2011 at 3:00 PM at the same > address: Town Hall, 367 Main St, Hyannis, Hearing Room, 2nd Floor;- > Attached are the minutes from the October 11, 2011 Board,of Health > meeting. > Thank you. > Sharon Crocker > >. -----Original Message---- > From: Alan Curtis [mailto:alan@curtisllc.com] > Sent: Friday, October 07, 2011 :1:46 PM > To: Crocker, Sharon > Subject: 204 Washington Ave in Osterville > Sharon, > I 'm writing to request a postponement to the Board of Health hearing > scheduled for Oct: 11, 2011 for the above referenced property. ' > I -received a letter from the Board of Health this week notifying me of > the hearing and that my house had a failed septic system. Prior to > receiving this letter I was under the impression that the septic. > system passed inspection when we purchased the property in 2005. Based > on our conversation today there seems to be some confusion because > there are two homes on the lot and it is unclear whether both homes > are tied in to the system that passed inspection in 2005-. I need 1 > additional time to have the property re—inspected and clear .up some of > the confusion before I. could address the Board of Health. > > Thanks, > Alan Curtis > > 617 .872.5711 > <Excerpt BOH Oct 2011 204 Washington Ave Ost.doc> 2 Flynn, Judith From: Crocker, Sharon Sent: Friday, October 07, 2011 1:52 PM To: Flynn, Judith; Malkus, Karen Subject: FW: 204 Washington Ave in Osterville FYI, To keep you both updated. Sharon -----Original Message----- From: Alan Curtis [mailto:alaniacurtisllc.com] Sent: Friday, October 07, 2011 1:46 PM To: Crocker, Sharon Subject: 204 Washington Ave in Osterville Sharon " I'm writing to .request a postpcnement to the Board of Health hearing scheduled for Oct. 11, 2011 for the above referenced property. I received a letter from the Board of Health this week notifying me of the hearing and that my house had a failed septic system. Prior to receiving this letter I was under the impression that the septic system passed inspection when we purchased the property in 2005. Based on our conversation today there seems to be some confusion because there are two homes on the lot and it is unclear whether both homes are tied in to the system that ' passed inspection in 2005. I need additional time to have the property re-inspected and clear up some of the confusion before I could address the Board of Health. Thanks, �y Alan Curtis � r ,. 61.7.872.5711 I a . r x r { Y.y� Z r - , Crocker, Sharon - From: Crocker, Sharon ---� 'ent: Thursday, November 03, 2011 2:37 PM - o: Flynn, Judith -- Subject: Alan Curtis - 24 Washington Ave`, Ost _ Importance: High Av - noticed on the updated summary of failed septics, you noted Mr. Curtis is having his system re-inspected before the BOH Meeting. Are you referring to the Nov 8 meeting? Did he call or email? Is he going to be at the meeting? Please let me know. Thanks, Sharon l mI Crocker, Sharon From: Crocker, Sharon _ Sent: Monday, October 31, 2011 3:57 PM _R To: 'alan@curtisllc.com' - Subject: FW: 204 Washington Ave in Osterville —r Excerpt BOH Oct , 2011 204 Washi... Alan, _..._. I am writing to make sure you `are aware the Board of Health di.d postpone the hearing --- for one month, until our next meeting - which is to be held on Tuesday, November 8, 2011 at 3: 00 PM at the same address:, Town Hall, 367 Main St, Hyannis, Hearing Room, 2nd -- Floor. Attached are the minutes from the October ll; 2011 Board of Health meeting. ' Thank you. Sharon Crocker _ -----Original. Message----- _�. From: Alan Curtis [mailto:alan@curtisllc.com] .. , Sent: Friday, October 07, 2011 1:46 PM To: Crocker, Sharon Subject: 204 Washington Ave in Osterville Sharon, I 'm writing to request a postponement to the Board of Health hearing scheduled for Oct. 11, 2011 for the above referenced 'property. I received a letter from the Board `of Health this week notifying me of the .hearing and --- that my house had a failed septic system. Prior to receiving this letter I was under the impression that the septic system passed inspection when we purchased the property in -- 2005. Based on our conversation today there seems to be some confusion because there are two homes on the lot and it is unclear whether both homes are tied in to the system that = passed inspection in 2005. I need additional time to have the property re-inspected and clear up some of the confusion before I could address the Board of Health. w — Thanks, �-- Alan Curtis - 617'.872.5711 :.. 1 ��. 0, 1r e 2sS Paa � Commonwealth of Mass setts Title 5 Official Insp ection dorm P' c . Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 611512000.Inspection forms may not be altered in any way: . A. Certification gg 9 Important 1 When filling out 1. Property Information: _. 3 ,4-1� p coputteer,use a Qq C.��tf�S h c�(���'2 � t-V lA i e CCU SY only the tab key Property Address to move your A-LLY=w cursor-do not Owners Name use the return key. � Q jDeJ P4r4k On,�:4 OwneeWdress /94. O'Q ILA city/Town Stater. - _ �ip.Code I Date of Inspection: Date 2. Inspector. _ Name of Inspector Company Name Company Address U c 6 Cityrrown I State lip Code Telephone Number Certification Statement: ---- I certify that I have.personally inspected the sewage di*9al.system at this address and that the information reported below is true, accurate and coiYiplete.2s.of the time of the inspection.The inspection was performed based on my training and experience in the_pyoper function and maintenance of on site sewage disposal systems.I am a 05-P approved systoti inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: asses ❑ Conditionally passes ❑ Fails ❑ Needs Further I.by the Local Approving Authority Inspectors Signature . .Date The system inspector shall submit a copy of this inspect . to the Approving Authority(Board of Health or DEP)within 30 days of completing this`ihspeefion, If the system is a shared system or has.a design flow of 10,000 gpd or greater;the inspector acid the system owner shall submit the report to the appropriate regional office of the bhp: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. ` t5insp.doc•I U2004 - Twe.5 Ofwal Inspection Form:Subsurface Sewage Disposal System _.. ------------ ----— ..-.. ._ _... ,. .._.. -, ... . .. .- Page 1 of 16 Commonwealth of Massachusetts s Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Usposal System Form A. Certification (cont.) t�04 "J AS 6 1 ki q ia&-i Ai -e Property PAIress Os -k--e-y u ► it e- Oato SS" . City/rown State Tip Code AtLfcw (2 uxAtis --- — 1 �- o owners Name Date of Inspection Inspection Summary:Check A,B,C,D or E/always complete all of Section D A) yytem Passes: erlihave not found any information Which ihdiCatc that-ahy of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15,304 exist.Any failure criteria not evaluated are indicated-below. Comments: t P r 0 nJ Ccl l �uf* t u s� srw.V`t- o In r►-y A-t_ B) System Conditionally Passes: ��� ❑ One or more system compohehts as descn'tsed-n i. a'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 Q 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 wilt pass inspection 4 the existirig tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection#iti Wstructuialy sound,not leaking and if a Certificate of Compliance indicating that the tank is lest;thah_ 6 ytsors bld is available. NO Explain: Wrtsp,doe•11r2004 Title 5 Offidal inspection Fomx Subsurface Sewage Disposal System• Page 2 of 16 I T Commonwealth of Massachusetts Title 5 Offici.al Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form -'A. Certification (cunt.) Property Address / CityTTown State r� Zip Code Owner's Name Date of inspection AB) 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 ❑ 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: C) Further Evaluation is Required by the Board of-fiiefilth: �--- ❑ Conditions exist which require further evaluattont.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 bordering vegetated wetland or a salt marsh Wnsp.doo•112004 Title 5 Oft'iaal.lnspection Form Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts Title ,5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form: r A. Certification (cont.) Property Addrdss Qy/Town State Zip Code. Owner's Name Date of Inspection /V C) Further Evaluation is Required by the Boalyd'bf health(cont.): 2. System will fail unless the Board of Health(and Public Water Supplier,if any) -determines that the system is functioning in a mariner 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 pF.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 5A.S and the SAS is within 50 feet of a private watery 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 wbll**. 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. t5insp.dm•11t2M Title.S Official Irispecgon Form:Subsurface Sewage.Disposal System Page 4 of 16 - Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) W 4-S6 tlu!j 4,;�)A.� Aw e- Property Address Qtyf town State ZipCode ALL Div Cjv 4i:ss -- _0 Owners Name Date of inspection 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 ❑ r,/+ Static liquid level in the distribution tox above outlet invert due to an overloaded L� or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6'below invert or available volume is less than%day flow ❑ Required pumping more than 4 times in the last year NOT due to dogged 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 its within a Zone 1 of a public well. O Any portion of a cesspool or privy is.within 50 feet of a private water supply well. ❑ Any portion of a cesspool of privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality.analys's. [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:riff other failure criteria are triggered.A copy of the analysis must be attached to this form.] Yes No ❑ 12/ the system fails;I have detoimined 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. t5insp.doc•1112t)04 Title 5 official IrlspecFion FoMr Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form. Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) AV-P, Property Address Cityrrown State Zip Code ®-T Owner's Name pate of frispedion V A E) Large Systems: To be considered a large system.the system must serve a facility with a. design flow of 10,000 gpd to 1.5,000 gpd. ��—for large systems,you must indicate either`yes"or"W to each of the following,in addition to the questions in Section D. YES NO' ❑ ❑ the system is within 400 feet of a surface drinldng water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ---- - ._ ._. -.. ❑ El the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone,ll of a public water supply well If you have answered fires"to any question in Section E the system is considered a significant threat, or answered`yes",in Section D above the'large cyst rh Fins: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: t rtsp.doc•112004 Titie 5 Offidal Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 • L Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments y Subsurface Sewage Disposal System Form B. Checklist Property Address City/Town State zip Code AtLP-tj Cook-AA' L 4 l a-as Owner's Name Date of Inspection 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 . ❑ g?"'I 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 WA) ❑ Was the facility or dwelling inspected for signs of sewage backup? ❑ Was the site inspected for sigr%of.bmak 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 ezampie;,a plan at the Board of Health. Kr ❑ 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)) t5insp.doa•11=4 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title 5 .0. ficial Inspection Form Not for Voluntary Assessments H Subsurface Sewage Disposal System Form C. System Information� ; A04 . shlij� -[onr A .I Property Address 05-� L �I� C14 Town State Zip Code ALI P_-A) C u YAI ss '-4- Owner's Name Date of inspection Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 for example: 110 � ( p gpd x#of bedrooms): . Number of current residents: SMOAUL Does residence have a garbage grinder? ❑ Yes M'O'No Is laundry on a separate sewage system?[if yes,separate inspection required] ❑ Yes 5 No Laundry system inspected? ❑ Yes ❑ No 1vA, Seasonal use? [ Yes ❑ No Water meter readings,if available(last 2 years usage(gpd)): Sump pump? ❑ Yes R"'No Last date of occupancy: 6 4 Date IV 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.1,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: - Last date of occupancy/use: Date Other(describe): t5insp.doc•112om Title 5 Official Inspection Form Subsurface Sewage Disposal System page 8 of 16 Commonwealth of Massachusetts Title 5 Official inspection Form Not for Voluntary•Assessments Subsurface Sewage Disposal System Form C. System Information (cunt.) 104 L.9 A.-ShL -QA A-Ve Property Address d y cLLp.. Citylrown State Zip Code Owner's Name Date of Inspection General information Pumping Records: Source of information: - .D W A)C� Was system pumped as part of the inspection? ❑ Yes Ua-'�No If yes,volume pumped: gallons . How was quantity pumped determined?- Reason for pumping: Type of System: ❑ Septic tank,distribution box,soil abs6rptton system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes;attach previous inspection records,if any) Innovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtaintrd froM system owner) ❑ Tight tank Attach'acopy of the DEp approval. ❑ Ot e describe): r0 CA- N'Ms �.�`� C,o - Lo c e ys4en Approximate age of all components,date installed(if known)and source of information: t Were sewage odors detected when arriving at the site?. ❑ Yes O-Nb Mnsp.doc•I W004 Title 5 Official inspection Form:Subsurface Sew age Disposal System Page 9 of 16 Commonwealth of Massachusetts Title 5 Official .Insp-6606n Form Not for Voluntary As Subsurface Sewage Disposal System Form C. System Information (cunt.) ®�s hO Ac � Property Address 03 rev v L 11-4L CitylTown State Zip Code Owner's Name --Date of Inspectiort • Building Sewer(locate.on site plan): tr Depth below grade: feed Material of construction: Vst iron VO PVC ❑other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,Wdehed of leakage;etc:): Septic Tank(locate on site plan): P 1 Depth below grade: `��t ���� 6: Q V4-v— fed Material of construction: Wec"Oncrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain) If tank is metal,list age:Alyears Is age confirmed by a Certificate of Compliance?(attach-'a copy of ❑ Yes [I No certificate) Dimensions: 40 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle o ra Scum thickness Distance from top of scum to top of outlet tee or Baffle IV Q 5 C 2-W*v Distance from bottom of scum to bottom of outlet tee or baffle Nw Ltd How were dimensions determined? CCA -L n► �trewa e S+ t5insp:doc•112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System• ' Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information(cont.) Property Address City/Town State Zip Code AIL l z� C`ta-t Owner's Name Date of Inspection Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑metal s ❑polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum'to top of outlet tee or-baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: „ Date Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as.related to outlet invert,evidence of leakage,etc.): Tight or Holding Tank(tank roust be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete metal 0 fiber9lass ❑polyethylene other(explain): t5insp.doc•11l21)04 Titl6 5 Official lnspectign Form Subsurface Se• wage Disposal System•' Page 11 of 16 Q . Commonwealth of Massachusetts Title- 5 Official Inspection form Not for Voluntary Assessments Subsurface Sewage Disposal System Form. C. System Information (cunt.) Property Address MA- City/Town r State Zip Code Owners.Name :. Date of Inspection Comments(note condition of pump chamber,conditiot_of pumps and appurtenances,etc.): Soil Absorption System(SAS) (locate on site plan,excavation not required): It SAS not located,explain why: Type f leaching pits number. s4cv ❑ 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.hydraulig:failure,level of ponding,damp soil,condition of vegetation,etc.): ; to r A-(._, a t5insp.doc•112004 .Tice S Offiaal~InIq*ctian Form:Subsurface Sewage Disposal System Page 13 of 16 •, Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cost.) cl O W_ _ A-S h 1 Nr,^FCC i i A y-e— Property Address Q in to S3 Cityrrown State Zip Code Owner's Name Date of Inspection N k Tight orHolding Tank(cunt.) ' Dimensions: Capacity: gallons Design Flow. gallons Per day Alarm present: d Yes ❑ No. Alarm level: Alarm in working order. ❑ Yes❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): IV Distribution Box(if present must be opened)(locate ph 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,eta): Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No Alarms in working order: Q Yes ❑ No t5msp.doc•11WU Title 5 Official Inspection Form:Subsurface Se. wage D'isposal System Page 12 of 1G Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) Property Address City/Town _ State Zip Code Owner's Name Date of Inspection Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool . Materials of construction Indication of groundwater inflow ❑ Yes ❑ .No Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, . � etc.): c s qoV 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.): t5insp.doc•112004 Title 5.Official Inspection Form Subsurface Sewage Dkgmal System Page 14 of 16 Commonwealth of Massachusetts Title 5 Official InspsCtioh Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Informati fon (cunt.) AA Pi6perty Address City/Town State zip Code OU—'iuners.Name Date of Inspection. 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 buildin . A-w YS c- 1` 0 ' t5insp.doc•11r2004 Title 5 Ofrrcial Inspection Form:Subsurface Sewage Disposal System Page 15 of 1s. Commonwealth of Massachusetts Title 5 Official Inspection Form . Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cunt.) Ave- Property Address Cityrrown Sta e .' Zip Code . 40����� Owners Name Date of Inspection Site Exam: Surface water Check cellar Shallow wells Estimated depth to ground water. Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked,date of design plan reviewed: Date - Observed site(abutting property/observation hole within 150 feet of SAS) 0 Checked with local Board of Health-explain: ❑ Checked with local excavators,installers-(attach documentation). Accessed USGS database-explain:: . ' You must describe how you established the high ground water elevation: t5insp.doc•1112004 Tie 5 Official.Inspection For n:Subsurface Sewage Disposal System Page 16 of 16 TOWN N.OF BARNSTABLE TI LO ON 0y_ASk 4o Ayc SEWAGE # VILLAGE � ASSESSOR'S MAP & LOTS 3 0?i3 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY CWPWI P) r SIA 11L C IV ao 1 LEACHING FACILITY: (type) Pi 1 (size) (,x&T /0W NO: OF BEDROOMS 5 r. FAlE® .INSPECTION BUILDER OR OWNER /,o/` TAT PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leactng facility) Feet Furnished by-X,n SDf. 11 ue1 �, �OtGI 13 p« A Q Hays4 ,. 3 13 13 Ap P.7 d!DN S-Z 7 REcE-iVED COMMONWEALTH OF MASSACHUSETTS NOV U 8 2004 EXECUTIVE OFFICE OF ENVIRONMENTAL AFC AII-R�S�OF BARNSTABLE HEALTH DEPT. DEPARTMENT OF ENVIRONMENTAL PROTECTION AP FAILED INSPECTION PARCE4 o LOT TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 204 Washington Avenuey Osterville,MA 02655 Owner's Name: Carrie Luke ' Owner's Address: 22 Old Colony Road - ,W-ellesley—_MA_02481 :r `7 -' Date of Inspection --October 20 2004 Name of Inspector: (P se-PrintrJames7Yl�ord r-- rn 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 urther Evaluation by the Local Approving Authority ✓ Fails P Ins ector's Signature: Date: October 21, 2004 The system inspector shall sub't�6o cpy 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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 204 Washington Avenue Osterville,MA Owner: Carrie Luke Date of Inspection: October 20, 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 L Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 204 Washington Avenue Osterville,MA Owner: Carrie Luke Date of Inspection: October 20, 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: 204 Washington Avenue Osterville,AM Owner: Carrie Luke Date of Inspection: October 20, 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 I _ ✓ 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.] NOTE.Single cesspools automatically fail in the Town of Barnstable Yes (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: 204 Washinvon Avenue Osterville, AM Owner: Carrie Luke Date of Inspection: October 20, 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: 204 Washin o Osterville MA Owner: Carrie Luke Date of Inspection: October 20, 2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): S DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 550 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): Yes Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gad 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 "'as 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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 204 Washington Avenue Osterville, AM Owner: Carrie Luke Date of Inspection: October 20, 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) Cesspool acting as a septic tank Depth below grade: Steel cover to grade Material of construction: _concrete _metal _fiberglass _polyethylene ✓ other(explain) Cesspool brick If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 4'W x 4'T x 6'bottom to grade Sludge depth: -- Distance from top of sludge to bottom of outlet tee or baffle: -- Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: -- Distance from bottom of scum to bottom of outlet tee or baffle: -- 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.): The cesspool had 6"of liquid on the bottom An outlet tee was present. The steel cover was to grade. 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 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 204 Washington Avenue Osterville,MA Owner: Carrie Luke Date of Inspection: October 20, 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: izallons 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 present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of l I OFFICIAL INSPECTIONYORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 204 Washington Avenue Osterville, MA Owner: Carrie Luke Date of Inspection: October 20, 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'(1000 gal.) leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: r Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): The leach pit was dry and clean No scum line was present The cover was 2.5'below grade. CESSPOOLS: ✓ (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: 1 -single Depth-top of liquid to inlet invert: -- Depth of solids layer: -- Depth of scum layer: -- Dimensions of cesspool: 5'W x 3'T x 6'bottom to grade Materials of construction: Cesspool block Indication of groundwater inflow(yes or no): None Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): The cesspool was dry. The cover was 2'below grade. The inlet pipe was Orangeburg. A single cesspool automatically fails in the Town ofBarnstable. 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 i Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 204 Washington Avenue Osterville, AM Owner: Carrie Luke Date of Inspection: October 20, 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 n Hgvs� � A a: a a aa� 30 1 13 /(0 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: 204 Washington Avenue Osterville,M4 Owner: Carrie Luke Date of Inspection: October 20, 2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 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: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: I hand augered down on the bottom of the pit to 11.5'below grade and no ground water was observed. Using the Cape Cod Commission technical bulletin the high ground water adjustment for this site(MIW 29, Zone A, 9104)was 2.5'. This report has been prepared and the system inspected and failed 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 DIRECTIONS: From Hyannis - Take Route 28 'towards Cotuit: ASSESSORS REF.: Take a left onto Phinneys lane, Stay left. on to Map 139, Parcel 083 •. _, 11 • t'it�o Main Street, Take d ri4M onto S. Main St;_ - Take a left onto East Bay Road,. then; a left onto Wianno Ave, and. a right onto Washington.: A;ve. OVERLAY DISTRICT: Property is on the right #204 % AP — Aquifer Protection District Land Court Bound - q Neck • '-,r y ram. / Bench Mork RP Resource Protection. Overlay District S80`52 50 ,VV / e0V 2O�VV / Elevation 104.25 {, FLOOD ZONE- 9 8 I Zone C & Zone B Community Panel No. #250001 0016 D July 2, 1992 � ' / Existin 100 al. Pr osed Existing Cesspool to be -V Pro osed- A rox. Location of L'GI (S'o � 'c z ,�11" §N" ¢ 9 . , q C�eanout A v __. REFERENCES:_..:..:-. . .. _ / ... .. /each Pit rt : Cleanout.- . ...- --- - bondoned-.or_.Rema ed _. RF 1. (RPOD) - % 2'.1 of S one i 1 LOCATION MAP / Deed .Book C176689 Area. (min.) 87,120:SF _ Fron to e (min) 20' (1"=2000±) j Plan Book 125/91 Width (min) 125' I. rox_locatio 35. l -,- >' ._ J _ 1271 , / . f rried- ed Setback Fron t s Ap 30' e/ ctri cables .- - - LCP 9596A 15109D Side 15. DESIGN DATA Z Re or, 15' Existing:Single Family �a lProposed PProx. J 5 Bedroom @ 110 GPD .. - Septic - ' #204 to dtion of Post " Tank. 1 Sty w/f- w Ear,line No Garbage Grinder.- Foundation. Dwelling s eptec Total Daily Flow=550 GPD ate Existing =� still Proposed Tank: c.—a.. - leonou t � C•JJ � - Two Kitchens . -� ^ F.G. 103.00f C r. rr in,as+uar C. ( F.C.'EL. t00.00t C _ 1 6, - Post Crawl RECRACE AS REOUIREO S. Use a two Colnpattinent F .-: Spdce aundotlo - Tank - •. _tee notes(typ.) 0 a Septic r-SEE N07E B�TT'P•) .. Appro . Location of `,102 ;Water rti , Existing Leach Pit Capacity. Existin Cessl to be Pit '81-99.67 EL azoo 550 GPD+ P oo �wwae P•ak EL 1 1. .. .. Aban aned or Removed- l Instnael.To EL 2000 action - - eptk Tank a-Box ompartmen ..xsYUWar.,:. _ CmRrnxl Prior S _ 'To AnYI{Work EL . EL Leaeh/ng Cam act B'caewit P g 10'. } CamPact Base -�Exfating pit hds more than 1 ol.stare.. SEPTIC NOTES. j - - Crawl Space_ #204 - -1 Nn'' - 10 Mtn. sob 1.Location of Utilities Shown on.This Plan Are Approx.At Least.72 Hours , : Foundation. 1 St w f• - - 20-Min.-Foundation - - - - Y / i,, Prior to Any Excavation For Project the Contractor Shall Make DEVELOPED __. --._ _ _ Regnired Dig Safeppro Appropriate Permits ' _ PROFILE OF SYSTEM. .- the Notification to El _Q .. 2.The Contractor is Required to Secure Appropriate Permits From Town NOT TO SCALE Agencies:For Construction Defined by This Plan. - 3.Wherever Sewer Lines Must Cross Water Supply Lines.Both Lines Shall + Stone Driveway - :(-"—"l r1 fry - - _ - Be Constructed of Class 150 Pressure Pipe and Shall be Water Tested to _ � - - , Assure Watertightness: In General,Water Lines Shall be Constructed in �>,. Water voileick - Coordination With COMM'Water,.and Shall be in Accordance - J r, - N80'51 '40 .E �� Walk`'a 78°38 80 F With 24S CMR1.00 7.00&310 CMR 15 00, 4.A Minimum of 9"of Cover is Required for All Components. _ - 5.All Structures BuriedsThree Feet dr.More or Subject 7.50 \ to Vehicular Traf cio be H-20 Loading.It is the Engineer's ' Recommendation that H-20 Always be Used. - ' 6.Install Watertight Access Risers and Covers to Within 6"of Finished } Grade Over SepticTank Inlet;Compartment Wall,Outlet and D Box. 7.Septic System to be Installed in Accordance With 310 CMR 15.00& /'� ( 248 CMR 1.00-7.00.Latest Revision and the Town of Barnstable. WashingTO n - 4'0.'. PUt7�IC �/.vQ,/ - � �us, t.l Board ofHealth Regulations. FF// ir/ (( '�Q �f 8.All Piping to be Sch.40 PVC. 9.D-Box Shall Have a Minimum Inside Dimension.of 12",and a Minimum v ump Road Layout per: - .. - `S -of6" . . Plan Book 127 Page 35 10.Septic Tank Shall be a 2,000 Gallon,with 2 Compartments. -- The First Compartment Shall Have a Volume of Not Less Than - `' 1,100 Gallons and the Second of Not Less than 550Gallons. .:�. The Compartments Shall be Interconnected by a Minimum 4"0 Vented Inverted U Shaped Pipe with a Gas Baffle on the Outlet 11.The Separation Distance Between the Septic Tank Inlets and. Outlets Shall be No Less than the Liquid Depth.Inlet Tees Shall Extend -a-Minimum of 10"Below the Flow Line.Outlet Tees Shall Extend 14" .1 Below the Flow Line,and Shall be Equiped With a Gas Baffle. — - - - - - - PREPARED FOR: ' - _ PREPARED BY.. - TITLE: . NOTES Site.Plan r The structures shown sera located on the.ar.und g g Proposed Improvements 20 0 10 20 a o 80 by ca tlanal survey methods on I/Jrne/2m2 CURTIS,�ALAN B & EAGAN, GAIL Sullivan En ineerin , Inc. 2.)The m pnopert Oe y fine Information shown hereon w g UNION PARK#1 Po Box 659 At `compiled from a suable rectal W—tion. Osterville,.MA 02655 J)The Intent of this pion i,fe,permitieq for o IG - (508J428-3J44(508)428-9617 fax - a-Ptt.upgrade only.Property I&—are aPP.-fmate. BOl%TON, MA. 02118 204 Washington Ave. '•' Y Bamst I W ab a osterv;�le Mass. W - - 77 � �DraR: CTR CTR/B �` � - - . JJ ) } - Draft: TR Camp.: 'CTR DATE: - SCALE.. h SC C7�e: =2 Pra/eat:Jzoa1J_arn� June 4,2012 1"=20'