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HomeMy WebLinkAbout0235 WIANNO AVENUE - Health (2) "B-�Woodlar'd=Road ' `-Ostery llevIA �A ' 140 ' 138 /3� e Town of Barnstable P# � 041HE 1pk o Department of Regulatory Services . RAMSTABrA : Public Health Division Date v� 0.19. `0� 200 Main Street,Hyannis MA 02601 Date'Scheduled / ( Time Fee Pd. Soil Suitability Assessment for Se e Disposal �c Performed By: S6puw A. l�}1 fern I ���� Witnessed By: , LOCATION & GENERAL INFORMATION Location Address � �Z Owner's Name N3,he.VV1ILe Address / CtJtStir ICe:�.Q r�vC 0`.�"+ct,V i(Q Assessor's Map/Parcel: Engineer's Name PIC NEW CONSTRUCTION C REPAIR Telephone# 570 . '771—-7:r0'Z Land Use Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Otter ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to(toles) rf� + Parent material(geologic) Q le c 16i.J OULwr.i�\ Depth to Bedrock Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater level PERCOLATION TEST Date l Z7(1/ Time ID2.W4M Observation Hole# #I Time at 9" Depth of Pere l57ey Time at 6" Start Pre-soak Time a lo;o/ D: Time(9"-6") e End Pre-soak Rate Min./Inch uno 6t, Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:HEALTH/W P/PERCFORM C4 2or/—o73:02� a DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistent %Gravel io y Z Z/Z 3 -8 MI--fLaA Ste( 10112 4/G No tJua r Obi ; ' • DEEP OBSERVATION HOLE LOG Hole# 2- Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistent %Gravel A �a�� sow Io Y►� a/�: �i�l`l�� L,oaw► 54kj 10 YIQ s�e 14a�/aS�" C fta "n 5anx 10YiQ Y14 S�m AtJ Sand 10 tie 4M L✓ O(Zf Gh sew DEEP OBSERVATION HOLE LOG Hole# 3 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistent %Gravel _7 a �'O away Sc,► I O`{1@ Z/1 -71'—/6 koaxy ScrtcQ 1 b kR S/G — DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistent %Gravel /.0 Y/R.31Z — aj= 2Oai ,� �.oar»y 5ahti l0 y2 14? "- 3 2" 64-. "t u qok 10 vie ./y �-- Flood Insurance Rate Man: Above 500 year flood boundary No_ Yes �C Within 500 year boundary No ')C_ Yes Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? Ks. ' If not,what is the depth of naturally occurring pervious material? Certification I certify that on A y�l 1? Y (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with k the required training,expertise and experience described in 310 CMR 15,017. Signatuure Date I Q:HEALTH/W P/PERCFORM C Zn ll—v73:a2� BAXTER NYE W 0 \ ` ENGINEERING& r SONR \ SURVEYING v . a .- I• �;\ �` -- Neglelered.Pro/a,ebnol EngNene P4 o and Land SU—M W 1_ Floor ✓/G H/mvih,Naeaadwm11.02601 �� \ \ Fhone-(SOB)771-7502 �r • _ ^`. \\ ` .. ... F.._ (SOB)771-7612 \IN ..P BrBNP Loan Map scole 1,0 1000 _ __ _ j. ``\ ♦ r i� 1 �I - _ .r GENERAL NOTES WMxmnn ne nar0 ona mmmn nEP.nEn FOn. IT NESS sa`b J• \ m ..83 Bunker R cer FM N . - 'l II \ ° ,w erv@e,MA 0260 ....... a �� u Nmn omann a FHOCE N AN ro aFm O 45 nr.,a7 G, aA G { i r �wa.ae.. .Ira N � r j e (Nm"�amFlNwva K �� I�OY d,Nc ��i' I I11 - \ ,J �Aml�S.o P .� niwF�n a p k ° .a✓iUai� r'nnar.'�•e,wa 7: "".°' -;' J 3j 1I' `I°f.�"®n � w, I sl I @ \\ •1 ,�una(.m a awc.a.n.una.aml. - > P aw, e 'a _ U _ eaa A aP mm S. Li � -- - .`N'' {�. I I N rY '�-"'�-. • / ' •�.erUmr: raP,o. ,Iowa.mFmr Q I _ i + �•1 j/./I- amiaoi6ioew�i+iiU4 vMn m¢ai A uo"vm wn � ,xa m II I � j - �nlxmurni`mia vo m w`ai r1O0mau�o�I ma�a / SHEET vai a oe nn ro eor.va mnoon.ma TITLE�IIdwO1M�11 . .a� Pr a�nx ` ���, �' r.ui wun,a,+»alw. e m`o F�omxMOConO.aw No wrmiac Al WOODLAND �W AVEfV —'\�/. !�• i MEET NO •e mm� - - - _-1 -.�- art 1 I I ` •TE:12 I Otl Q O ---��-� 1 1• 10 0 10' 20 1 1 BOPLE IN FEET � I nP4P1 � .'�mw.Br n•eu •. m Pxeo .. 0 6) - No. /1 ^�v ` Fee o 6 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftpl Lation for Misposal 6pstrm Construction permit Application for a Permit to Construct( ) Repair()() Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Q d Owner's Name,Address,and Tel.No. Ass ssor's Map/Parcel ©Sv n , Installer's Name,Address,and Tel.No. s o�_ Z 74_1 7�3 Designer's Name,Address,and Tel.No. pjr��_n Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Rp Cip^`R_" pd kj.Q w-e4 An JIp o n d o ciJ 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 Si TM Date Application Approved Date Application Disapproved by Date for the following reasons Permit No. �C� 1 ` �� Date Issued No. Fee /�a11 � � ( _ /06 3 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ' Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pplitatlon for Disposal 6pstem Construction Permit Application for a Permit to Construct air x Upgrade Abandon Complete System Individual Components PP ( ) 1P ( ) P1�' ( ) ( ) ❑ P Y ❑ P Locatiln/Address or Lot No. S �O Q U Owner's Name,Address,and Tel.No. Assessor's Map/Pareel 5 loll y Installer's Name,Address,and Tel.No. �o 7Q.. S-3 Designer's Name,Address,and Tel.No. { Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil ` f i Nature of Repairs or Alterations(Answer when applicable) t_ I p on d Ina (0 r 4�- Date last inspected: Agreement: y i ? 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. ig e f Date I Application Approved Date i Application Disapproved by Date - ' for the following reasons Permit No. ��O, — 3� Date Issued . '-'-------------------------------------------------------------------------------------_----------------------=---------------- -- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate- itofr horn Y a I k,L ' THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(/ Upgraded( ) Abandoned( )by i at $ W �C ct hn� fil�.iPd �°��Vc1/.q� I has been constructed in accordance with the provisio s of Title S�,and the for Disposal System Construction Permit No.,! '/)f ' dated 1 Installer At rn,r �� '` Designer #bedrooms Approved designflowt gpd The issuance of this te rit it shal of be construed as a guarantee'that the s'yste. will f n ti , s de 'geed. i j Date ' Inspector --------------------------------------------------- ---- ---; --------f - ------------------------------------ No. 3 { t i +tY r iI Fee / THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal *pstem Construction Permit Permission is hereby granted to Construct f( ) 1Repair( ) Upgrade( ) Abandon System located at U.�Ood rA P�Y1L� JJ�. �(�o ArV 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. f ` Provided:Construction\must be completed within three years of the date of this p nnit. Date I ' I I ) Approved by IRIM ' ^ d CO • � • I •;+ Nn W ,^ t LnPostage $ Certified Fee <,! Crj,�.✓ stma* p Return Recelpt Fee ( � Here M (Endorsement Required) + 2 l-3 Restricted Delivery Fee O (Endorsement Required) Total Postage&Fees $ W G E3 o i Ms Janice Craig 8 Woodland.Road Osterville, MA 02655 Certified Mail Provides: a A mailing receipt s o A unique identifier for your mailpiece'" c A record of delivery kept by the Postal Service for two years Important Reminders: , o Certified Mail may ONLY be combined with First-Class Mails or Priority Mail®. o Certified Mail is not available for any class of international mail. o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For Valuables,please consider Insured or Registered Mail. o For an additional fee,a Retum Receipt maybe requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. n For an additional.fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". o If a postmark on the Certified Mail receipt is desired,pplease present the arti- cle at the post office for postmarking. If a•.postmark on the.Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT.Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 t� COMPLETE • ■ Complete items 1,2,and 3.Also complete A. Signature item 4 if Restricted Delivery is desired. ❑Agent X ■ Print your name and address on the reverse ❑Addressee so that we can return the card to you. B. co ed Printed Name) C. Date of Delivery ■ Attach this card to the back of the mailpiece, or on the front if space permits. , D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑No I =MA 3. Service Type ❑Certified Mail ❑Express Mail ❑ Registered ❑ Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. I! 4. Restricted Delivery?(Extra Fee) ❑Ye 2. Article Numbert , (rransfer from service/alien� +} 1 E 1 f i i �s1,1 0�4 70 &0 O 01 4¢5 2 5 ?6 2 8 NPS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 UNITED STATT s eras Paid I • Sender: Please print your name, address, and ZIP+4 in this box • I I I I I c Town of Barnstable I Public Health Division i 200 Main Street I I Hyannis, MA 02.601 I I I I I I I ��i!-ll.lti!1Ji!A 1iflld.}!{i11j lF_3eiltFl�F�FF ` OF THE Tp� Town of Barnstable Barnstable P ti s o A�America C"�h► .� Regulatory Services Department' BARNSCAQLE, - 9 MASS. $ibgq• Public Health Division �� m Arf°""AAA 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644. Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL # 7011 0470 0001 4525 7628 September 8, 2011 Ms. Janice Craig 8 Woodland Road Osterville, MA 02655 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 1301 Old Post The septic system located at 8 Woodland Rd., Osterville,MA was last inspected on 8/15/ 2011,by Robert Paolini, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • - Probable backup of sewage into facility or system component due to over loaded or clogged SAS. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH i Tho as cKean, R.S., CHO Agent of the Board-of Health Q:\SEPTIC\Letters Septic Inspection Failures\TEMPLATEI.doc �� bwbG� k� � ;nd o �s� f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments "a 8 Woodland Rd. Properly Address Janice Craig Owner Owner's Name information is required for every Cisterville Ma. 02655 8/15/2011 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, I use only the tab 1. Inspector: key to move your cursor-do not Robert Paolini use the retur Name of Inspector Robert A.Paolini Sepic Service Company Address Yarmouthport Ma. 02675 City/Town State Zip Code (508)362-3555 S 14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and thatAe information reported below is true, accurate and complete as of the time of the inspection. The inspeeption was performed based on my training and experience in the proper function and maintenance of on she sewage disposal systems. I am a DEP approved system inspector pursuant to=Section 1"40 o.Fjitle 5(310 CM 16.000). The system: --L ❑ Passes 0 Conditionally Passes ❑ Fails t°- ❑ Needs Further Evaluation by the Local Approving Authority tv 8/15/2011 Insp ors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 Official InspectionnSubsSewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Woodland Rd. Property Address Janice Craig Owner Owner's Name information is required for every Osterville Ma. 02655 8/15/2011 page City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 13 System Conditional) Passes: Y Y ❑x One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. 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. ❑ Y ❑ N ❑ ND (Explain below): Line between main cesspool and overflow needs to be replaced. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Woodland Rd. Property Address Janice Craig Owner Owner's Name information is required for every Osterville Ma. 02655 8/15/2011 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Woodland Rd. Properly Address Janice Craig Owner Owner's Name information is required for every Osterville Ma. 02655 8/15/2011 page City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *` This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ❑x Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ z Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ❑x Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins-11/10 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 r X Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .�' 8 Woodland Rd. Property Address Janice Craig Owner Owner's Name information is required for every Osterville Ma. 02655 8/15/2011 page City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ rx-1 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ❑x 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. ❑ ❑x Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ z The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ 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. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Woodland Rd. Property Address Janice Craig Owner Owner's Name information is required for every Osterville Ma. 02655 8/15/2011 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No 0 ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ 0 Were any of the system components pumped out in the previous two weeks? 0 ❑ Has the system received normal flows in the previous two week period? ❑ 0 Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ 0 Were as built plans of the system obtained and examined?(If they were not available note as N/A) 0 ❑ Was the facility or dwelling inspected for signs of sewage back up? 0 ❑ Was the site inspected for signs of break out? 0 ❑ Were all system components, excluding the SAS, located on site? 0 ❑ 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: ❑ 0 Existing information. For example, a plan at the Board of Health. ❑ 0 Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Woodland Rd. Property Address Janice Craig Owner Owner's Name information is required for every Osterville Ma. 02655 8/15/2011 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: NA Does residence have a garbage grinder? ❑ Yes ❑X No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes 0 No Laundry system inspected? 0 Yes ❑ No Seasonaluse? n Yes ❑ No Water meter readings, if available last 2 ears usage d NA 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ❑X No Last date of occupancy: NADate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Woodland Rd. Property Address Janice Craig Owner Owner's Name information is required for every Osterville Ma. 02655 8/15/2011 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool � Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 8 Woodland Rd. Property Address Janice Craig Owner Owner's Name information is required for every Osterville Ma. 02655 8/15/2011 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes 0 No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron Z 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ p pp y feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑,polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Woodland Rd. Property Address Janice Craig Owner Owner's Name information is required for every Osterville Ma. 02655 8/15/2011 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? 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 ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Woodland Rd. Property Address Janice Craig Owner Owner's Name information is required for every Clsterville Ma. 02655 8/15/2011 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): I *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °V 8 Woodland Rd. Property Address Janice Craig Owner Owner's Name information is required for every Osterville Ma. 02655 8/15/2011 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System SAS locate on site Ian excavation not required): rp Y ( ) ( P If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 r- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Woodland Rd. Property Address Janice Craig Owner Owner's Name information is required for every Osterville Ma. 02655 8/15/2011 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑x overflow cesspool number: 2 ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy soil.No signs of hydraulic failure.Both overflows were dry.Stain line was up to invert in 1st overflow.No stain line observed in 2nd overflow. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration 1 main and 2 overflows. Depth—top of liquid to inlet invert 6" Depth of solids layer 2° Depth of scum layer 2" Dimensions of cesspool 61x6' Materials of construction Concrete block Indication of groundwater inflow ❑ Yes ❑x No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Woodland Rd. Property Address Janice Craig Owner Owner's Name information is required for every Osterville Ma. 02655 8/15/2011 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Sandy soil.No signs of hydraulic failure.Main cesspool was over outlet invert.Line needs to be replaced.Overflow cesspools were dry. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Map Page 1 of 2 b Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size ❑ Zoom Out fl fl o n fl D fl fl®In L?5 3 goo m ;1 I ; O I O - y h 4 f � 5 Set Scale 1° = 20 I Aerial Photos I MAP DISCLAIMER rnnvrinhf'JMF_'JM(1 Tnu,n of Pnrnefohlc nne All r;inhfc roccna http://66.203.95.236/arcims/appgeoapp/map.aspx?propertylD=140138&mappar... 9/1/2011 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Woodland Rd. Property Address Janice Craig Owner Owner's Name information is required for very Osterville Ma. 02655 8/15/2011 e page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑X Check Slope Surface water ❑ Check cellar ❑ Shallow wells Bottom of CP 18' Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED :USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts ` Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Woodland Rd. Property Address Janice Craig Owner Owner's Name information is required for every Osterville Ma. 02655 8/15/2011 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑x Inspection Summary: A, B, C, D, or E checked ❑x Inspection Summary D (System Failure Criteria Applicable to All Systems) completed 0 System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17