Loading...
HomeMy WebLinkAbout0250 SMOKE VALLEY ROAD UNIT #A - Health (9) R oa C � aa � 1 hod � I TOWN OF BARNSTABLE LOCATION %0 SMOL V 1. SEWAGE# 6 ?7-6 o;" VILLAGE —A Nj ASSE SOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY / So Q LEACHING FACILITY:(type) 1'1 C l� (size) NO.OF BEDROOMS OWNER CAC 77 V 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 leaching facility). feet FURNISHED BY /AS r� c1 la �� i WAUJAI COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS RTMENT OF ENVIRONMENTAL PROTECTION C.Gi.dr� r� TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE(DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 250 Smoke Valley Road-Cottage. l A q ✓+t �'�'' iHe,MA 02655 W Owner's Name:. Carstensen Realty Trust 0� Owner's Address: _ r Date of Inspection: September 2 2008ZE r.� Name of Inspector:(Please Print) James M Ford Company Name: James M. Ford ? Mailing Address: P.O.Box 49 Osterville MA 02655-0049 Telephone Number: (508) 862-9400r— CID rr CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my' training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector'pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ai s Inspector's Signatpre: Date: September 15, 2008 The system inspector shall sub�acopy 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 Coimnents ****This report only describes conditions at the time of inspection and under the conditions of use at that time..T p Y This inspection does not address hoW the system will perform in the future under the same or different conditions of use. l Title 5 Inspection Form 6/15/2000 page I l3 l Page 2 of 1 I ' OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 250 Smoke Valley Road Osterville, AM Owner: Carstensen Realty Trust Date of Inspection: September 2. 2008 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 detennined(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: 250 Smoke Valley Road Osterville. MA Owner: Carstensen Realty Trust Date of Inspection: September 2, 2008 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to detennine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone l 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 fora. 3. Other: 3 a No. f fi4;/ P V�Se- Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for Th5poaI 6pgtemc Con.5truction Permit Application for a Permit to Construct O Repair( )_ Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. P J® fy��klw.U''Al k, o Owner's Name,Address,and Tel.No. Assessor's Map/parcel �"1 B 1011L IS CA('J� 't.ln A Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. '3uipos - T-For2 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) f AS lAeew l T or\ 1,eAuk r tT- Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in 'i accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board f Health. �� Sign V Date 01 O n Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. Date Issued ;xNo �� 06e � Fee ^� f_ s _— THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: s PUBLIC;HEALTH DIVISION - TOWN AFBARNSTABLE, MASSACHUSETTS Ye �,✓r- � ritotion for'3iohpol r5tem Cowaruction Permit Application for a Permit to Construct O Repair( ;). Upgrade`( ) Abandon O ❑.Complete System ❑Individual Components Location Address or Lot No: Q1 S© (V�)®kL► !a f/,"t<"m ) Owner's Name,Address,and Tel.No. f Us Assessor's Map/Parcel e' /Mo Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No\� t, Goc�on i3Un��tls - T Ford i Type of Building: ' 'Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other_. Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures i 4 Design Flow(min.required) gpd eDesign flow provided gpd Plan Date Number of sheets Revision Date Title �_r Size of Septic Tank Type of S.A.S. ti Description of Soil Nature of Repairs or Alterations(Answer when applicable) (n5 1/dl1 lAcmw`/ ton on 14e�Uk Rl— Date last inspected: Agreement: The undersigned agrees to ensure,the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance hasbeen issued by this Board of Health. Sign �Q�AA� Q Date O u p R Application Approved by Date Application Disapproved by: I Date for the following reasons Permit No.' Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance w THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( ) Abandoned( ),by R u r",a 1 S • S'rd r� at _SMAP_ V(a yi v 0S71irj j 112_ has b n constructed in poordance e with the provisions of Title 5 and the fJr Disposal System Construction Permit No. — dated lJ� Installer () 9uLP0_S Fort Designer % r1 #bedrooms I Approved design flow i 11/h gp \� a The i3sua icc of this permit sh not b construed as a guarantee that the system c 'o. si ed. D Date Inspector y _———=—————————————————— No. Fee THE COMMON WEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS igogar �&pgtem Con.5truction Permit ,, Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) System located at S Srn VA`�t� STtfu,16 and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Constructs M14At be coinpleted within three years of the date of this erm� Date _, by , OWN O BARNSTABLE LOCATION S(V1Q — (/ �Q,\ SEWAGE# VILLAGE nsnerV)lit, ASS SSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY / &In LEACHING FACILITY:(type) (size) STQV� NO.OF BEDROOMS-3 OWNER. CA r SIC CCAIT T PERMIT DATE: COMPL 1ANCE 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 BYE A2 t(, , e � 9 41 ks- D D r 3 a- 51 y3 3 3S Sa /�v�- TOWN OF BARNSTABLE LOCATION SC) S w►o Inc.. V II e S/ SEWAGE# VILLAGE M4rS L�% '•/�S' ASSESSOR'S MAP&PARCE t INSTALLER'S NAME&PHONE NO. O ' Ok. ' -SEPTIC TANK CAPACITYC;DL /Sc►o C'a/ /y 20 LEACHING FACILITY.(type) e e.,C A-+it F ft It/ (size) 7,3 r 3� NO.OF BEDROOMS S Sy S • 1�Q g's''`� �� /G �e� OWNER G�,'r PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY s b Ma ca -t o -7466 s - i rm G t-�/3•b- S -ivy $•/$S �-J2S��6 L /3S 7 TOWN OF BARNSTABLE LOCATION O conokk-, v a //-e y/ 2V SEWAGE# VILLAGE'Yhk-S,10,t-4 •`�/J ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. ,:'bQ jk a(_L S 64' �/, Q c/dgG SEPTIC TANK CAPACITY /SDm S C/ — /Oey a( LEACHING FACILITY:(type) (size) r NO.OF BEDROOMS ,6 e 4 L4 64 a SO OWNER (R 011 i a,u. .cJ PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY sc-h A o Oe- a t G�LIA .sf N h ,Awava_ j� C,?V6 rh6 Of—- �. �j VOW D �I��/ I� Fee f�No. a THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYitation for Misposal *pstem Construction permit Application for a Permit to Construct V Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. �6ln Brown�^ �L5 0 Smote Vaa Rd► Mars4v�s 9116 IY1ou-u� �1, -re Assessor's Map/Parcel a ► n MA I er's Ngt, d ess, n Tel.No. ��/ t{k9��i Designer's Name,Ad An and Tel.No. / •I '�r'I � � �'� l-i nal.a`J'.P,,.�,P�, c su Type of Building: Zo (Za.f«+il 1 9,o66'- �A•I 5bFf S 1"1.ro S ell 92 Dwelling No.of Bedrooms Lot Size '5A, s+.R. Garbage Grinder(q) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) -0 gpd Design flow provided 166-0 gpd Plan Date b-4 17.I13 Number of sheets j Revision Date 67AL14 Title `r0j2? [d k%�- D►S0?Se-1 1"S" Size of Septic Tank Type of S.A.S. o q"Q--, A-rf,Ms ® L-1�,12 X%p Q.rcA% Description of Soil dam Nature of Repairs or Alterations(Answer when applicable) (it) isw! a k.Y , S Qb(- �1uS+ t OO ti e��®+1 D�M►� 15'bO $ 1bf% (arm t�orr,1r+e.►r 32� A 1` CP.rG r:lG u,r�Q Gl►SOerso.l 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 Environmentomode and not to ace the system in operation until a Certificate of Compliance h�sued by this rd of Deal i e AV Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued 4 � PDv �_ s v No. w--Vl 1"W"t IS C_ Fee Entered in computer: THE COMM}paNWEALTH OF MASSACHUSETTS Yes PUBLIC HEALTH DIVISIQI TOWN OF BARNSTABLE, MASSACHUSETTS Rpplicatiort-for misposal *- pstem Cotlstruttion Permit { Application for a Permit fo Construct Repair ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components E Location Address or Lot No. Owner's Name,Address,and Tel.No. k Mtn Brown-r- Assessor's Map/Parcel 2 t11 t y (( Installer ss N g,Address,� Tel.No. jqf!r(o Designer's Name,Ad ress,and Tel.No. tlin �� a O l at. T OP 0-< K MM Type of Building: C9[�C� �O��� ?!v 2 .fe(wi j �A., k1Pr5 ^S PAJI S i -5b3-&J2.v_g'1�2 Dwelling No.of Bedrooms�� Lot Size Garbage Grinder(�) f Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) /650 gpd Design flow provided ��'OS13 gpd Plan Date- 041?-111 Number of sheets r' Revision Date Title '�rol�oSrdWa V►S��SaSM aj ':7" Size of Septic Tank Type of S.A.S.1 )won tc.( �r `rt� G� S�CrCn 1 Description of Soil 5 ' Nature of Repairs or Alterations(Answer when applicable) (it) ►540 c�a�lan 5,-0'► . 4 ,,j s l k" 61tl /I±SOJ 4u,Ilan h�N� �, .1,L✓ �I - 1� 0e�G r e- {,�'r,�k Date last inspected: f 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 ode and not to ace the system in operation until a Certificate of Compliance has been issued by this of Heal td a / Date - Application Approved by , ,✓�� , , l Date { Application Disapproved by V Date for the following reasons Permit No. `"" Date Issued - ------------- ----------.---------------- - - -- ---- - �yTHE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTSCD - Certificate of Compliant e THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( Repaired( ) Upgraded( ) Abandoned( )by n(p a L ` has been constructed ip acco e with the'piovisions of Title 5 and the for Disposal System Construction Permit No t, Installer 1 Designer #bedrooms Approved design flow : / e gj d The issuance of this ;e �Itall `ot be construed as a gu ^ tee that the systemJlEf)unlion as de igned. Date / / �l '` t.f G Inspector / i,7 �' 3U f -- - - - - - - = - ------------ -- No. -- - ..` Fee THE COMMONWEALTH OF MASSACHUSETTS S S ; PUBLIC HEALTH DIVISION—BARNSTABLE,MASSACHUSETTS Misp sal 6pstem Construction J)ermit r Permission is hereby granted to Construct({ , Repair( ) Upgrade( Abandon( ) System located at63 and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Cons t ction ust b completed within three years of the date of this permit. Date Approved by i Town of Barnstable �YMEPp�,� Regulatory Services k Richard V. Scali, Interim Director + MBNWABLE. 9 114AS& �� Public Health .Division 0 - 39. Thomas NkKean,Director 200 Main Street,Hyannis,MA 02601 t Office: 508-862-4644 Fax: 508-790-6304 f Installer & Designer Certification Form i Date: Z/ / Sewage Permit# Assessor's Map\Parcel Designer: I,._,.rv�,-T, Q,,-,1„ :Installer: _T =I �k 150ac C_ Address: ?,D 2-:\ Address: ac �jre uS-�-c✓� �'hA p 2 b 3) /�A�r�T6.�fS f///GGS On � .Ji /`` �j,T e--' was issued a permit to install a (date) (installer) septic system at ;, b Sn-oLe- Vc he-.j g,�t, based on a design drawn by � ` (address) P,6 dated %L30/, s (designer) 1 certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. _ 1 certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision.or certified as-built by designer to follow. Strip out (if required) was inspected and the soils were found satisfactory, i i 1 certify that the s stem referenced above was constructed in coon liance with the terms of the appro a letters icable) y 5k%OF c f � I LINDA J. �G PINTO (lnsta -'s ignature) CI .o Q c. el'yJ� iF�e/ST AE• fit' e"__ Designer's ignature) (Affix.Desig ere) PiLEASE RETURN TO BARNSTA.B.LE PUi:BLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THiS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DiVISI THANK YOU, :; Q:\Septic\Designer Ceniiication Form Rev 8-I4-13.doc COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ;Q \�I,y,Jnvzv t�A 62-4�y TITLE 5 OFFICIAL INSPECTION FORM_ NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM s PART A CERTIFICATION Property Address: 250 Smoke Valley Road-Cottarze Osterville. MA 02655 Owner's Name:,- Carstensen Realty Trust Owner's Address: Date of Inspection: September 2, 2008 Name of Inspector: (Please Print) James M, Ford %7[ ' •-:5 Company Name: Janes M. Ford : -_ Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 r 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 perfonned based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector'pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ✓ ai s Inspector's Signature: Date: September 15, 2008 • V The system inspector shall slit'.. 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. 07— Title 5 Inspection Form 6/15/2000 page I. � J 310 CMR: DEPARTMENT OF ENVIRONMENTAL PROTECTION 10.29: continued (3) When a Barrier Beach is Determined to be Significant to Storm Damage Prevention.Flood Control Marine Fisheries or Protection of Wildlife_Habitat. 310 CMR 10.27(3) through 10.27(6) (coastal beaches) and 10.28(3) through 10.28(5) (coastal dunes) shall apply to the coastal beaches and to all coastal dunes which make up a.barrier beach. (4) Notwithstanding the provisions of 310 CMR 10.29(3),no project maybe permitted which will have any adverse effect on specified habitat sites of rare vertebrate or invertebrate species, as identified by procedures established under 310 CMR 10.37. 10 30- Coastal Banks (1) Eieamblc. Coastal banks are likely to be significant to storm damage prevention and flood control. Coastal banks that supply sediment to coastal beaches, coastal dunes and barrier beaches are per se significant to storm damage prevention and flood control. Coastal banks that, because of their height, provide a buffer to upland areas from storm waters are significant to storm damage prevention and flood control. Coastal banks composed of unconsolidated sediment and exposed to vigorous wave action serve as a major continoes source of sediment for beaches,dunes,and barrier beaches(as well as other land forms caused by coastal processes). The supply of sediment is removed from banks by wave action,and this removal takes place in response to beach and sea conditions. It is a naturally occurring process necessary to the continued existence of coastal beaches,coastal dunes and barrier beaches which,in turn,dissipate storm wave energy,thus protecting structures of coastal wetlands landward of them from storm damage and flooding. Coastal banks, because of their height and stability, may act as a buffer or natural wall, which protects upland areas from storm damage and flooding. While erosion caused by wave ` action is an integral part of shoreline processes and furnishes important sediment to downdrift landforms,erosion of a coastal bank by wind and rain runoff,which plays only a minor role in beach nourishment,should not be increased unnecessarily. Therefore,disturbances to a coastal bank which reduce its natural resistance to wind and rain erosion cause cuts and gullys in the bank,increase the risk of its collapse,increase the danger to structures at the top of the bank and 4 decrease its value as a buffer. the bank and reduce the rate of erosion due to wind and Bank vegetation tends to stabilize rain runoff. Pedestrian and vehicular traffic damages the protective vegetation and frequently leads to gully_erosion or deep "blowouts" on unconsolidated banks. Therefore, any project permitted by 310 CMR 10.30 should incorporate,when appropriate,elevated walkways. A particular coastal bank may serve both as a sediment.source and as a buffer, or it may i + serve only one role. When a proposed project involves dredging,removing,filling,or altering a coastal bank,the issuing authority shall presume that the area is significant to storm damage prevention and flood control. This presumption may be overcome only upon a clear showing that a coastal bank does n or flood control,'and if the issuing authority makes not play a role in storm damage preventio a written determination to that effect. When issuing authority determines that a coastal bank is significant to storm damage s prevention flood control because it supplies sediment to coastal beaches, coastal dunes or barrier beaches,the ability of the coastal bank to erode in response to wave action is critical to the protection of that interest(s). When the issuing authority determines that a coastal bank is significant to storm damage prevention or flood control because it is a vertical buffer to storm waters,the stability of the bank,i.e.,the natural resistance of the bank to erosion caused by wind and rain runoff,is critical to the protection of that interest(s). y statBank he seaward face or side of any elevated landformo other means t than a coastal dune,which lies at the landward edge.of a caastalbeach,..landsubject to tidal action,other-wetland""''""' t 310 CMR•367 10/3/97 (Effective 10/6197) S Epp SHE Tp�y Town of Barnstable Barnstable Regulatory Services Department. j e'caCfty 6AfLY5'CA6LE, ' MASS. (X Public Health Division �p i63q. `gym W Arfb MAl a' 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7006 2150 0002 1041 8269 November 14, 2008 Carstensen Realty Trust PO Box 1180 So. Yarmouth, MA 02664 �M RE: 250 Smoke Valley Road—Cottage, Qj�- ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 250 Smoke Valley Road - Cottage, Osterville MA was inspected on September 15, 2008 by James Ford, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system FAILED under the guidelines of 1,995 TITLE V (310 CMR 15.00) due to the following: 1) Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool, and 2) Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. You are ordered to repair or replace the septic system within Sixty(60) days from the date of this notification. You also have the option of tying into the current Title V System. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures\250 Smoke-Valley Rd Cottage Ost.doc Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 250 Smoke Valley Road Osterville, MA Owner: Carstensen Realty Trust Date of Inspection: September 2. 2008 D. I 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 '/i day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. _ ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] YES. (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No _ the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or.a mapped Zone 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: 250 Smoke Valley Road Osterville. MA Owner: Carstensen Realty Trust Date of Inspection: September 2. 2008 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 nonnal 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,Aimensions,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 detennined 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) [31.0 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: 250 Smoke Valley Road Osterville. MA Owner: Carstensen Realty Trust Date of Inspection: September 2. 2008 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): N/a DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a Number of current residents: 3 Does residence have a garbage grinder(yes or no): n/a. Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): no Seasonal use(yes or no): no Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently C OMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): . GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or 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: Date of installation unknown . Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 250 Smoke Valley Road Osterville, MA Owner: Carstensen Realty Trust Date of Inspection: September 2. 2008 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 15" 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: 750 pal.? Sludge depth: - Distance from top of sludge to bottom of outlet tee or baffle: - Scum thickness: - Distance from top of.scum to top of outlet tee or baffle: - Distance from bottom of scum to bottom of outlet tee or baffle: - How were dimensions determined: Measure stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.). The liquid level was up past the riser and to the cover. Backing up from the leach field. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 250 Smoke Valley Road Osterville, MA Owner: Carstensen Realty Trust Date of Inspection: September 2, 2008 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: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alann and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: above 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 liquid level was up over the cover and filling the hole, backing up from the leach. 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.): b 8 Page 9 of I 1 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION(continued) Property Address: 250 Smoke Valley Road Osterville, MA Owner: Carstensen Realty Trust Bate of Inspection: September 2. 2008 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type _ leaching pits,number: leaching chambers,number: leaching galleries,number: ✓ leaching trenches,number,length: ,No info available . . 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.): The field was backing up into the D-box and tank. 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): Continents (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: 250 Smoke Valley Road Osterville. MA Owner: Carstensen Realty Trust Date of Inspection: September 2. 2008 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. -- 11 ------------ wgTc.r' i 1 WA l 4JA 10 �f Page 11 of I OFFICIAL INSPECTION FORM e NOT FOR VOLUNTARY ASSESSMENTS. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 250 Stnoke Valley Road Osterville, MA Owner: Carstensen Realty Trust Date of Inspection: September 2 2008 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 6'+1- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: 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: Using Barnstable topographic and water contours maps the maps were showing ap&oximately 6'+1-to groundwater at this site. Saltwater bay is approximately 30'away. This report has been prepared only for the septic system and components described herein. This septic system has been inspected and failed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected. 11. J 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 PART A CERTIFICATION,,� Property Address: 250 Smoke Valley Road Osterville. MA 02655 Owner's Name: Carstensen Realty Trust s Owner's Address: Date of Inspection: September 2. 2008 CM e Name of Inspector: (Please Print) James M. Ford Company Name: James M.Ford 7 Mailing Address: P.O.Box 49 a „ Osterville,MA 02655-0049 = Telephone Number:. (508)862-9400 ' CERTIFICATION STATEMENT co I certify that I have personally inspected the sewage disposal system at this address and that the i ormation 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 N ds Further Evaluation by the Local Approving Authority F ' s Inspector's Signature:. Date: September 15, 2008 The system inspector shall subm' 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. 1 /2000 page I ] Title 5 Inspection Form 6/ 5 p g UD �'2 Page 2 of 11 OFFICIAL,INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 250 Smoke Valley Road Osterville, MA Owner: Carstensen Realty Trust Date of Inspection: September 2 2008 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 deternined",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 I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 250 Smoke Valley Road Osterville, MA Owner: Carstensen Realty Trust Date of Inspection: September 2 2008 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to detennine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I 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 DE.P certified laboratory, for colifonn bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. .3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 250 Smoke Valley Road Osterville, MA Owner: Carstensen Realty Trust Date of Inspection: September 2.2008 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 tunes pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] 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 II of a public.water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact.the appropriate regional office of the Department. 4 Page 5 of I I OFFICIAL, INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 250 Smoke Valley Road Osterville. MA Owner: Carstensen Realty Trust Date of Inspection: September 2. 2008 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 detennined based on: Yes No ✓ Existing infonnation. For example,a plan at the Board of Health. ✓ Detennined 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: 250 Smoke Valley Road Osterville, M4 Owner: Carstensen Realty Trust Date of Inspection: September 2. 2008 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): n1a Is laundry on a separate sewage system(yes or no): n1a [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)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Qpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of infonnation: Unavailable. Was system pumped as part of the inspection(yes or no): Yes If yes,volume pumped: gallons--How was quantity pumped detennined? Reason for pumping: Maintenance 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: Date of installation 12119178-as built 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: 250 Smoke Valley Road Osterville. MA Owner: Carstensen Realty Trust Date of Inspection: September 2. 2008 BUILDING SEWER(locate on site plan) Depth below-grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments (on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth.below grade: 14" 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: 2" Distance from top of sludge to bottom of outlet tee or baffle: 29" Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measure stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.). The tees were present. The liquid level was even with the outlet invert .A Riser was installed and the inlet cover is to rape GREASE TRAP: None(locate on site plan) Depth below grade: Material of construction: concrete _metal _fiberglass _polyethylene _other (explain): — Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or.baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 250 Smoke.Valley Road Osterville, AM Owner: Carstensen Realty Trust Date of Inspection: September 2, 2008 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: sallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Corn ments(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 normal. 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 a NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 250 Smoke Valley Road Osterville, AM Owner: Carstensen Realty Trust Date of Inspection: September 2. 2008 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 -6'x 6'w/]'stone-per design plan 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.): The nit was dry. There did not appear to be any signs of failure The nit is in the driveway and a heavy ton riser and steel cover was added see permit#2008-363 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): Conunents (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 III •J. � Il Page 10 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 250 Smoke Valley Road Osterville, MA Owner: Carstensen Realty Trust Date of Inspections September 2. 2008 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. /�I Ffon i D r a a E 3 10 Page I I of I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 250 Smoke Valley Road Osterville, MA Owner: Carstensen Realty Trust Date of Inspection: September 2, 2008 SPTE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 35 +/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: 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: Using Barnstable togoriraphic and water contours maps the naps were showing approximately 35'+1-to ground water at this site This report has been prepared only for the septic system and components described herein. This septic system has been 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 septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected. 11