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HomeMy WebLinkAbout0435 WIANNO AVENUE - Health 435 WIANNO AVENUE Osterville A = 163 - 001 j �I i cz n 1� J63- O° No. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for Mispo9al 6pstem Construction Permit Application for a Permit to Construct( ) Repair(-. Upgrade( ) Abandon( ) ❑Complete System ndividual Components Location Address or Lot No. U 3 S L.)ik^.\U qv-t, Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Cho Installer's Name,Address,and Tel. Tel No f M[)u� 2� Designer's game,Address,and Te No. Scot tr-�� kL3 C kj ye- e, o t 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) 1 _0 or t/,V e `r, [L-Ay" - f`U �SeeQ} 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 Date Application Approved by Date ZZ Application Disapproved by Date for the following reasons Permit No. 00Z'-__ Date Issued, ! A0 . —-_--_--_-----_--_---_---_- -_ - =_--------= --- No. y E% - '~ Im - (#�' !r • Fee 47r THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplication for Disposal 6pstem Construction 3permit Application for a Permit to Construct( ) Repair(--.o)''"Upgrade( ) Abandon( ) El Complete System [:�')d vidual Components Location Address or Lot No. U S (,,)1 C�1�� U �V-<- Owner's Name,Address,and Tel.No. Assessor's Map/Parcel i G )3 V' `'Z Q�� C S Installer's Name,Address;and Tel.No. ! Designer's Name,Address,and Tel.No. S c t k r C,vt \1 3 O`d Y4,f M ULl*\— Type of Building: r : 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) e"'"" gpd Design flow provided ..-- gpd Plan Date l: Number of sheets Revision Date =� Title <' Size of SepticyTank J Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ��d-.->\r- L—P �/� C-�� Le+-L T(-U M 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. ` Si9mled / f Date 4443 a Date " Application Approved by' .r Application Disapproved by . _. Date for the following reasons ` S• r Permit No.. GV(�-�' 1 J>5 Date Issued / J THE COMMONWEALTH OF MASSACHUSETTS reA^,ru�`� . BARNSTABLE`;MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( r,.� Upgraded( ) Abandoned( )by r \1�, e!!!!$ Grr_'at U Z '� `(^ w n e-, /A t 1-f C has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.70Z7. -(/�'J dated u��r (T,L1 7 a Installer [ l �`�"N Designer #bedrooms - �^ --Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system Will�func'tion as.designefdh �f Date L�I �'1 Z Inspector \ • ,/�' ' �9,_�// `+�- "------- '---`-- ---"---=----'=------ ------'----- -=- `_- -------- ----------- ' No 267 ' _l, Feed V THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,_MASSACHUSETTS bistlosal *pstem Construction Vermit. V Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon.( System located at t and as described in the above Application for Disposal System Construction Permit. The applicant re7, gnized his/her duty to comply with Title 5 and the following local provisions or special conditions. ' Provided:Constr'�uc'on must be completed within three years of the date of this permit. Date u !n ?�}7�7 Approved by; STABLE LOCp►'-'ION SBWhGB# ... _. vtLt.a 5 f Gr�� INSTPaiLEIt'S NAMB t Pt4I�IE I�IO SFsFUC TAVj C,APAG1fiY L IIMIVAMITY (typ.,) Y 2!7UILDER'oft: AM ERM%T SepAratiott�c oe I3stweota.Slaa. g Mttx4tx►um Adjps�d GxaurAdwta Tabie Ia the Boltatn oachn k��cility '' �I'ilva9�s'�t'mtcr:;ugly VJe�I acid t,.oas�iag 1�acil�ty ��+►Y��iDs cxtst att sstc or.w3tW 200 feet of 1040.4 8 fV!;;9 ty) 'kToc�9 P.cdLe' �r+►ledanrl cuid'1LeAchin Pacali �I�any wetNiiils s�ist v.JWAn'{UQ feet at leua6tinS IaallsrY) _».w - fee i ^? dZ � l7 '� -�- 33' -� c{ ��� �33' ��a•moo 8� s Commonwealth of MassachusettsI /(Q 3— 00/ Tew, .� Title 5 Official Inspection Fora ,W. hF Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `s 435 Wianno Ave ' J Property Address Regina Sullivan °' Owner Owner's Name/ information is Osterville ✓ MA ' 02655 10-17-19 required for every �- 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. A. Inspector Information Shawn Mcelroy Name of Inspector - Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000);I have personally inspected the sewage disposal system at theproperty address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes r 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 10-17-19 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 c Commonwealth,of Massachusetts �i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 435 Wianno Ave Property Address Regina Sullivan Owner Owner's Name information is required for every Osteryille MA 02655 10-17-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ', _k , ® 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: System is in good working order with no sign of failure. 2) System Conditionally Passes: ❑ One or more system components as described in the "ConditionalPass" 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 I Commonwealth of Massachusetts wt' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 435 Wianno Ave Property Address Regina Sullivan Owner Owner's Name information is required for every Osterville MA 02655 10-17-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipes) oar 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 ON ❑ ND (Explain below): ❑ obstruction is removed ❑Y ❑N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 c Commonwealth of Massachusetts 3 Title 5 Official Inspection Form �?l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 435 Wianno Ave Property Address Regina Sullivan Owner Owner's Name information is required for every Osterville MA 02655 10-17-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts r� f. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 435 Wianno Ave Property Address Regina Sullivan Owner Owner's Name information is required for every Osterville MA 02655 10-17-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (coot.) Yes No ❑ ® 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 'hy da flow ' ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® . Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ❑ Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. '❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems:To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section.CA. Yes No ❑ ❑ the system is 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Fora wa i,,l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 435 Wianno Ave Property Address Regina Sullivan Owner Owner's Name information is required for every Osterville MA 02655 10-17-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.)p rY ( If you have answered "yes"to any question in Section C.5 the system is considered a significant threat or answered "yes"to an question in Section CA above the large system has failed. The Y any 9 Y owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for aH inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as 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? ® ❑ Wasthe facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Fora hI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �cT f 435 Wianno Ave Property Address Regina Sullivan Owner Owner's Name information is required for every Osterville MA 02655 10-17-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Description: Number of current residents: 0 Does residence have a garbage grinder? - ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 2019 Date I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i ib► Subsurface Sewage Disposal System Form Not for Voluntary Assessments 435 Wianno Ave Property Address Regina Sullivan Owner Owner's Name information is required for every Ostefville MA 02655 10-17-19 page. City/Town State Zip Code Date of Inspection D. System.Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form wa Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 435 Wianno Ave Property Address Regina Sullivan Owner Owner's Name information is required for every Osterville MA 02655 10-17-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (If yes, attach previous Inspection records, If any) ❑ 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): Approximate age of all components, date installed (if known) and source of information: 2000's Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site,plan): r Depth below grade: 30" feet Material of construction: ® cast iron 2 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 c Commonwealth of Massachusetts r� Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 435 Wianno Ave Property Address Regina Sullivan Owner Owner's Name information is required for every Osteryille MA 02655 10-17-19 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 24"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Comments on pumping recommendations inlet and outlet tee or baffle condition, structural integrity, ( P p 9 liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 f Commonwealth of Massachusetts r� ,w Title 5 Official Inspection Fora ,hI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !/r1 435 Wianno Ave Property Address Regina Sullivan Owner Owner's Name information is required for every Osterville MA 02655 10-17-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): ,... Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts ,Y Title 5 Official Inspection Form bi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 435 Wianno Ave Property Address Regina Sullivan Owner Owner's Name information is required for every Osterville MA 02655 10-17-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up. t5insp.doc-rev.7/28/2018 Title 5 Official InsP ection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts r� 3 Title 5 Official Inspection Fora i�l wa ,�f <,°i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .. � :.✓ ;> 435 Wianno Ave Property Address Regina Sullivan Owner Owner's Name information is required for every Osterville MA 02655 10-17-19 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: Infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form w. Subsurface Sewage Disposal System Form Not for Voluntary Assessments ,frl 435 Wianno Ave Property Address Regina Sullivan Owner Owner's Name information is required for every Ostetyille MA 02655 10-17-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Infiltrator leach field in good working order and empty at inspection with no sign of back-up into d-box or surrounding stone. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts 3 Title 5 Official Inspection Form w. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 435 Wianno Ave Property Address Regina Sullivan Owner Owner's Name information is required for every Osterville MA 02655 10-17-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction`. Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts 3 Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 435 Wianno Ave Property Address Regina Sullivan Owner Owner's Name information is required for every Osterville MA 02655 10-17-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately CL t ,d. v� D ,/�33 r d r b ,31 - 39 . tv t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form Not for Voluntary Assessments 435 Wianno Ave Property Address Regina Sullivan Owner Owner's Name information is required for every Osterville MA 02655 10-17-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells -Estimated depth to high ground water: 12 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: USGS and town maps show groundwater at greater than 12'. I Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts r� 3 Title' 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �_✓J,,> 435 Wianno Ave Property Address Regina Sullivan Owner Owner's Name information is required for every Osterville MA 02655 10-17-19 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate ,4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Ni. Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 5/ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zipprfcatiou for Mi.5po!5a1 *proem Cou5truction 3permit Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 43([ W ` &fo AvF— Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 1�D3 Q® 4 l,t v Lje5 Installer's Name,Address,and Tel.No. a� ��" "[ ��` �7 Designer's Name,Address and Tel.No. CAP(_:--Wt10d &JTral4.t dJSE_S 1 Type of Building: Dwelling No. of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building kQ[L)6a9'[tok- No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided Aj/4- 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) 569(- LL�4 KIP& SeF?k_' .-T-AI)t A0 1r A+,ck T tZ �1i�Z 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. Signed Date 17 Application Approved by Date `® /7, ( Application Disapproved b . Date for the following reasons Permit No. 1 3� Date Issued to 1Z No. 0_ —3 ' Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 4/ F PUBLIC HEALTH DIVISION .- TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for Zfgpogal *pgtem Cougtruction Permit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System El individual Components Location Address or Lot No. `L�35 W to Uf10 A VF Owner's Name,Address,and Tel.No. �u L.1 uS• t DoRat t;�y �,f4 V��IV� Assessor's Map/Parcel t 1o3 o o &ST I L 2 ( . )� VD Au is A ,� C "T 7 /W V llh Installer's Name,Address,and Tel.No. SO O" 477"2 i"11 Designer's Name,Address and Tel.No. 1,,,,APEe(A),j)6 inabPKJSE-S 153 G I ST L Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building kG;&t1) 10(4• No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided i(JA- gpd Plan Date Number of sheets Revision Date ` Title Size of Septic Tank: Type of S.A.S. s V S.o'Description of Soil t. i Nature of Repairs or Alterations(Answer when applicable) 3s9L Le-x(<i P& Sey�[(G -r-Aut- 7+ OD 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. Signed 1 i Date t y -i;L -7 Application Approve by -d Date &0fiz/7.0r Application Disapproved Date for the following reasons . Y Permit No.Z,0 1_� �t{�j Date lssued /t)J/1 1 7,01"3 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( x) Upgraded ( ) Abandoned( )by CAP&W 1 U E E�_JT CLC&g at 41C L40 IkAtmo Ave aS-cC V16Lo=- has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.�: r? dated,Z' Installer APE"47h E C-1UT'!wl(S _s Designer #bedrooms_� , Approved design(flow A)#1 gpd t The issuance of this permit hall n be/onstrued as a guarantee that the system will fictionDate � �� �/ Inspecto !\, No. �tJ - ---------- -- __ ------ -Fee 1 . - - P tJ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS wigogal *pgtem Congtruction Permit Permission is hereby granted to Construct ( ) Repair ( X) Upgrade ( ) Abandon ( ) System located at 423 S 11-SIAM10 AVF and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction must be completed within three.years of the date of this pef,�mit. / '-- Date :��/ I� Zo 19- %` Approved by Commonwealth of Massachusetts W -00/ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 435 Wianno Ave Property Address Leslie Averna as Owner owner's Name information is required for every Osterville MA 02655 10-31-17 page. City/Town State Zip Code Date of Inspection 't 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. filling form A. General Information filling out fom'ls �/* / ^��8 use only thon the e tabute �r ��N"���LSN OF rM�s ", y 1. Inspector. lt'`Z 49.., sy .,, key to move your :�+ • C) ' cursor-do not James D.Sears 0ff- JAMES N' keethereturn ; SEARS 4 y Name of Inspector o• ; Capewide Enterprises %*' ICI Company Name �'•.. 'p 153 Commercial Street $ INSPE��O``�`• Company Address 1u11nn1 Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S 1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that,the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority low 11-1-17 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 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. VS 151ns.doc•rev.6/16 Thle 5 official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 g t a5ed xed dH t b:ZZ L 60Z 60 AoN 1 ' • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 435 Wianno Ave Property Address Leslie Avema Owner Owner's Name information is required for every Osterville MA 02655 10-31-17 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E 1 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 C'MR 15,304 exist. Any failure criteria.not evaluated are indicated below. Comments: The system is a 1500 Gat. Tank D Box and five chamber's. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass, Check the box for"yes","no"or"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 ff 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): r5irmdoc•rev.6116 T11e 5 Official Inspadon form.Subsurface Sewage Disposal System-Page 2 of 17 61, @lied xeJ dH St,:22 L 1,0E l,0 AcN t N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 435 Wianno Ave Property Address Leslie Averna Owner Owner's Name Information is required for every Osterville MA 02655 10-31-17 page. CityrTown State Zip Code Date of InspWion B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ NO(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO(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 ❑ NO(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.doc rev.W6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pepe 3 of 17 02 a6ed xed dH 9V:2Z L I.OZ I.0 AON Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 435 Wianno Ave Property Address Leslie Averna Owner Owner's Name information is required for every Osterville MA 02655 10-31-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health land Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well"*. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in MOM= is less than 6" below invert or available volume is less than day flow tgc#iv6 l5ins.doe-rev.6116 Title 5 ONicial Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 tZ, a5ed xe:l dH 9t?:ZZ L 602 60 AON T Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments, 435 Wianno Ave \V�ij Property Address Leslie Averna Owner Owner's Name Information is required for every Osterville MA 02655 10-31-17 page. City(Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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 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- 10,000g pd. ® The system falls. 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, Mins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 ZZ a5ed iced dH 9t7ZZ C60Z I.0 AON f Commonwealth of Massachusetts urf Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 435 Wianno Ave Property Address Leslie Averna Owner Owners Name required Information is Osterville MA 02655 10-31-17 required for every page. Cityrrown 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: it Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health 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 Ill ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302l D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual); 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins.doc•rev.6/16 Title 50Hicial Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 £Z abed Rzl dH LV:ZZ L 60Z L0 AoN Commonwealth of Massachusetts P. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments k Vz:5;/1 ' 435 Wianno Ave Property Address Leslie Averna Owner Owner's Name information is required for every Osterville MA 02655 10-31-17 page. City/Town State Zip Code Date of Inspection D. System Information Description: 1500 Gal. Tank D Box and five chamber's. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2015-139,000Gal g ( y g (gp }' 2016-101,000Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(9pd) 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: l5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 bZ a5ed xe� dH LbZZ L 60Z l,0 AoN Commonwealth of Massachuaetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 435 Wianno Ave Property Address Leslie Averna Owner Owner's Name information is required for every Osterville MA 02655 10-31-17 page. CityrT'own State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancyluse: Date Other(describe below): General Information Pumping Records: Source of information: NA 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 IIA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Ws.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 SZ a6ed xeJ dH L7ZZ LLU Lo AON Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 435 Wianno Ave Property Address Leslie Averna Owner Owner's Name required for is Osterville MA 02655 10-31-17 required for every page. Citylrown State Zip Code Date or Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1995 Permit #95 - 183. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 32"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pi ein is 4" PVC SCH-40. Septic Tank(locate on site plan): Depth below grade: 21"feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal. Precast H-10 Sludge depth: 211 l5ins.doc•rev.SMS Title 6Official Inspection Form:Subsurface sewage Disposal System-Page 9 of 17 gZ a5ed xe:1 dH WZZ L 602 60 AON Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 435 Wianno Ave Property Address Leslie Averna Owner Owner's Name information is required for every Osterville MA 02655 10-31-17 page. Cityrrown 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 28" Scum thickness Distance from top of scum to top of outlet tee or baffle 21, 9„ Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Asbuilt-TapeSludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at 21" below grade w/both cover's at 5". In tee, outlet baffle.No sign of leakage or over loading. 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 t o bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc-rev.W6 Title 5 official Inspection Form:Subsurface Sewage Disposal System Page 10 of 17 LZ a5ed xe:1 dH 8b:ZZ L 60Z 60 AoN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 435 Wianno Ave UIV-1, Property Address Leslie Averna Owner Owner's Name information is required for every Osterville MA 02655 10-31-17 page. City/Town State Zip Code Date of Inspection D. System Information (cant.) 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.00c•rev.&16 TBIe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 gZ abed xed dH WZZ L 60Z l.0 AoN Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Farm -Not for Voluntary Assessments 1W# 435 Wianno Ave Property Address Leslie Averna Owner Owner's Name information fo is Osterville MA 02655 10-31-17 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Sox(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box, etc.): D Box is 16"x16"-29" below grade. Box is clean and solid w/two lines. No signof overloading or solid carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order,system is a conditional pass. Soil Absorptlon System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: lNris.doc-rev.6116 Title 5 Official Inspection Force:Subsurface Serfage Disposal System-Page 12 of 17 62 a5ed xe:1 dH 9V:ZZ L 602 l,0 AoN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 435 Wianno Ave Property Address Leslie Avema Owner owners Name information is required for every Osterville MA 02655 10-31-17 page, CityrTown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 5 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Typetname of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is five infiltrators w/2'stone. Ck D Box and camera out to chambers. Chambers are clean and dry. No sign of over loading or holding water. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc-rev.d116 Tale 5 official inspection Form.Subsurface Sewage D Systam-Page 13 of 17 06 a5ed xe� dH 6t,:ZZ L 1,0Z I,0 AcN Commonwealth of Massachusetts U Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 435 Wianno Ave Property Address Leslie Averna Owner Owner's Name information is Ostervllle required for every MA 02655 10-31-17 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.): 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.): tbins.doe•rev.6/16 Tale 5 OfHdal Inspection Form:Subsurface Sewage Disposal System Page 14 of 17 6£ a5ed xed dH 6bZZ L 60Z i•0 AON i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 435 Wianno Ave Property Address Leslie Avema Owner Owner's Name infoffnrequired s Osterville MA 02655 10-31-17 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cant.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately CARP at A 8 PAfTo r 14 I5ins.doc•rev.6!16 ritla 5 official Inspection Form:Subsurface Sews"Oisposal System•Page 15 of 17 ZE a6ed xed dH 6b:ZZ L 60Z 60 AcN 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 435 Wianno Ave Property Address Leslie Averna Owner Owner's Name information is required for every Osterville MA 02655 10-31-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 10' 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: pate ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Auger T.H. 10"no G.W... Bottom of chamber's at 45' below grade. Bottom of chamber's at 6'+above T.H. Depth. Before fling this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 66 a6ed xeJ dH WZZ L 60Z I,0 AON f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 435 Wianno Ave Property Address Leslie Averna Owner Owner's Name information is required for every Osterville MA 02655 10-31-17 page City/Town State Zip Code Date of Inspedion E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doo-rev.W16 Title s official inspection form:Subsurface Sewage Disposal System-Page 17 of 17 �£ a5ed xed dH 0522 L60Z I,0 AoN '0C THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE AV•Vlirativit for Di-rip Sal lVnr1w Towitrnrtiun rrrmit Application is hereby made for a Permit to Construct ( ) or Repair (k an Individual Sewage Disposal System at: Yd � � ..................................... Location/:\ddress or t No. .................: �= .E- z`'v:!! ��..•...........--•--•-- ......•-----....... _���`C'( ..� ____ -- - _ Owner � Address/•► ,t•- r Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling— No. of Bedrooms_____ ___________________________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fi:�Wses ------------------------------ -- W Design Flow.......... ......................:..gallons per person pe[ day. Total daily flow..__._..q_1-to....................gallons. WSeptic Tank-t-Liquid deity/. 4D..gallons Length_40--------- Width___0____._... Diameter................ Depth................ x Disposal Trench—No. __ 111 t C Width___------------ Total Length_.33......... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date......................................... aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water...................... (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ......... •------------........... 0 Description of Soil---------------•------••--------•----------••---------------•-----------------....-----------------------------••-----------------------------------------•------------- x W •---•-•----------- ---------------------------------•--•-•----------------------------- --------------------------------------------- -----------------------.---------.......-------•---......-------- UNature of Repairs or Alterations—Answer when ap licable.- ..... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate of Compliance has•been`issuedV bthe'n oard.of health. Signed ......... .. - 40- - .... ......a,e . Dace Application Approved By ----- - - -- ------------.._...-------------- v.---- -- ........ ......................... ... .. ................ ...... .................Date.................. Application Disapproved for the following rear n . .................................................................................... - ........_-... ------ ---- - y, ------------- Permit N ------------------- Issued ..... ................-----.-- -----------. .Y .. Qt✓...........�J....;........ 0. ace Y 00 Y r vj THE COMMONWEALTH OF'MASSACHUSETTS } t- BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Dig pw3al Worlai Tomitrnr#ion- Vamit Application is hereby-made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at-.• -/. ilaYw t� 4 .. -------------------------------------------------••• --•--•-•••--•---•••-••-----•--...•--••--••------•-•-.........----••-•-•----•--------•--•------••- -Location '\ddress or Lot No. . -••-••••--...... -:......� « v � '�ltic •--••-•-•-••-•••• .__.TC_f-cat 1 .......................................... Own�er/� �f kn Address ...••• •••••-••---••--------- ............. 1.4 M Installer Address UType of Building Size Lot............................Sq. feet 0-4 Dwelling— No. of Bedrooms-----N___________________________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons_.--_-.__.-_________-..--.- Showers ( ) — Cafeteria ( ) 04 Other fixtures --------------------------------------------------------------------------------------- -------------- wDesign Flow..........-)..........................gallons per person pef day. Total daily flow--------- .:._..._..._.--.__gallons. WSeptic Tank Liquid c cityI- _gallons Length._I:0--------- ��Tidth_._ -------- Diameter.___..__.___.__ Depth................ x Dis osal Trench—No. . . Ely: !p- � Width_._�_____________ Total Length. ....... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter...........--------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by--••---------------------------------------------------------------------- Date........................................ Test Pit No. I----------------minutes per inch Depth of Test Pit--.--.--.--______.__ Depth to ground water........................ G14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ P+ •--•••••-•••----------------••--•-•••••-•••-•-----••----••-••••--•••--•----••--••-•---------._.;:.........---•-----•--•--••--••••••--•••----•.._..••••-_..... ODescription of Soil....................................................................................................' ` x -----------.......................................................... w = ----------- --- V Nature of Repairs or Alterations=Answer when ap licable.:. Gam` . .k' ._.-!G re 7 C?44_� ._.. ------...l- :.`t, .t�.`...------=a�� -��1!i''�LL`��-e .. O.... geil 6 _���"�Y`"'�-- ------------•.....---•-••------•.....••-- Agreement-.: t -' The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State-Environmental Code` I The undersigned further agrees not to place the system in operation until a Certificate of-Compliant has een ssue by the'�oarda•f health. Signed . .. . ..:. '/ .. ----I------------------------------ � � 6 � '1 ,�/ ° Dare Application\A roved B l` f>I f. / " � .tf'.vL('........ 4 PP PP y ------ ------ / �- -------------------- ........................................ 1-1 Application Disapproved for the following reafa- ..................................................................................... ................... . ............ .. . ----------------------------------------------- te Permit No. / ,� / '._ .................. Issued ------------- Q //�............ / t we-------T -e-:—.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Tertifirate of Crompliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by .------------------------...---------- ---- --------------------------......---------------------------------------- Ins rall� at . ................................ � ��1.Gc..v!.<.��... �— .. ..........--------------..... ........ has been installed in accordance with the provisions of TITLE 5/of T�State.En-vilronmental Code as described in the application for Disposal Works Construction Permit No. ._.7-�.. ---- dated ...........__.._------------_------__.... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE//CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE f". - 1-Ins ec �rv..... .. ------------------------- ----------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS / BOARD OF HEALTH TOWN OF BARNSTABLE No.... .h7 .........- FEE..rW.. �io�roottl orl;� C�rrno�rUan �prmi� Permissionis hereby granted............... '.e .4.....a............. ... ....... /-f ............................................................ to Construct ( ) or.Repair ( -) an Individual Sewage Disposal System at No......................................4- <..._CL i ` ``t=' .. _ '_ ---------y ---- ... ------------------------------------- •--_•_____- Street as shown-on the application for Disposal Works Construction Per it No. ___.._,!-__ l�Dat ���..._...................... .:. L-� Boar of Health DATE...............�--- ; r FORM 36508 HOBBS 6 WARREN,INC..PUBLISHERS r I (Oste v e, MA Notes: r 1, ' Parcel 1 . Assessors Map 63Main Street Cert. 160409 a1 z-. East Bad L.C. Plan 7985— / �. Road s This parcel is located In the Resource c� Protection Overlay District Q _ This Parcel; i n ! I'rl the Flood n East Bay ss not located t ©cad Zone Crystal t�l e _ L Cak s C Road t, R -_33.10 ' 1 ' L 5 . 4'3 Locus �o Cr f� Locus Map N. (,S, �. Zone: RF 1 43�} , C1 E .01 61001 �. 20 F r n tCC Garage rr �! Width ., S tbcck .... Front 3 � Lot 39 S'de 15' Paved D/W 0 73 ± Acres �� ' ' House 43� Rear 1 . Pr Gate Prop, p Gate ;� ,. 1 ro{�a ed Decorative' Pool Code Fence Existing Septic shown 2 U' per Septic As— Wit C) Plot Plcn Proposed PooV Equipment ���' for a Proposed Poo Prepared For Psed Decorative erapo Code Fence 0 A _ Joyce Landscaping 1 � V I a P 10,5I Parcel '� C�CCIteC� at 435 I r �lanno A, venUe Ostervll.. e , MA Date April 9 2018 �. ..{� 9 Mop139 ` "� �,, Scale: � „ 2 ' �� Parcel Proposed Chan Link Pool Code Fence Prepared by: All Cape Septic. and Surve G y 618 Route 2 ; We st Yarmouth, a mouth M,4 02673 -s 54 � ) 771 --4 as CTE: r, ®(icapeseptic@gmaii.com LOCATION OF UTILITIES IS APPROXIMATE AND ALL >. .� UNDERGROUN D Na AND OVERHEAD UTILITIES MUST DE ,y RI ' DETERMINED IN THE FIELD PR TO COMMENCEMENT GRAPHIC SCALE G OF ANY WORK, THIS INCLUDES, BUT NOT LIMITED TO, ao Q ,f) zQ 40 REO UESTS TO DIGSAFE, ANY PRIVATE UTILITY COMPANIES. ' AND THE LOCAL WATER DEPARTMENT. IN FEET 1 inch m 20 ft. DWC AC-1020