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HomeMy WebLinkAbout0044 WIANNO CIRCLE - Health 44 Manno>Cerclek P h All A 39 024 x„ I li Comment: P re m'itb#: Q100ep Date Nottficat�on®afe ,En /Installer;` RepaiR&eatlline Date Data entry Date 10/7/2004 2500 Assessors;Map:: 139 Parce`I 024 Lot 129 ., Busmes's VNurntier 44 lWianno Avenue vuW Osterville our S Inspector:'' Robert Paolini a;, Inspec date:`, 10/1/2004 System Status P `r Ga„ me` nt Fe mit# 200 Repair Date; y,, �NottfcadonDate,� Engllnstaller� � ,`�.-'� Repa,i�,De�aclline�©ate DatatD,ate` 8/31/1999 Septiclnsp cNo. Assessors Map: 139 1024 Lot; Business Number 44 � Adclress ... � 3. Wianno Circle wuiage Osterville Inspector:; James M. Ford In pest date:; 8/19/1999 SY tStatu F/R Comment x�^ Permit - 99665 ERI-P Dated 10/8/1999 `?Notifi¢atiom 0a e' Eng/Installer:° IRepair Deadl'ine�®ate Commonwealth of Massachusetts �a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 44 Wianno Cirlce pqn L Property Address David&Julie Gesner ' Owner Owner's Name information is Osterville Ma 02655 '8-17-18 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. Important:When filling out forms A. Inspector Information on the computer, use only the tab Brett Hickey key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key.,._,.. 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code rwera (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that: 1 am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property 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 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 8-17-18 Inspector'svYlatureDate 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 Commonwealth of Massachusetts �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Wianno Cirlce Property Address David&Julie Gesner Owner Owner's Name information is Osterville Ma 02655 8-17-18 required for every 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: ❑■ 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: The system was in working order at the time of inspection. 2) 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 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 44 Wianno Cirlce Property Address David&Julie Gesner Owner Owner's Name information is Osterville Ma 02655 8-17-18 required for every 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 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): 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 f Commonwealth of Massachusetts �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Wianno Cirlce Property Address David&Julie Gesner Owner Owner's Name information is Osterville Ma 02655 8-17-18 required for every 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 aseptic 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 ❑ 0 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ 0 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 Title 5 Official Inspection Form 1' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Wianno Cirice Property Address David&Julie Gesner Owner Owner's Name information is Osterville Ma 02655 8-17-18 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ a Liquid depth in cesspool is less than 6° below invert or available volume is less than '/2 day flow ❑ O Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ El Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ 0 Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 0 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.] ❑ a The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ El 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 l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 r Commonwealth-of Massachusetts Title 5 Official Inspection- Form • Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Wianno Cirlce Property Address David&Julie Gesner Owner Owner's Name information is Osterville Ma 02655 8-17-18 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The 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 all inspections: 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? ❑ a 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) ❑ [D Was the facility or dwelling inspected for signs of sewage back up? El ❑ Was the site inspected for signs of break out? El ❑ Were all system components, excluding the SAS, located on site? E ❑ 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? ❑ El 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: El ❑ 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 f c Commonwealth of Massachusetts �n Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Wianno Cirlce v Property Address David&Julie Gesner Owner Owner's Name information is Osterville Ma 02655 8-17-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 4 4 Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440/gpd Description: . 4 Number of current residents: Does residence have a garbage grinder? ❑ Yes El No Does residence-have a water treatment unit? ❑ Yes g] No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? ❑ Yes El No . 1 Seasonaluse? ❑ Yes [E No See below Water meter readings, if available(last 2 years usage(gpd)): Detail: ***2016-222,000gallons 2017-106,000gallons*** Sump pump? ❑■ Yes ❑ No current Last date of occupancy: Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 c Commonwealth of Massachusetts �- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Wianno Cirlce u� Property Address David&Julie Gesner Owner Owner's Name information is Osterville Ma 02655 8-17-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA 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: Owner- last pumped 2 years ago Was system pumped as part of the inspection? ❑ Yes 0 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Wianno Cirlce L Property Address David&Julie Gesner Owner Owner's Name information is Osterville Ma 02655 8-17-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: l 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: 1999 Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No . 5. Building Sewer(locate on site plan): 26" Depth below grade: feet Material of construction: ❑ cast iron ❑■ 40 PVC ❑other(explain): Town water Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Wianno Cirlce Property Address David&Julie Gesner Owner Owner's Name information is Osterville Ma 02655 8-17-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 1411 Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) I z If tank is metal, list age: - years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 1500 gallons Dimensions: 10" Sludge depth: 2611 Distance from top of sludge to bottom of outlet tee or baffle 5" Scum thickness 611 Distance from top of scum to top of outlet tee or baffle 11" Distance from bottom of scum to bottom of outlet tee or baffle measured , 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.): The tank was in working order at the time of inspection. The tank is in need of pumping at this time and should be pumped every two years for maintenance. t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Wianno Cirlce u, Property Address David&Julie Gesner Owner Owner's Name information is Osterville Ma 02655 8-17-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to flop 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.): 4 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): NA 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 Title 5 Official Inspection Foam 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Wianno Cirlce V Property Address David&Julie Gesner Owner Owner's Name information is Osterville Ma 02655 8-17-18 required for every 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): o,r Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box was in working order at the time of inspection. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Wianno Cirlce Property Address David&Julie Gesner Owner Owner's Name information is Osterville Ma 02655 8-17-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): NA If pumps or alarms are not in working order, system is a conditional pass. j 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: (2)500 gallon chambers Q leaching chambers number: ❑ 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 Offidal Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ii Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Wianno Cirlce v� Property"Address David&Julie Gesner Owner Owner's Name information is Osterville required for every Ma 02655 8-17-18 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.): The leaching was in working order at the time of inspection.6"of standing water was present in leaching with no high staining. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):. Number and configuration NA 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts r ,,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Wianno Cirlce Property Address David&Julie Gesner Owner Owners Name information is Osterville Ma 02655 8-17-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: NA 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 c Commonwealth of Massachusetts �m Title 5 Official Inspection Form +' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 44 Wianno Cirlce L Property Address David&Julie Gesner Owner Owner's Name information is Osterville Ma 02655 8-17-18 required for every 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 Fire hydrant A Al-57'6" A2-55'6" A3-55' 131-27' 92-29' 63-31' 6 C/o 00 � - _ ._._ ..�. .,._. Fence 0 a Pool l I I . I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts �a p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 44 Wianno Cirlce Property Address David&Julie Gesner Owner Owner's Name information is Osterville Ma 02655 8-17-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑� Check Slope ❑■ Surface water ❑■ Check cellar ❑0 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: Date 0 Observed site(abutting property/observation hole within 150 feet of SAS) E Checked with local Board of Health -explain: Information at the Board of Health ❑. Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Information provided by the Local BOH showed ground water to be greater than 15' Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Wianno Cirlce Property Address David&Julie Gesner Owner Owner's Name information is Osterville Ma 02655 8-17-18 required for every 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 FRECE,l�E OCT 0 6 2004 TOWN OF BARNSTABLE HEALTH DEPT. DATE 1011104 7RP PROPERTY ADDRESS 44 Vianno Ciacee r jZ9 Maz.3. 026 5 5 On the above date, the.soptic system at the address above was Inspected. This system consists of the following: 1.- 1- 1500 ga-Uon zep.tic tank.- 2. 1-Diztaigution Sox. 3. 3-500 gaiion eeaehing cham9eaz 4'ztone Based on inspection, I certify the following conditions: 7hiz .ins. a 7itiz Five Septic Syztem. The zept-ic 3y,6.tem j,3 .gin paopea woaking oadea at the paehent t.ime.- Leaching aaea iz day.. r SIGNATUR ' ' ✓ i �- I C-t E ! -TI Name: Robert A. Paolini «I' ' Company: Joseph P. Macomber & Son Inc . co Address: P. O. Box 66 M Centerville, Mass 02632 Phone: 508-775-3338 or 508-775-6412 JOSEPH P. MACOMBER & SON, INC. Tan ks-Cesspools-ILeachf fields Pump®d & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775.3338 775.6412 • fl �\ COMMONWEALTH OF MASSACHUSETTS ExECUTIvE OFFICE"OF EIS-iR4NM'PNTAL AFFAIRS d DEPARTMENT OF +NVI 4N'1VIENTAL�'RMMON Y TITLE 5 OFFICIAL INSPECTION FORM—NOT VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART•A CERTIFICATION. Property Address: .4 4 O iann o Cijz c ee O77e2vi e Pe l7c owner's Name:/Viche-U dg.,P_kv_a Owner's Address: 307 n n r/ z gewoo 07450, Date of Inspection: 1011104 Name of Inspector: (please print) Company Name: ,e - P..Aacom apm .Sion 1AC, Mailing.Address: en ezv.c e, 174.6 7.•02632 Telephone Number: 5 0 8—7 7 _3 3 3 8 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at.this address and that the.information reported below is true.,accurate and complete as of the time of the inspection.The inspection-was performed based on my training and experience in-the proper function and maintenance of on.4ite sewage disposal systems.I am a DEP approved system inspector pursuant tor Section.15:340.of-Title 5(31.6 CMR15:900j The system: XXXFasses -Conditionally Passes Needs Further Evaluation by the Local Approving.Authority a' M Dater 69/ Inspector's Signgtu e: 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:s'.a.shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner.shall submit the'report to the appropriate regional,office of the DEP.The original should be sent to-:the system owner and copies sent to the buyer,if applicable,and the approving. authority. Notes and Comments ""This'report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under.the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION;FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.IIISPOSAL SYSTEM.INSPECTION FORM PART A CERTIFICATION(continued) Property Address:4 4 W a n n o C l a c e e Oz5tezyLe.ee N.a_ OwnerPl�cheeev_ Date of Inspection: Inspection Summary: Cheek A;B C;D or.E/ALWrAY'sycomplete�all of Section.D A. System Passes: NO I have not found any information which indieates`tbatany-of the failure criteria described in 310 CMR 15.303.or in 310 CMR 15.304 exis -Any failure criteria not evaluated are indicated below. Comments: SOPY1 . A14Aiom iz in R2opea wbak.i.ncr oadea a,t .the Pee-6eat .tame. B. System Conditionally Passes: n o One or more system components.as described in.the"Conditional Pass"section.need t0 be replaced.or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,.will pass. Answer yes,.no or not-determined(Y,N,ND)in the for the following statements.If"not determined"please explain. N b `The septic tank is metal and.over 20 years old*or the septic-tank(whether metal or:not):is-structurally unsound,exhibits substantial!infiltraO-qn or exfiltration.or tank failureAs,imminetit: System will pass inspection if existing tank is replaced with'a complying septic tank.as-approved by.the Board of Health. •A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: N o . 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)' Na broken.pipe(s)are replaced. . 7T obstruction is removed 7 distribu(tion box as leveled brf6placed ND explain: NO The system requiredpumping.-more than 4 times a year due to broken or obstructedpipe(s);The s stem will Y 9 Y Y pass inspection if(with approval of the Board of Health): - Na broken pipe(s)are replaced N.4 obstruction is removed ND explain: Page 3 of 11 OFFICIAL WSPECTION FORM-NOT VOR VOLUNTARY ROS;aiiL�S��INSP�CTI�ON�RM ASSESSMENTS SUBSt"ACE SEWAGE�S PART:A CERTMCATION(continued) : Property Address: 44 Uianno Ciltc-ie 0,3 eavi iTi Ma Owner:.N.iche,e e Oa ,2 Date of Inspection: 10/1/0 4 C. Further Evaluation-is Required by the Board of Health: no Conditions.exist which require further•evaluation•by.the,,Board:of;Heaith;in-order,to:determine ifthesystem: is failing to protect public,health, safety or the environment. 1. System will pass unless Board oi'�iealth determines�in accordance with 310.CM1<t 15:303�] bOO that the system is not functioning in-a.MR. lner-which:wjll•protect public health,safety andIhct .environment: no Cesspool or privy is within;50 feet of aswface water no Cesspool or,privy is within 50 feet of•a bordering vegetated wetland or a salt marsh. 2. System will fail unless the Board-of Health{and Public Water Suppliers-If any),determines:that the system is functioning in a mariner that protects thepublic health,safety and environment: n n The system has a septic tank and soil absorption system(SA•S).end the SAS is within 100 feet.of a surface water supply or-tributary to a.surface water supply. n o The system has-aseptic tank and SAS and the;SAS is within a Zone 1 of apublic watensupply. no The system has a septic tank and.SAS:and-the SAS is within,-50 feet of a private water.supply well. n 0 The system has a septic tank and SAS and the-SAS is less than 100 feet..birt 50 feet or.Thore front a private water supply well".Method used to determine distance- "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from-pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5.ppm,provided that no other failure criteria are triggered.'A copy of the analysis must be-.attached to-tis form. 3. Other: Page 4 of 11 OFFICIAL•INSPECTION FORM-NOT'FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.1NSPECTION FORM � PART A CERTIFICATION(continued) Property Address: 44 Oianno Ci/t., Owner: Nz'che-e- e lVaekelz Date of Inspection: 10/1/ 4` D. System Failure Criteria applicable to all systems:. You must indicate"yes"or"no"to.each.of the:following.for all inspections: Yes No x. Backup of sewage.:into faefiity:or system component due.to overloaded,or clogged SA:S...or.cesspool x Discharge:or ponding of effluent to the surface of the:g. round or..surface:waters due to.an•overloaded or clogged SAS or cesspool x 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 thank"below invert or available volume is less than May flow x 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. _ x Ariy,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 l of a:public.well— Any z Any portion of a cesspool or privy is within.50 feet of a private water supply well. x Any portion of a.cesspool or privy is less than 100 feet but greater.than 50 feet from a.private water supply well with no acceptable water quality analysis..[This.system.passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic,compounds indicates:that the well is free from pollution:fr..om:that,facflity and:the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than ppm,provided that no other failure criteria are-triggered:A copy of the analysis must be attached.to this fort0.1 .no (Yes/No)The system fails.I have determined that-one or.more,,of:the:above.failure::criteria exist as described in 310 CMR 15.303,therefore the-system-fails.The system owner.should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the:systlem must.serve,a:faeility,with a design flow of 10;000 gpd to 15;000. gpd• You must indicate either"yes"or"no"to.each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the-system is within 400 feet of a surface drinking water supply the system.is within 200 feet of a tributary to a surface drinking water supply the system is located'in a nitrogen sensitive area Interim Wellhead Protection Area_IWPA)or'a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant.threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional.office of the Department. 4 Page S of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS �- $jJBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 44 ld-iaano. Ci2.• e2v.c e, a.,• Owner:. Nichei.2e .Ida.e e2 Date of Inspection: 9 XA/©xl Check if the following have been done You must indicate"yes"or"no"as-to each of the following: Yes No x _ Pumping information was provided by the owner,occupant,or Board of Health _ x Were any of the system components pumped out in the previous two weeks? x Has the system received normal flows in the previous two week period? x Have large volumes of water been introduced to the system recently or as part of this'inspection? x Were as built plans of-he system*obtained and examined?(If they were not available note as N/A) x Was the facility.or-dwelling inspected for signs of sewage back up? x Was the site inspected for signs of break out? x _ Were all system components,excluding the SAS,located on site 9• x _ Were the septic tank manholes uncovered)opened,and the interior of the tank inspected for the condition . of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? x _ Was.the facility owner hand occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS).on the site.bas been determined based on: Yes no x — Existing information.For example,a plan at the Board of.Health. _ ria related to Part C is at issue approximation of distance x Determined in the field(if any of the failure crite . is unacceptable)[310 CMR 15.302(3)(b)j Vi;. . s Page 6 of 11 OFFICIAL I. SPFC'TI N.--]F-ORM'-NOT FOP,VOLUNTARY ASSESSMENTS SUBSURFACE-SEWAGE DI$POSAir SYSTEM,INSPECT14QN:FORM PART••C SYSTEM:INFORM' ATION PropettyAddress: 44 ianno .a e2v.c e, a.• Owner: Miche.Ue Va..9ke2 Date.of Inspection:_ I 0^/4/:0 4 , FLOW CONDITIONS RESIDENTIAL 4 Number of bedrooms(desig):. —;: ;Number of bedrooms•(actual): 401 0=4 4 0 gl?cl DESIGN'flow based on.S IO CIG'ITt 15.203':(for erto4le:'110'gpd x#•of'bedrooms)i Number of current residents: __ Doevresidence have a garbage grjtder(yes br no):is laundry on a separate sewage.system.(yes or.no):.p_0 [if yes separate inspeption required] Laundry system inspected(yes or no): ,, Seasonal use:(yes or no):-��, a�a172, D Water meter readings, if available(last 2 years usage(gpd)): 00Q A56�6fb Sump pum (yes or no): ,o,a Last date o occupancy: o_ 10 4 COMMERCIg Zi , USTRIA:L Type of estat Wi nt: NA �. DesFgn flgw.: . ��on310 CMR 15.2U3):. d Basis.of dMign'`tlow(seats/persons/sgft,etc.):, Grease trappresent(yes or no):'N,4 Industrial waste holding tank present.(yes or no)*l/.�__ Non-sanitary waste discharged to the Title 5 system-(yes or no): IVA Water•.meter readings,if available: NA Last date of occupancy/use: N A OTHER(desgribe):. N . GENERAL INFQATION Pumping Records Source of information: . Na Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons--How was quantity pumped determined? Reason for.p..umping: TYPE OF SYSTEM , � YSeptic tank,distribution box,soil absorption system —Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative-technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) —Tight tank. _Attach a.copy of the DEP.approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: 1999 Were sewage odors detected when arriving at the site(yes or no):fQ L Page 7 of 11 . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM A PART C SYSTEM INFORMATION(continued) Property Address:4 4 O ianno 'C4L2 c Qe U�s.fertv.i-C (7ri Owner: Date of Inspection:_1()/l/ BUILDING SEWER(locate on site plan) Depth below grade: 7 2" ;F Materials of construction: cast ironX 40 PVC_other(explain): Distance from private water supply w or suction line: 0 Comments(on condition of joints,venting,evidence of leakage,etc.); _ 7Oo ini,3 ' a2e t iglz�.: Ve.tned th2oa h house vend .s z .n of- .leakage No SEPTIC TANK:y'"(locate on site plan)15 0 0 ga-eio n, ,tank. Depth below grade:7" Material of construction:X concrete_metal fiberglass___Polyethylene --other(explain) N 4 If tank is-metal list age. _ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a co of certificate) copy Dimensions: 10' 6"L X 5' 8nY& .X 5' 7"/i.. Sludge depth: z a c e Distance from top of sludge to bottom of outlet tee or baffle: o Scum thickness: .t 2 a c e Distance from top of scum to top of outlet tee or baffle: n o Distance from bottom of scum to bottom of outlet tee or baffle: n o How were dimensions determined; m e a n��o d Comments(on pumping recommendations,inlet and outlet tee or baffie condition as related to outlet invert,evidence of leakage,etc.): 'structural irateglrih',liquid levels I ae�sen.t. no '3.igns o", ieakage. sound GREASE TRAP: /VO(locate on site plain) Depth below grade>7/A Material of construction: concrete—metal fiberglass___polyethylene_other (explain): NA — — Dimensions: ft Scum thickness:T�T — Distance from top of scum to top of outlet tee or baffle: NA Distance from bottom of scum to bottom of outlet tee orbaifle;� Date of last pumping: NA �. Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural irate as related to outlet invert,evidence of leakage,etc.): sty,liquid levels aea�e tea ins no.t 12 2e.6en.t Titles S TnenPMinn T7nrm 4/1 S/7/1M 7 Page 8 of OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS M:��RF A,CE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4 4 (d 'fin n n C.i n r.Pe Owner:•P1inhp_LPn l,Irnko)7 Date of 1-bspectlon: 10/1/0 4 N TIGHT or HOLDING TANK:NO (tank must be pumped at time of inspection)(locate on site plan) Depth below,grade: NA Material of construction: concrete metal fiberglass____polyethyleneother explain): N,4 y - Dimensions: NA Capacity: N,4 gallons Design Flow: N4 gallons/day Alarm present( es or no Alarm level: . NO Alarm.M working order(yes or no): Date of last pumping: N,4 Comments(condition of alarm and float switches,etc.): light o2 hoidincl tunkz ate not RaezL",, DISTRIBUTION BOX:ye-3 (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.) RoX 'hn.t )no gnfonn p No zignz of 6o Tid caa3�Uoyaz . no z.cgns oZ ieakacre .in o2 pal n4 knx_ PUMP CHAMBER:No (locate on sife.plan) Pumps in working order(yes or.no): NR Alarms in working order(yes or no):NA Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): Puma chamPv_a_ a-.s n_n.t_ . PaziPn1 8. Page 9 of 11 OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS -- • SUBSURFACE SEWAGE DISPOSAL SYSTEM I.NSPECT.ION FORM PART C SYSTEM INFORMATION(continued) Property Address: 44 Oianao C.i2cee Ma OwnerOicheiie Uai e z Date of Ins pection:M.cc e.P e lda eke2 SOIL ABSORPTION SYSTEM(SAS):_-(locate on site plan,excavation not required) If SAS not located explain why: Located See Pa see 6 Type no leaching pits,number:_ �� glpaching chambers,number:3 n o leaching galleries,number: no leaching trenches,number,length: no leaching fields,number,dimensions: no overflow cesspool,number: no innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil, condition of vegetation, ' etc.): Loamy to medium .3and. So.ii.3 ate d2 -no .6-i ns o h d2au-e.ic a.c YI e e yetat.ion .i.3 noltma e CESSPOOLS: NO (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: NA Depth—top of liquid to inlet invert; NA Depth of solids layer: NA Depth of scum layer: NA Dimensions of cesspool: NA Materials of construction: NA Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc:): Cezz ooiz a)ze no.t .¢e sen.t PRIVY NO (locate on site plan) Materials of construction: NA Dimensions: NA Depth of solids. NA Comments(note condition of soil,signs of hydraulic failure,level ofponding,condition of vegetation,etc.): l a.iv ih not aehent.' 9 Page 10 of 11 ✓ OMCIAL INSPEC-TIQN-FORM,NOT FOR,,V-OLUNTARY-ASSESSMENTS SUg'SUIWA:CE SEWAGEMISPOSAL SYSTEMINSPECTIONi:FO►RM PART C, SYSTEM FNF•ORMATLON(nontitused)` Property Address: 4 4 W a n n o C--i lLa P_a_ Z3�e2v.�.Q"Qe Owner: Nichp-i a Oaihea Date of Inspection: 10/I I I " SKETCH OF SEWAGE-DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two perinanerit refbrence landmarks or enchmarks.Locate all wells within 100 feet.Locate where public water supply enters.the building. No PI Permission System located Is hereby g G m loc at 4• r� r+t°� 0 and as desc '. bed in the a comply witb Title Sandi co a r ar •. �1 Provided:Construe . Date: tiOn m 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.0 SYSTEM INFORMATION(continued) Property Address:4 4 04-'anno ( .in_r a Owner:1' icheiig Naikea Date of Inspection: 1011104, SITE EXAM Slope Surface water Check cellar. Shallow wells Estimated depth to ground water 3 0 feet Please indicate(check)all methods used to determine the high ground water elevation: N Obtained from system design plans on record-If checked,date of design plan rgviewed. LPbserved site(abutting property/observation hole within 150 feet of.SAS) �1[r) Checked with local Board of Health-explain: L A Checked with local excavators,installers-(attach documentation) 41E_�4ccessed USGS database:explain: You must describe how you established the high ground water elevation: Gahelt.t y 98 i etc z lrlode.e 12116194 -Oat e2 etevat.ion alcove zee . eve USGS • Oezezva.t.ion wei.9 data Top of Oround Leaching a Pit 8 ;eet Groundwater?3 Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Fra, terr Method Therefore,the vertical-separation distance between the bottom of the leaching pit and the adjusted groundwater table is 13. 8 0 feet. 11 "^ ��,�..-„R,.,,..,e r..=.,..n.,,,•. 1U N OF Barn tas kjl . WARD OF 11EALT11 SUl191JRFACR SENA(;F I)18!'0,� L SYSTEM IN811FCTION FORM - PART D•- CERTIFICATION i „-•,'irl,R+,rvRnTLT�R' �� RRIn•evrr+ns�.srew.rnnvnrrr•r-•�• .-•.• r...z,.,.T•• TJIS��� Tf 'R�IT+IRRfRIZR�R71 -TiPC OR PRIN-T CLEARLY- PROPERTY INSPECTED STREET ADDRESS 44 Njanno ci4cie 139-024 ASSESSORS MAP , 13I�OCK AND PARCEL # OWNER'' s NAME l�l.icheUe Waikea PART D - CERTIFICATION i.in.i NAME OF INSPECTOR Ro&At Pao: • . COMPANY NAME Joseph P. Macomber & 'Son Inc COMPANY ADDRESS Box 60 Centeruille Mass 02:632 Street Town or clty Stata CIP COMPANY TELEPHONE ( 508 ) 775-33-38 FAX ( 508 ) 790-1.578 RI Cr,R'fIf ICAT,ION. STATEMENT I certify that I .. have personally inspected the sewage system at ;this Rddr.ess and that the information reported is true , accurate, and yomplete as of the time of ,inspection, The inspection was per'Pormed and any 'recommendations regarding upgrade-, maintenance , ana repair are consistent witl) my' training and experience in the proper function and maintenance of on- site sewage disposal systems , Check one ; Systeoi .PASSED The inspection which I have conducted has not found any information which indicates that th.e system fails to adequately protect public health or the environment as defined i.n 310 CMR 16 , 303 , Any . failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form , Syste® FAILED* The inspection which I have condtltted. has found that the system fails tc protect the jiub.lic health and the environment in accordance with Title 5 , 3.10 CMR 16 , 3Q3 , and as specifically noted on PART. 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Mk ,yrt� tll ,..a: " ! x s. ,aa �:,, `v-Fr"nZ„e �- , at P. ,"Ww ,, " , - '� , x1. l Y $F r -t - �+T% A� f•, } �h`3P txt <'Et tta t f t "� tY F t 4 �`� 3 X b F�a 1 „> 1� ,;, - - � - � ��:I", �, - " �_',",��,,,_�', �­;�!:,��.�, I ,- '.., -7_7 ,- ,�,�,����;��,,���,�,�,�,�,��'���'�,",�:,;,-����'..- ­�,11�11z� „ ., .. t .. , TOWN OF BARNSTABLE LOCATION y GU!A 41N O CIS SEWAGE #.,7,P—to VILLAGE ()����'C/``L12 ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. -� A4 4 co or Rex r SQAI SEPTIC TANK CAPACITY LEACHING FACIL=: (type)3��"L ruC 1�4,�v��,�s (size) ®� ,NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet J Private Water Supply Welland Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r . . r" r� t + iL v��`'- �, L\bv o � � I , �� � J � C) �.. ;I I :9` �� No. d Fee $ 5 0. 0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Zipprication for Digonl *potem Construction 30ermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) complete System ❑Individual Components Location Address or Lot No. 44 Wianno Circle Owner's Name,Address and Tel.No. 4 2 8-3 2 5 7 Osterville,Mass . 02655 44 Wianno Circle Assessor'sMap/Parcel /5 91 091 Osterville ,Mass . 02655 Installer's Name,Address,and Tel.No. 5 0 8-7 7 5-3 3 3 8 Designer's Name,Address and Tel.No.5 0 H-7 7 5-3 3 3 8 J.P.Macomber & Son Inc . J.P.Macomber & Son Inc . Box 66 Centerville ,Mass , 02632 Box 66 Centerville ,Mass . 02632 Type of Building: Dwelling XXNo.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons 2 Showers( ) Cafeteria( ) Other Fixtures Design Flow 4 6 2 gallons per day. Calculated daily flow 4 X 1 1 (L4 4 0 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 15 0 0 Type of S.A.S.3—,5 0 0 gallon leaGhi R g Description of Soil chambers . 4 ' Stone all around . Nature of Repairs or Alterations(Answer when applicable) Omitting two block c e.s p n n 1 s , Installing 1-1500 gallon tank, l-Distribution box and 3-500 gallon leaching chambers packed in 4 ' of 12" stone . 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 Environment Code and not to place the system in operation until a Certifi- cate of Compliance has been iss ed by i o of Hea Signe Date 10/7/9 9 Application Approved b Date ` Application Disapproved for the following reasons Permit No. Date Issued No. ,� Fee $ 50. 00 Entered in computer: _ THE COMMONWEALTH OF MASSACHUSETTS , Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Rpprication for Migonl *p5tem Construction Permit Application,for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Dr—omplete System ❑Individual Components Location Addressvr Lot No. 4 4 W i a n n o C i r c l e Owner's Name,Address and Tel.No.4 2 8—3 2 5 7 Osterville ,Mass . '02655 44 Wianno Circle Assessor's Map/Parcel /5 q O O s t e r v i l l e,Mass.0 2 6 5 5 Installer's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No.5 0 8—7 7 5—3 3 3 8 J.P.Macomber & Son Inc. J.P.Macomber & Son Inc. Box 66 Centerville ,Mass, 02632 Box 66 Centerville,Mass. 02632 Type of Building: Dwelling X X No.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons 2 Showers( ) Cafeteria( ) Other Fixtures Design Flow 4 6 2 gallons per day. Calculated daily flow 4 x 1 1 0=4 4 0 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1500 Type of S.A.S.1-9flo gallon leaching Description of Soil chambers. 4 ' Stone all around . Nature of Repairs or Alterations(Answer when applicable) M m i t t i n g two block cesspools. Installing 1-1500 gallon tank, l—Distribution box and 3-500 allon Backing chambers packed in 4 ' of 1111 stone . _r Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environment Code and not to place the system in operation until a Certifi- cate of Compliance has been iss ed by . i�o d of Hea h. Signe Date 10/7/9 9 Application Approved b � -Date,,Zd am f Application Disapproved for the following reasons Permit No. yr Date Issued M A ————— ------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance / U r THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded�X X) Abandoned( )by J.P.Macomber & Son Inc . ., at 44 Wianno Circle O s t e r v i l l e,Mass . has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 9 A+Z dated A4'- Installer _J.P.Macomber & Son Inc, Designer J.P.Macomber Son n c T The issuance of this permit shall not be—c-onsirued as a guarantee that the s 7 1 function as esigged, Date �� Inspec sw' r No. � �"�' � �--------------------------Fee $50.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mioosar *pstem Construction Permit Permission is hereby granted to Construct( )Repair( )Upgrade(XX)Abandon( ) System located at 44 Wianno Circle Ost.erville.Mass. and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to r comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date: ✓ Approved b 44 e 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I,Joseph P.Macomber J r . hereby certify that the application for disposal works construction permit signed by me dated 10/8/9 9 concerning the property located at 44 Wianno Circle _Osterville ,Mass . meets all of the following criteria: t✓ The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system /There are no private wells within 150 feet of the proposed septic system •✓ There is no increase in flow and/or change in use proposed •'/There are no variances requested or needed. • The bottom of the proposed leaching facility will nQt be located less than five feet above the maximum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor method when applicable] t •v If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14) feet above the maximum adjusted groundwater table elevation, Please complete the following: .s A) Top of Ground Surface Elevation(using GIS information) eV B) G.W. Elevation I �+the MAX. High G.W. Adjustment.1 _ DIFFERENCE BETWEEN A and B SIGNED : DATE: 10/8/9 9 (Sketch pr posed plan of system on back]. q:health folder een I 4, . � d�o� e _ ,. d� - _ �� �� � y 'L_ TOWN OF BARNSTABLE LOCATION Y Y GU!A AIN 0 CIX SEWAGE # VILLAGE n S 7 e e i/r'11 a ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. —T A4 4 coo i?ae r sew SEPTIC TANK CAPACITY /, f e LEACHING FACILITY: (type)�: f Lvu�C//ig,l�gc�,�5 (size) moo NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility), Feet Furnished by O .