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Home My WebLink About0055 WINTERGREEN CIRCLE - Health 55 WINTERGREEN CIRCLE OSTER_ `'IEEE " A = 119 037 v i F e R r 1 X i r r}��\ Commonwealth of Massachusetts . Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r s a`' 55 Wintergreen Circle „rl Property Address Albert Saganich ;ID Owner Owner's Name information is wired for ever y ry Osteryille ✓ Ma. 02655 05-21-2018 iml page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms 03(p on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael T Bisienere use the return Name of Inspector key. Cape Septic Inspections � Company Name 624 Old Barnstable Road Company Address Mashpee Ma. 02649 City/Town State Zip Code 508-280-3356 S13938 Telephone Numberr, 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 4 05/22 _ 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 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. I t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Wintergreen Circle Property Address Albert Saganich Owner Owner's Name information is required for every Osterville Ma. 02655 05-21-2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A;B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This 3 bedroom home has a H-10 1000 gallon septic tank and a H-10 D-Box feeding two leaching pits. At the time of the inspection there were no visible signs of past hydraulic failure in the leaching pit behind the garage. 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 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. El Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6/16.: Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of.17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w ,•''y 55 Wintergreen Circle Property Address Albert Saganich Owner Owner's Name information is Osterville Ma. 02655 05-21-2018 required for every page. Citylrown State Zip Code Date of Inspection 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 ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M SVey`'e 55 Wintergreen Circle Property Address Albert Saganich Owner Owner's Name information is required for every Osterville Ma. 02655 05-21-2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® 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 i or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts M - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 55 Wintergreen Circle Property Address Albert Saganich Owner Owner's Name information is required for every Osterville Ma. 02655 05-21-2018 page. Cityfrown 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- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you imust indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments wM 55 Wintergreen Circle Property Address Albert Saganich Owner Owner's Name information is required for every Osterville Ma. 02655 05-21-2018 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components.pumped out in the previous two weeks? ❑ ® Has the'system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not ❑ ® available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: N ❑ 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)] D. System Information Residential Flow Conditions: Numberof bedrooms(design): 3 Number of bedrooms (actual):, 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): - 330 plug gpd t5ins.doc•rev.6/16. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6.of 17 f Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Wintergreen Circle Property Address Albert Saganich Owner Owner's Name information is required for every Osterville Ma. 02655 05-21-2018 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 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 years usage (gpd)): Detail Sump pump? ❑ Yes ® No Last date of occupancy: Fall 2017 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 4 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Wintergreen Circle Property Address Albert Saganich Owner Owner's Name information is required for every Osterville Ma. 02655 05-21-2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Offic,ial Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 55 Wintergreen Circle Property Address Albert Saganich Owner Owner's Name information is required for every Osterville Ma. 02655 05-21-2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all :omponents, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18"feet Material of construction: ❑ cast iron E 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of.certificate) ❑ Yes ❑ No Dimensions: Standard H-10 1000 gallon septic tank 1 , Sludge depth: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 55 Wintergreen Circle Property Address Albert Saganich Owner Owner's Name information is required for every Osterville Ma: 02655 05-21-2018 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 36 11 Scum thickness 1 � 511 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Sludge 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.): I would recommend the new owner put the tank on a maint. plan with a local septic pumping co.The Barnstable Health Dept. has a list of local septic pumping co. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °N 55 Wintergreen Circle Property Address Albert Saganich Owner Owner's Name information is required for every Osterville Ma. 02655 05-21-2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 l _ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Wintergreen Circle Property Address Albert Saganich Owner Owner's Name information is required for every Osterville Ma. 02655 05-21-2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): - Depth of liquid level above outlet invert 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.): The H-10 D-Box had no visible signs of leakage or evidence of past hydraulic failure. 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 Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6116. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 55 Wintergreen Circle Property Address Albert Saganich Owner Owner's Name information is required for every Osterville Ma. 02655 05-21-2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection there were no visible signs of past hydraulic failure in the leaching pit behind the garage. 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 Bayer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 55 Wintergreen Circle Property Address Albert Saganich Owner Owner's Name information is required for every Osteryille Ma. 02655 05-21-2018 page. Citylrown 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.): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "t 55 Wintergreen Circle Property Address Albert Saganich Owner Owner's Name information is required for every OSterville Ma. 02655 05-21-2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 01 l3l- as Ala- A a °"� A3- ao s M4- a3 Sq. 3c GS- A - 5 ^3� 7 � } Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments. °,M ,.•'' 55 Wintergreen Circle Property Address Albert Saganich Owner Owner's Name information is required for every Osterville Ma. 02655 05-21-2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow well's Estimated depth to high ground water: 12 plus feet 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 U'SGS database-explain: You must describe how you established the high ground water elevation: I augered a hole at a lower elevation and I shot it with a transit. Before filing 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 Commonwealth of Massachusetts - Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 55 Wintergreen Circle Property Address Albert Saganich Owner Owner's Name information is required for every Osterville Ma. 02655 05-21-2018 page. Cityrrown State Zip Code Date of Inspection 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 ;31 t. �=� TOWN OF BARNSTABLE Pee L( ATION S� W,.tTt lS ru•�, C l KCAL SEWAGE # VVzLAGE D Sn-'V-1� ASSESSOR'S MAP & LOT 03 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) Pi 1 &5CG. (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leachi g facility) rr Feet Furnished by �n SpGyor+ J •t0/ A 9 bQ M r6 cb Cb rb rb M 1 Cb � pq ST y J Q '1 V'y..:'.?.> TOWN OF BARNSTABLE 1.0�.TION �S��a�ltr®r�C� G'i°1^�le SEWAGE a - VIIlAGE C'*s7r, ,! /e ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. P hf k,k ,Gh, SEPTIC TANK CAPACITY LEACHING FACILITY:(type) �� % (size) NO. OF BEDROOMS _PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: -7 G - q DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No f� (\ ''^, 9 r l ASSESSORS MAP NO: ® PARCEL NO: C �7 30.00 No.. ....... Fps............._............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ftniOtew,CAPPROVEt) TOWN OF BARNSTABL �Cor*cry 'O"�eAartme�t Allp iration for Dispntial Works Tomannrt' rr a Date Application is hereby made fora Permit_to Construct ( ) or Repair �X ) an Individual Sewage Disposal System at: 55 Whiter Green Circle Osterville ................_................................................................................ ...••--••--------•-••••-----•-----._......-•-•-----------.........._•----•---------.............._ Location-Address or Lot No. Crocker ..... _.:....................:......er Add...•-----------.._.....--•--------•-----•---- ..........--...................................__..ress............................................... Own W J.P.Macomber Jr. Installer Address Q Type of Building Size Lot............................Sq. feet DwellZ No. of Bedrooms........... ______________________________Expansion Attic ( ) ., Garbage Grinder ( ) p, Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures -------------------------------- W Design Flow............................................gallons per person per day. Total daily flow-------.....................................gallons. WSeptic Tank—Liquid capacity._._._.____gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No_ ____________________ 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 ( ) � Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water......................... f14 Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................ ---------------------------------------------------------•-------------.........._...-------._....__......................................................... 0 Description of Soil---------------han--d-- Gra--------veT------------------------------------------------•---------------- ------------------------------------------- x 8c v ..__.._..-•-•-----------•--•-----•--------•------------------------------------------------------------------------------------------------------------------------------•----------•-----------•------- W �,f R ,e, when applicable----------------------------------------------------------------------------------------------- U ttr� Re' 'I$Hn�'1 e� Y1�1n�'r> `J_ --------------------------------------------------•----------------N---------------•--............-----•--------------------------------------------.................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complia ce has ee issued by th boar f health. Signed ... n 7/ . ----------------- Dace ApplicationApproved By ------- ------------- --- .......... .... ................. . .. ......................................... ------------.----Dace-'......-'------ Application Disapproved for the following reasons: ........................ ........................................................ .................................------ PermitNo. .. --^------------------------------ ------ Issued ------......------............-------------------...---Dace------ Dace No....... ._...4 _ Fps....$....30.00 THE COMMONWEALTH OF MASSACHUSETTS ;:-� - BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Disposal Works Towitrur#i/tt Prrmit Application is hereby made for a Permit to Construct ( - ) or Repair �X) an Individual Sewage Disposal System at: 55 Winter Green Circle Osterville ................_...........----........................................---•------.........-- .. -....---------------------.....-•-------•-----------------------......___•----•-- Croaker Location-Address or Lot No. Owner Address ...P.Macomber Jr .................................................. ••--__--•-• --•----••-----•-----•-...•-----.........--- Installer Address Type of Building Size Lot............................Sq. feet DwellingxX No. of Bedrooms............ ..............................Expansion Attic ( ) Garbage Grinder ( ) aa Other—T e of Building YP g -------------•----•--------• No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ---------------------------------------------------------------------•----------------------------•------------------------ W `Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No-------:............. Diameter...._............... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ 4 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0-4 44 Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................ 9 ---------------------------------------------------•------------•--••----------.....•----•--•----•--......................................................... O Description of Soil...................................... ......... xSand & Gra �--------------------------------------------------•---------------------------------•-------------------....-•------ V --------------------------------------------------------------------------•.............----------------------------------------------------------------------------------W ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•--------.......---...._. U N ture of epair or Al rations—Ans er when applicable...____......................................................................................... -l0VOR Gals]on eacning p`i C. ----------------------------•-----------------------------------------------------------.....-------------------------------- ------------------------------------------------------------......_...---- 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 Complia ce has been issued by the,board of health. a ned .... ....� w .. ... 7161.9� Date ApplicationApproved BY ---- --- ------ - - --------------------------------- ----- ......................................... ---------------------------------------- Date Application Disapproved for the following reasons: .......:.. ----------------------- . --............... ------------------------- ----------'-------------------------------'-----........,. - -. — — —- -------...........--'--------- ---- ----------------------- ....... Date PermitNo. ..-- ---- . --�......... .. .. ....................... Issued -- ---------- -------- ----------------- ------......---- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE t GPrtifira E of V'lantylialare THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XXX) by --J.P.Macomber Jr, --- -------------------------------------------- --- - -------------------------- ------------------------------------------------------------------------------- Winter Installer at -..-55..................... Green Circle Osterville -- -- ---- -------------------------------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE The S e ironmental Code as described in the application for Disposal Works Construction Permit No. ..... '�.... � -- dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT B CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE--------------------------�..-_�-- -- " ---.......... Inspector ....----- ..-.-..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Noq ...... TOWN OF BARNSTABLE Flu.... --... .00 Disposal Workii %"Nnnotrnr#inn -ermit J P.Macomber Jr. Permissionis hereby granted...............................................................................................------...-----------•--------------------------------•----- .............................................. to Construct , or Repair (X}c) an Innddwid al Sewage Disposal System at No..... __ inter Green Circ i �stervllle -------------------------•-•---------- .............................-----Street- ------- 1�;- ---= ..as shown on the ppli tion for Disposal Works Construe rmit No.____ .._. _ -ated........... . . DATE.. . ............ ............................... Bodid of�Health FORM 36508 HOSE Q WARREN.INC.,PUBLISHERS t .1 mum Town of Barnstable Board of Health 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Susan G.Ras PLS.FAX: 508-790-6304 Sumner Kaufman,MSPH Wayne Miller,M.D. May 17, 2004 Revised Mr. Albert Saganich 55 Wintergreen Circle Osterville, MA Dear Mr. Saganich, Your request for a variance to construct a family room addition, with a full . foundation, in close proximity to existing leaching facility is not granted. The variance you requested was as follows: 310 CMR 15.211: To construct a new foundation wall only twelve (12) feet away from the existing leaching facility, in lieu of the twenty (20) feet minimum setback required. The Board suggested that you instead construct a four feet (crawl space) foundation wherever the separation distance is twenty feet or less to the existing leaching facility. The remainder of the foundation areas located beneath your new family room may be constructed with a full foundation. You are granted the following variance.however: 310 CMR 15.211: To construct a new foundation wall only seven (7) feet away from the existing septic tank, in lieu of the ten .(10) feet minimum setback required. This variance is granted with a condition that you install a polyethylene liner between the foundation wall and the septic tank. Sincerely yours, rne Miller, M.D. Town of Barnstable NAM Board of Health 200 Main Street, Hyannis MA 02601 Office: 508-8624644 Susan G.Rask,RS. FAX: 508-790-6304 Sumner Kaufman,MSPH Wayne Miller,M.D. May 17, 2004 Revised Mr. Albert Saganich 55 Wintergreen Circle Osterville, MA R ; M 5Wnt�rgreenit cle . t " � � � Dear Mr. Saganich, Your request for a variance to construct a family room addition, with a full foundation, in close proximity to existing leaching facility is not granted. The variance you requested was as follows: 310 CMR 15.211: To construct a new foundation wall only twelve (12) feet away from the existing leaching facility, in lieu of the twenty (20) feet minimum setback required. The Board suggested that you instead construct a four feet (crawl space) foundation wherever the separation distance is twenty feet or less to the existing leaching facility. The remainder of the foundation areas located beneath your new family room may be constructed with a full foundation. You are granted the following variance however: 310 CMR 15.211: To construct a new foundation wall only seven (7) feet away from the existing septic tank, in lieu of the ten .(10) feet minimum setback required. This variance is granted with a condition that you install a polyethylene liner between the foundation wall and the septic tank. Sincerely yours, ^L 1*nve Miller, M.D. 1 Town of Barnstable Board of Health 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Susan G.Rask,R.S. FAX: 508-790-6304 Sumner Kaufrnan,MSPH Wayne Miller,M.D. May 17, 2004 Revised Mr. Albert Saganich 55 Wintergreen Circle Osterville, MA Dear Mr. Saganich, Your request for a variance to construct a family room addition, with a full foundation, in close proximity to existing leaching facility is not granted. The variance you requested was as follows: 310 CMR 15.211: To construct a new foundation wall only twelve (12) feet away from the existing leaching facility, in lieu of the twenty (20) feet minimum setback required. The Board suggested that you instead construct a four feet (crawl space) foundation wherever the separation distance is twenty feet or less to the existing leaching facility. The remainder of the foundation areas located beneath your new family room may be constructed with a full foundation. You are granted the following variance however: 310 CMR 15.211: To construct a new foundation wall only seven (7) feet away from the existing septic tank, in lieu of the ten .(10) feet minimum setback required. This variance is granted with a condition that you install a polyethylene liner between the foundation wall and the septic tank. Sincerely yours, tnt Miller, M.D. DATE: •y070 K, r : * FEE: ( VOr • BARNSTABLE y MASS. i639• ♦0 REC. BY __\_\� Town of Barnstable 1-j $\3 SCHED. DATE: Board of Health 200 Main Street, Hyannis MA 02601" Office: 508-8624544 ' Susan G.Rask,R.S. wFAX508-790- 04 Sumner Kaufman,M.S.P.H. J -- Wayne A.Miller,M.D. VARIANCE REQUEST FORM S S• O �=LOCATION 2PropTy Addr h e e 41 C /.J` C L`� sser's Map and Parcel Number: / l �. .w Size of Lot: wetl2js Within 300 Ft. Yes Business Name: No r! Subdivision Name: y APPLICANT'S NAME: Phone ' Did the owner of the property authorize you to represent him or her? Yes. No , PROPERTY OWNER'S NAME CONTACT PERSON � L SEr�'f GthfC� r45 Name: Name: �1 1W 4 .5 t ,,�(o� 1 d ess: o` Address: �� 5 f w d i P��r to Prj ev//? d Phone: 7 0 8 '-4 ® Phone: VARIANCE FROM REGULATION(List Reg.) REASON FOR VARIANCE(May attach if mo pace needed) NATURE OF WORK: House Addition 1300000 House Renovation ❑ Repair of Failed Septic System Checklist (to be completed by office staff-person receiving variance request application) Please submit copies in 4 separate.completed sets. _ Four(4)copies of the completed variance request form _ Four(4)copies of engineered plan submitted(e.g.septic system plans) Four(4)copies of labeled dimensionaffloor plans submitted(e.g.house plans or restaurant kitchen plans) . Signed letter stating that the property owner authorized you to represent him/her for this request .Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense (for Title V and/or local sewage regulation variances only) _ Full menu submitted(for grease trap variance requests only) Variance request 'application fee collected (no fee for lifeguard modification renewals, grease trap variance renewals .,[same owner/leasee only], outside dining variance renewals [same owner/leasee only], and variances to repair failed sewage disposal systems [only if no expansion to the building proposed]) Variance request submitted at least 15 days prior to meeting date VARIANCE APPROVED Wayne A.Miller,M.D.Chairman NOT APPROVED Sumner Kaufman,M.S.P.H. REASON FOR DISAPPROVAL Susan G.Rask,R.S. Q-:\HEALTH\Application Forms\VARIREQ.DOC ,i. 4• e THE fps Town of Barnstable Regulatory Services a Thomas F.Geiler, snaxsznsce, = , Director Building Division rEnr Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office:. 508-862-4038 FAX 508-790-6230 .HOMEOWNER LICENSE EXEMPTION Please Print DATE r" JOB LOCATION:. ,r :S W G -� �. E A?Q+'1 G .f d t'e number " / street village "HOMEOWNER': C a r o f` f711 P`��•t E C Q r name liome phone# CURRENT MAIL)NG ADDRESS: S S w i h 4-e/ of A 8.P Y) C=r1!i f �,.S 14E d V I C t city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is,or is intended to be,a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that.he/she shall be responsible for all such work performed under the building perm it. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with.the State Building Code and other applicable codes,bylaws,rules and regulations. ----- The:undersi-gned."homeowner"certifies that.he/she understands the Town of Barnstable Building.Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeo s Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger,will be required to comply with the State Building Code Section 127.0 Construction Control. - HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." , Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed' Supervisor. The homeowner acting as Supervisor is ultimately responsible. t • ' To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:forms:homeexempt '. . I IKE F yRARNSUBLA ' � tee$ y i TOWN OF BARNSTABLE Zoning Board of Appeals ° Application for a•Variance, , Procedure for Filing: Application forms are available at the Zoning Board of Appeals Office, Planning Division,,200 Main Street, Hyannis, MA. Three(3) completed application forms, along with all required information and materials must be submitted. One(1)application is to be filed with the Town Clerk, and two (2)are to be submitted to the Zoning, Board of Appeals. Failure to supply required information is sufficient reason fora denial of your request. Completed applications must be submitted to the Town Clerk's Office,to be time and date stamped. One(1) shall remain with the Clerk's Office,.and the other two(2)copies:shall immediately be filed with the Zoning Board of Appeals Office, along with all required materials and a check payable to the Town of Barnstable for the ' applicable filing fee.- It is strongly recommended that.all applications be reviewed by the Planning Division prior' to clocking at the Town Clerk's Office to ensure a complete application. The fee schedule fora Variance, including modification of,existing Variances, is as follows: s Single and Two Family Bulk and Lot Dimensional Variance. $100.00/per lot a All Other Variances $100.00 Multi-Family,Commercial Business and Industrial # Bulk and Lot Dimensional Variances Use Variances under 4,999 gross sq.ft.of structure $200.00*" 5,000 to 9,999 gross sq.ft.of structure $300.00*, ` above 10,000 gross sq.ft.of structure $400.00*plus $100.00 for each additional 10,000 sq.ft. above * In addition,lots and developments fronting or accessing.onto Routes 132,28, 6A,and West Main Street, Hyannis add $100.00 for location and traffic review. , Note-You will receive an invoice from the Barnstable Patriot for your portion ofthe legal notice` `' 5 The Zoning Board of Appeals will hold a Public Hearing on your(application within 65 days and shall render a decision within 100 days of the date the application is submitted. You and your abutters will be notified by mail of the date of the Public Hearing. You and/or your representative should attend the Public Hearing to explain the request and to address those conditions that justify the granting of a Variance. ' The Decision and Notice is processed within 14 days after the Board renders its decision and isfiled with the, Town Clerk. There is an.appeal period,of 20 days from the date the decision is filed with the Town Clerk. After the appeal period has elapsed, and if no appeal has been taken, the Town Clerk'shall certify.the decision and mail a copy to you. You must record the certified decision at the Barnstable County Registry of Deeds for it to be in effect. A copy of that recorded document should be submitted to the:Board's files and is required fora ` building permit application., The rights granted under Variance shall lapse unless they are exercised within one (1)year of the date of the certified decision. If an appeal is taken, the outcome,of your,request will be determined by the courts. „ Please review all applicable zoning rules and regulations prior to applying. Be' prepared to establish those ; unique conditions and circumstances justifying the grant of a variance but not affecting,generally the zoning ' district in which it is located. It must also be shown that a literal enforcementof the provisions of the ordinance would involve substantial hardship, financial or otherwise, and that desirable relief maybe granted without, substantial detriment to the public good and without nullifying or substantially derogating.from the intent or, purpose of the Zoning Ordinance. ` Revision Date 12-17-01 file zba-f-Application for Variance.doc T Val :BARNIMABM: Fc,vs TOWN OF BARNSTABLE Zoning Board of Appeals' , Application for a Variance Date Received For office use only:. Town Clerk's Office: ,, Appeal# Hearing Date Decision Due The undersigned hereby applies to the Zoning Board_ of Appeals for a Variance, in the manner and for the reasons set forth below: EA /2 1 Applicant Name: ` , Phone:_j�j�o d/7A Applicant.Address: Property Location: 1'IS Property Owner: 0 , Phone: Address of Owner: / If app(cant differs from owner, state nature of interest:' Assessors Map/Parcel Number: Zoning District: �11 Number of Years Owned: Groundwater Overlay District: Variance Requested: Cite Section & Title of the Zoning Ordinance, ` Descripfiomof Activity/Reason for Request: (� Attach additional sheet if necessary Does the property have any existing Variance or Special Permit issued to-it? Permit No.: ' If the applicant differs from owner,the applicant will be required to submit one original notarized letter,copy of a proposed purchase&sales agreement or lease,or other documents with the application to'prove standing and interest in the parcel or structure. k Application for a Variance -.Page 2' r Existing Level of Development of the Property- Number of B 'Idings Present Use(s): ross Floor Area:ITC' sq.ft. JK Proposed Gross Floor Area to be Added: sq.ft., Itered: " lad��' sq.ft. Description of Construction Activity(if applicable): - i - 3 � Attach additional sheet and plans if necessary Site Plan Review(required to be completed.prior to applying to the Zoning Board of-Appeals)q Site Plan Review Number, Date Approved _ [ Not Required-Single or Two Family use Is the property located in a designated Historic District?... [ ] No Yes If yes [ ] -Old King's Highway Regional Historic District Date Approved!(if applicable) F ' [ ] - Hyannis Main Street Waterfront Historic District Date Approved (if applicable) Y g Is the building a designated Historic Landmark?.;., '...................................................... ..... Yes [ ] No [ Have you applied for a building permit?.................................................................. ....... ..... Yes [ ] No Have you been refused a building permit? ........ '..:.: ..................... ....... ... Yes [ J a No[ The following information must be submitted with the application at the time of filing."Failure_to do so may result in a denial of your request. • Three (3)copies of the completed application form-, each with original signatures • Three (3)copies of a certified property survey(plot plan)and one (1)reduced copy(8 1/2"x 11"or 11"x 17") showing the dimensions of the land, all wetlands,water bodies, surrounding,roadways and the location of the existing improvements.on the land. s a • Three (3)copies of a proposed site improvement plan and one(1) reduced copy•(8 1/2"x 11"or 11"x ,' 17"), drawn by a certified professional and found approvable by the Site Plan Review Committee (if applicable). This plan must show the exact location of all proposed improvements.and alterations on.the land and to structures. See"Contents;of Site Plan", Section 4-7.5 of the Zoning Ordinance,for detailed w s. requirements. w . j • The applicant may submit any additional supporting_documents to assist the Board'inmaking its determination. r r Signature: Date: Applicant's or Repre tative s Sign Lure - a . Representative's „ Phone Address: Fax No. ` Town of Barnstable Zoning Board of Appeals Agreement to Extend Time Limits for Holding of a Public Hearing and Filing of a Decision on a Variance In the Matter of , the Petitioner(s), in Appeal No.- the Petitioner(s)and the Zoning Board of Appeals, pursuant to Mass. General Laws, Chapter,40A, Section 9, agree to extend the required time limits for holding of a public hearing and filing of a decision on this petition for a Variance for a period of days beyond that date the hearing was required to be held,and the decision was to be filed. ¢ , In executing this Agreement, the Petitioner(s) hereto specifically waive any claim for a constructive grant of relief based upon time limits applicable prior to the execution of this Agreement. - .Petitioner(s): Zoning Board of Appeals Signature: Signature: Petitioner(s)or Petitioner's Representative Chairman or Acting Chairman Print: Date: . Date: Address of Petitioner(s)or Petitioner's Representative . Zoning Board of Appeals office Planning Division Zoning Section' 200 Main Street, Hyannis, MA 02601 Phone(508)862-4685 Fax(508)862-4725 r . cc: Town Clerk Petitioners) File .. `•. ;� � ' �� . �` � � � �, . � �� ' _ • - 5�� ,4 r s e . . � � _ . i _� y � n , �, fc�- �� ' _ . � - . - � - _ � •. �., 4 - q Y - `^'� l , T � 1 IT F • 1 `V 1 � ti scp o it O 'V 77 4-. - 7 A j r TOWN OF BARNSTABLE LOCATION SEWAGE # 01 VILLAGE O ST��v� ASSESSOR'S MAP & LOT 11 03 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �U1 h LEACHING FACILITY:(type) 52- is (size) 140.OF BEDROOMS BUILDER OR OWNER (►S PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachi g facility) Feet Furnished by 5 C, 75,�0/ _— A l— 10 ,\0 Ful (P `7 13aZ" a•(0 c 3 --eJ AN- a 3 ems- 19 f; r Si ,r3; TOWN OF BARNSTABLE y LOCATION Si,�/in lCr VILLAGE ASSESSOR'S MAP & LOT ) _ INSTALLER'S NAME 6t PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) /�` % (sue) —40 NO. OF BEDROOMS PRIVATE WELL OR.PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: -7 . DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No � 0 1,5 22' i � 2` , b2' 2? 2$ 23 b �3 I ' ar, COMMONWEALTH' OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM F PART A CERTIFICATION Property Address: 55 WinterQreen Circle ��p��® Osterville, MA 02655 Owner's Name: Christopher Hallett _ Owner's Address: Same OCT 3 0 Z001 . Date of Inspection: October 15, 2001 TOWN OF BARNSTABLE HEALTH DEPT. Name of Inspector:(Please Print) James M. Ford Company Name: James M. Ford Map:119 Mailing Address: P.O. Box 49 Parcel:037 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CAM 15.000). The system: ✓" Passes Con ''onally Passes Neix s further Evaluation by the Local Approving Authority 'Fail ; Inspector's Signature: Date: October 17, 2001 The system inspector shall su it a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 55 Winterfreen Circle Osterville, MA Owner: Christopher Hallett Date of Inspection: October 15, 2001 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 55 Wintergreen Circle. Osterville.MA Owner: Christopher Hallett Date of Inspection: October 15, 2001 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)(6)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland-or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a'DEP certified'laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5,ppm,provided that no,other failure criteria are triggered. A copy of the analysis must be attached to this form. t 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 55 Wintergreen Circle Osterville, MA Owner: Christopher Hallett Date of Inspection: October 15, 2001 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No _ ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. _ ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. _ ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analy.0s, 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 Friteria are triggered. A copy of the analysis must be attached to this form.] 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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either`yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 1I of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART B •CHECKLIST Property Address: 55 Wintergreen Circle Osterville, MA Owner: Christopher Hallett Date of Inspection: October.15. 2001 , Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No _ ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected_for signs of break out? ✓ Were all system components,excluding the SAS,located.on site.? ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: SS Wintergreen Circle Osterville, AM Owner: Christopher Hallett Date of Inspection: October 15, 2001 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: 1 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 2000-55,000 gals.; 1999-52,000 gals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): end Basis of design flow(seats/personsAgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped on July 1198-per treatment plant Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: July 7192-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: SS Wintergreen Circle Osterville. MA - Owner: Christopher Hallett Date of Inspection: October 15, 2001 BUII.DING SEWER(locate on site plan) j Depth below grade: Materials of construction: _cast iron 40.PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 12" Material of construction: ✓ 'concrete metal fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 30" , Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or bafflecondition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.):� , ' Tees were present. The liquid level was even with the outlet invert. There were no signs of leakage. GREASE TRAP: None (locate om site plan) „ Depth below grade: Material of construction: _concrete metal„_fiberglass polyethylene _other (explain): Dimensions: k Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid_ levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 55 Wintergreen Circle Osterville, MA Owner: Christopher Hallett Date of Inspection: October 15, 2001 TIGHT or HOLDING TANK: None. (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete metal fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: jzallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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 level There were no signs of solids or leakage PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: SS Wintergreen Circle Osterville, MA Owner: Christopher Hallett Date of Inspection: October 15, 2001 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)' a If SAS not located explain why: Type ✓ leaching pits,number: 6'x 6' -1000 gal. leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: ✓ overflow cesspool,number: I , Innovativelalternative system Typetname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The pit had Y of water on the bottom. The scwn line was at the same level. There were no signs offailure. The bottom to grade was approximately 9' The cover was 2'6"below grade, The cesspool was dry. There were no signs of failure. The bottom of the cesspool to grade was approximately 8. The cover was 16"below grade. CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 55 Wintergreen Circle Osterville, MA Owner: Christopher Hallett Date of Inspection: October 15, 2001 Map: 119 Parcel.037 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 3q� Q 10 lea- I a ga:- a c� A3- ao 3 33- a� ray- 3a 10 Page 11 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued), r Property Address: SS Wintergreen Circle Osterville. AM ; Owner: Christopher Hallett Date of Inspection: October 15, 2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 50' +/- feet (Adjusted High Ground Water Level is 45.3) Please indicate(check)all methods used to determine the high ground water elevation:. Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: The bottom of the leach pit to grade was approximately 9' Using the Barnstable topographic map and the Cape Cod Commission water contours map the maps were showing approximately 50'+1-to groundwater at this site. Using the Cape Cod Commission Technical Bulletin the high ground water adjustment for this site(Ml W 29, Zone C, 9101)was 4,,7' t This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties, or guarantees, either expressed,written or implied, relating to the system, the inspection and/or this report. 11 ' o � o c � s � 2 3 3 2 Q ,y BARNSTABLE I CERTIFY 'THAT THIS SURVEY AND PLAN WERE MADE IN ACCORDANCE WITH THE PROCEDURAL AND TECHNICAL �n STANDARDS FVR THE PRACTICE OF LAND SURVEYING IN 6U COMMON WE M SACHUSE775// l; PAUL A.° hA�,L2OO2 .�, R RGAD yJYA. WINTERuTREEN CII CLE, ►sly ' , LOCUS N85 8�0 W 149. 09 `x WINTERGREEN �� CIRCLE �0 cn �• ,� Q JOSHU Q ND A.M. 119/19-2 (ks LOCUS SNAP / 76.8' 14 4• ' ASSESSORS MAP.- .119 PLAN REF 206/9, 166/107 6., ti ZONING. RC" FLOOD ZONE- C" COMM. PANEL Af 250001 0016 D A.M 119136 DATED. 7102192 / l°�T ?A- 119 : 7 .D. 7077/93 OVERLAY "WP / 1 44� / ARE4=25.18B_ S.F. / vw PLO T PLAN v� / o OF LAND A.M. 119/20 ` LOCATED AT 55 WINTERGREEN CIRCLE OSTER VILLE, MA. PREPARED FOR ALBERT SA GANICH OCTOBER 9, 20 ,2 / S28 / 1,27 54 - i ICB A..V 119/34_3 YANKEE SURVEY CONSULTANTS GRAPHIC SCALE M UNIT 1, 40B INDUSTRY ROAD . so . o 15 30 so 120 — RSTO P. O BOX 265 �YA NS MILLS, MASS. 02648 - i TEL 428-0055 FAX 420-5553 ( I FEET ) - 1 inch = 30 f t. J,)V 53250 DCB r r �r w 3 E � , r sit f it L ` 3 t a � --U Sr A �r