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HomeMy WebLinkAbout0981 MAIN STREET (OST.) - Health (2) 981 MAIN ST OSTERVILLE =,.11,7 :026 i� 1 - , ST- ICE FAILED INSPECTIO COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION� 0 16 TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 981 Main Street(rear garage) Osterville. MA 02655 Owner's Name: Don Harding Owner's Address: Same Date of Inspection: October 26, 2001 Name of Inspector:(Please Print)James M. Ford Company Name: James M. Ford N Mailing Address: P.O. Box 49 gARNSTABLE OF Osterville,MA 02655-0049 T�WHEALTH OF 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 CMR 15.000). The system: Passes Conditionally Passes N er Evaluation by the Local Approving Authority ✓ Fails Inspector's Signature: Date: November 1, 2001 The system inspector shall su . 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 1 Page%2 of�11 "1iri3, !'" OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION continued Property Address: 981 Main Street(rear Qarage) Osterville, MA Owner: Don Harding: Date of Inspection: October 26, 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 J Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 981 Main Street(rear garage) - Osterville. AM Owner: Don Harding Date of Inspection: October 26. 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)(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 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. 3. Other: 3 Q Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 981 Main Street(rear garage) Osterville. MA Owner: Don Harding Date of Inspection: October 26, 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 '/z 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.] * fails. I have determined that one or more of the above failure criteria exist as Yes (Yes/No)The system fa s 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. *NOTE. Single cesspools jail in the Town of Barnstable. 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 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 981 Main Street(rear garage) Osterville. AM Owner: Don Harding Date of Inspection: October 26, 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? _ n/a 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 I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 981 Main Street(rear garage) Osterville. AM Owner: Don Harding Date of Inspection: October 26, 2001 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no): [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use(yes or no): Water meter readings, if available(last 2 years usage(gpd)): Sump Pump(yes or no): Last date of occupancy: COMMERCIALANDUSTRIAL Type of establishment: Garage/work shop Design flow(based on 310 CMR 15.203): -- gpd Basis of design flow(seats/persons/sgft,etc.): -- Grease trap present(yes or no): No Industrial waste holding tank present(yes or no) No Non-sanitary waste discharged to the Title 5 system(yes or no): No Water meter readings,if available: Total for all buildings:2000- 77,000 gals.; 1999-135,000 gals. Last date of occupancy/use: Approximately 35 years ago '�--� OTHER(describe): The single cesspool was disconnected approximately 35 years ago-per owner GENERAL INFORMATION Pumping Records Source of information: None on file 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: Unknown 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: 981 Main Street(rear garage) Osterville. 1M Owner: Don Harding Date of Inspection: October 26, 2001 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): 3, Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): 2 S SEPTIC TANK: None (locate on site plan) Depth below grade: 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: 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP: 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: 981 Main Street(rear garage) Osterville. AM Owner: Don Harding Date of Inspection: October 26, 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: gallons/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: None (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: 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: 981 Main Street(rear garage) Osterville. AM - Owner: Don Harding Date of Inspection: October 26, 2001 SOIL ABSORPTION SYSTEM(SAS): None (locate on site plan,excavation not required) If SAS not located explain why: t Type leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovativelalternative system Typetname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): CESSPOOLS: ✓ (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: 1 Single cesspool Depth-top of liquid to inlet invert: -- Depth of solids layer: Dry Depth of scum layer: -- Dimensions of cesspool: 5'W x 6'T x 8'bottom to grade Materials of construction: Brick Indication of groundwater inflow(yes or no): No Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): The cesspool serviced the front and rear garages many years ago A new system was installed for the front building and the plumbing was removed from the rear building approximately 35 years ago-per owner. 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 i l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 981 Main Street(rear garage) _ Osterville. MA Owner: Don Harding Date of Inspection: October 26, 2001 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. Old �spvo I ne y S S�trv� � O � I O � I Air -PuMps i I QA�k G�r4q� Work shop 10 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 981 Main Street(rear garage) Osterville. MA Owner: Don Harding Date of Inspection: October 26, 2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 30'+1- feet (Adjusted High Ground Water Level is 25.3) 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: 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 cesspool to grade was approximately 8' Using the Barnstable topographic may and the Cape Cod Commission water contours map the maps were showing approximately 30'+1-to ground water at this site. Using the Cape Cod Commission Technical Bulletin the high groundwater adjustment for this site(MI W 29 Zone C 9101)was 4.7. This report has been prepared and the system 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 system, the inspection and/or this report. 11 Ct SPOO a r 3 / �/.-7 I 30-0 G�av„c�wwT�� �e vc A (SAS bTA4-10N AIR FJ t�s r k Strop 919 y" ped, 0 Ginr�gC S-forP'°I� 01 Co��q t G,a,r,ygt q$ -5 cr - �f FAILED INSPEC49 COMMONWEALTH OF MASSACHUSETTS a t,i° hew-.— a� EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM A./ PART A CERTIFICATIO Property Address: 981 Main Street(cottage) Z n D r�- Osterville, MA 02655 o w Owner's Name: Don Harding Owner's Address: Same Date of Inspection: October 26, 2001 RECEIVED Name of Inspector:(Please Print)James M. Ford Nov 2 6 2001 Company Name: James M. Ford Mailing Address: P.O.Box 49 TOWN OF BARNSTABLE Osterville,MA 02655-0049 HEALTH DEPT. 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 CMR 15.000). The system: Passes Condition ly Passes Needs Fvtt er Evaluation by the Local Approving Authority ✓ F ils Inspector's Signature: Date: November 3, 2001 The system inspector shall submi 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 1 Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 981 Main Street(cottage) Osterville. MA Owner: Don Harding Date of Inspection: October 26, 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: 981 Main Street(cottage) Osterville. MA Owner: Don Harding Date of Inspection: October 26, 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)(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 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. 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: 981 Main Street(cottage) Osterville. MA Owner: Don Harding Date of Inspection: October 26, 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''/z 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. *NOTE: Single cesspools jail in the Town of Barnstable. 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 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 981 Main Street(cottage) Osterville. MA Owner: Don Harding Date of Inspection: October 26, 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? n/a 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: 981 Main Street(cottage) Osterville. MA Owner: Don Harding Date of Inspection: October 26, 2001 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 1 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110 Number of current residents: 0 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)): Total for all buildings: 2000- 77,000 gals.; 1999-135,000 gals. Sump Pump(yes or no): No Last date of occupancy: 15 years ago COMMERCIAL/INDUSTRIAL 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: None on file 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: Unknown 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: 981 Main Street(cottage) Osterville. MA Owner: Don Harding Date of Inspection: October 26. 2001 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: None (locate on site plan) Depth below grade: 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: 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP: 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: 981 Main Street(cottage) Osterville. AM Owner: Don Harding Date of Inspection: October 26, 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: gallons/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: None (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: 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: 981 Main Street(cottage) Osterville. MA Owner: Don Harding Date of Inspection: October 26. 2001 SOIL ABSORPTION SYSTEM(SAS): None (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: 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.): CESSPOOLS: ✓ (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: I single Depth-top of liquid to inlet invert: S' Depth of solids layer: 0" Depth of scum layer: 0" Dimensions of cesspool:4'W x S'T x 6'bottom to grade Materials of construction: Bricks Indication of groundwater inflow(yes or no): No Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): The cesspool was dry and has been empty for approximately 15 years-per owner. The cover was to grade. The cottage is used for storage PRIVY: None locate on site plan) ( P ) 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: 981 Main Street(cottage) Osterville, AM Owner: Don Harding Date of Inspection: October 26, 2001 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. C 0TrAI 10 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 981 Main Street(cottage) Osterville. MA Owner: Jon Harding Date of Inspection: October 26. 2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 15'+1- feet (Adjusted High Ground Water Level is 10.39 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: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: The bottom ofthe cesspool to grade was approximately 6' Using the Barnstable topographic map and the Cape Cod Commission water contours map the maps were showing approximately 15'+/-to ground water at this site Using the Cape Cod Commission Technical Bulletin the high groundwater adjustment for this site(M]W 29, Zone C, 9101)was 4.7'. This report has been prepared and the system inspected and failed as of the date of inspection. This report is not a warranty or guarantee that the system will junction properly in the future. There have been no warranties or guarantees, either expressed, wrtten or implied,relating to the system, the inspection and/or this report. 11 G� /2vc Zq . C 9 1 GAS bTA4-1oN O A�R F�It�s q�sl GAe-Acl t work Strop O O GArA4q t -t- S�forAq� 01 C OTT-Aq c STorA9 C- COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION FAILED INSPECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM a PART A CERTIFICATION Property Address: 981B Main Street ' 1 Osterville, MA 02655 Owner's Name: Don Harding Owner's Address: Same Date of Inspection: October 26, 2001 FRE7CEIVEDName of Inspector: (Please Print)James M.'FordCompany Name: James M. Ford Mailing Address: P.O. Box 49 Osterville,MA 02655-0049 TOWN OF B NSTABLE 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 CMR 15.000). The system: Passes Condit* ally Passes Needs er Evaluation by the Local Approving Authority ✓ Fails Inspector's Signature: Date: November 3, 2001 The system inspector shall sub4 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 1 Page 2 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS q SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 981B Main Street Osterville. hU Owne OIT:3 a�,,"" AtDonWardinQ.. Date of Inspection: "V it Oelober,26:A2001 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: 981B Main Street Osterville, AM Owner: Don Harding Date of Inspection: October 26, 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)(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 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. 3. Other: 3 Page 4 of 11 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 981 B Main Street Osterville, MA Owner: Don Harding Date of Inspection: October 26, 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 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 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 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 981 B Main Street Osterville, MA Owner: Don Harding Date of Inspection: October 26, 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 J maintenance of subsurface sewage disposal systems? 1 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: 981 B Main Street Osterville, AM Owner: Don Harding Date of Inspection: October 26, 2001 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 2 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)): Total for all buildings:2000- 77,000 gals.; 1999--135,000 gals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COIVEVIERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CUR 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: To be pumped after the inspection-per owner 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: 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: Unknown 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: 981B Main Street Osterville, MA Owner: Don Harding Date of Inspection: October 26, 2001 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) Cesspool acting as a septic tank Depth below grade: Cover to grade Material of construction: _concrete _metal _fiberglass _polyethylene ✓ other(explain) Block If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: S'W x S'T x 8'bottom to grade Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: — Scum thickness: 0" 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: Measuring 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 cesspool was full up to the outlet pipe There was no outlet tee present. The cover was to grade. 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: 981B Main Street Osterville, MA Owner: Don Harding Date of Inspection: October 26, 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: gallons/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: None (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: 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: 981E Main Street Osterville, MA Owner: Don Harding Date of Inspection: October 26, 2001 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: leaching fields,number,dimensions: v' overflow cesspool,number: 2 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.): One overflow cesspool 02)was S'Wx 6'Tx 8'6"bottom to grade and was full. Liquid was up to the outlet pipe. The cover was S"below grade The other overflow cesspool 03)was S'W x 7'T x 10'bottom to grade and was dry. The cover was 10"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 I Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 981E Main Street Osterville, MA Owner: Don Harding Date of Inspection: October 26, 2001 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. 3 , . a 3 T s?— 10 Page I 1 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 981E Main Street Osterville, MA Owner: Don Harding Date of Inspection: October 26, 2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water II'+/- feet (Adjusted High Ground Water Level is 6.39 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: 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 overflow cesspool to grade was approximately 10'. 1 hand augered down 1'on the bottom of the cesspool to ,groundwater,which was I1'belowgrade. Using the Cape Cod Commission Technical Bulletin,the high groundwater adjustment for this site(MI W 29 Zone C 9101)was 4 7' The system is in the high groundwater elevation. This report has been prepared and the system 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 system, the inspection and/or this report. 11 Gr,4 d l �,3 1-I �9� 6rw^Cw�v evc.l o19 �,o 6ran„c�14 re- letut (SAS b'rA4'1oN I A'fR F,It+c�s F lop q � l '/� H- ae d. 00 GAr/agt q$ I C o-rrIAq c. GArAgt cr? COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 1 TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 981A Main Street Osterville, MA 02655 Owner's Name: Don Harding Owner's Address: Same Date of Inspection: October 26, 2001 �ECFj\jE® Name of Inspector:(Please Print) James M. Ford Company Name: James M. Ford Nov + 001 Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 TOWN OF TH DEFT APNSTABLLE 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 CMR 15.000). The system: ✓ Passes Conditionally Passes N Further Evaluation by the Local Approving Authority . Fai s Inspector's Signature: Date: November 3, 2001 The system inspector shall subm copy of this inpection report to the Approving Authority(Board of Health of 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 1 C Page 2 of i l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 981A Main Street Osterville, AM Owner: Don Harding Date of Inspection: October 26, 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 r Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 981,4 Main Street Osterville, MA Owner: Don Harding Date of Inspection: October 26, 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)(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 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. 3. Other: 3 Page 4 of l l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 981A Main Street Osterville, AM Owner: Don Harding Date of Inspection: October 26, 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 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 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 981,4 Main Street Osterville, MA Owner: Don Harding Date of Inspection: October 26, 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? V' 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: 981A Main Street Osterville, MA Owner: Don Harding Date of Inspection: October 26, 2001 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 0 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): Empty for years Water meter readings,if available(last 2 years usage(gpd)): Total for all buildings:2000- 77,000 gals.; 1999-135,000 gals. Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL 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: None on file 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: Nov. 12199-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 f Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 981A Main Street Osterville, MA Owner: Don Harding Date of Inspection: October 26. 2001 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: 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: 1500 gal. Sludge depth: 0" Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness: 0" 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: 14" How were dimensions determined: Measuring 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.): Tees were present The liquid level was even with the outlet invert There were no signs of leakaize. No scum/sludge was present. The house has been empty for a couple of years 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: 981A Main Street Osterville, AM Owner: Don Harding Date of Inspection: October 26, 2001 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) e Depth below grade: Material of construction: _concrete metal fiberglass _polyethylene _other(explain): Dimensions: Capacity: izallons , Design Flow: gallons/day Alarm present(yes or no): I 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. There were no signs of backup or failure from the SAS. 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: 981,4 Main Street Osterville, MA Owner: Don Harding Date of Inspection: October 26, 2001 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: S-Cultec 330s-per as built card leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Typetname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The leach field was not dug up There were no signs of failure in the D-box. The bottom to grade was approximately 4'. CESSPOOLS: ✓ (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): According to the owner there are 3 old cesspools Two were filled(see drawing) Recommend filling all abandoned cesspools. 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: 981A Main Street Osterville, AM Owner: Don Harding Date of Inspection: October 26, 2001 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. �l S � 3 A A , _ �p A3- 13 B3- a All a� fay- 3o pie Casspvals (Y.c.o,h.�c•+c� F,Il��cl O 10 Page I of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 981A Main Street Osterville, MA Owner: Don Harding Date of Inspection: October 26, 2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25' +/- feet (Adjusted High Ground Water Level is 20.3) 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: 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 trench to grade was approximately 4' Using the Barnstable topographic map and the Cane Cod Commission water contours map the maps were showing approximately 25'+1-to ground water 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'. 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 G .. I CL.A +',c.s 5. A.s mil,o ao,3 Ac7� 6.du,�(,--4 rc- levc l ✓-1 d urr/vu,� M,w ac -c 9!01 i a5 0 6�uv.,�w�rTc� lcve� q8 ( G a s 5°rA 4-10 04 O O AlP q$I GAraq e- work skoP 00 G/-�r/agt STpraq� Ski CoT Acl Giar,Agt °1$� 'r3 STorAgt _� L-J-(3�• f QQ TH F MA ACHUSETTS tAFFAIR COMMONWEAL O SS EXECUTIVE OFFICE OF ENVIRONMENTAL DEPARTMENT OF ENVIRONMENTAL PROTEC�'T�I�[�� ', TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 981 Main Street Osterville,MA 02655 Owner's Name: Don Harding Owner's Address: Same Date of Inspection: October 26, 2001 RECEIVED Name of Inspector:(Please Print) James M. Ford Company Name: James M. Ford N O V 2 -6 2001 Mailing Address: P.O. Box 49 Osterville,MA 02655-0049 TOWN OF BARNSTABLE Telephone Number: (508) 862-9400 HEALTH DEPT. 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 Condi ' ally Passes Need F er Evaluation by the Local Approving Authority Fails Inspector's Signature: SX Date: November 3, 2001 The system inspector shall subrac'ODV of this in ection 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 1 Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR,VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 981 Main Street Osterville, MA Owner: Don Harding Date of Inspection: October 26, 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 I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 981 Main Street Osterville, MA Owner: Don Harding Date of Inspection: October 26, 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)(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 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. 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: 981 Main Street Osterville, MA Owner: Don Harding Date of Inspection: October 26, 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 '/z 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.] 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 11 OFFICIAL INSPECTION~FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 981 Main Street Osterville, MA Owner: Don Hardin- Date of Inspection: October 26, 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) v' 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: 981 Main Street Osterville, MA Owner: Don Hardin-- Date of Inspection: October 26, 2001 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x It of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no): [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use(yes or no): Water meter readings, if available(last 2 years usage(gpd)): Sump Pump(yes or no): Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Gas station Design flow(based on 310 CMR 15.203): -- gpd Basis of design flow(seats/persons/sgft,etc): 2 bathrooms Grease trap present(yes or no): No Industrial waste holding tank present(yes or no) No Non-sanitary waste discharged to the Title 5 system(yes or no): No Water meter readings,if available: Total for all buildings:2000- 77,000 gals.; 1999-135,000 gals. Last date of occupancy/use: Currently occupied OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: To be pumped after the inspection-per owner 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: 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: Mar. 13198-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 f Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 981 Main Street Osterville, MA Owner: Don Harding Date of Inspection: October 26, 2001 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: Cover to grade 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: 1500 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 10" 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: 5" How were dimensions determined: Measuring 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.): Tees were present The liquid level was even with the outlet invert. There were no signs of leakage. The owner was to have the tank pumped after the inspection. 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 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: 981 Main Street Osterville, MA Owner: Don Harding Date of Inspection: October 26, 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: gallons/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: -- 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 under an asphalt parking lot and was inaccessible. 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: 981 Main Street Osterville, AM Owner: Don Harding Date of Inspection: October 26, 2001 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 2-500 gal. leach chambers with 3'stone-per as built card 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 chambers were dry and in new condition. No scum line was present. The bottom to grade was approximately 4. 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: 981 Main Street Osterville, AM Owner: Don Harding Date of Inspection: October 26, 2001 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. 13�aG Al J. 4/ ►q3- y� „ 33� 4/Q, a O - 3 10 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 981 Main Street Osterville, MA Owner: Don Harding Date of Inspection: October 26 2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30' +/- feet (Adjusted High Ground Water Level is 25.3) 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: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: 7'he bottom of the leach chambers to grade was approximately 4. Using the Barnstable topographic map and the Cape Cod Commission water contours map the maps were showing approximately 30'+/-to ground water at this site. Using the Cape Cod Commission Technical Bulletin the high ground water adjustment for this site(MI W 29 Zone C, 9/01)was 4.7'. 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 I� C v sriHe,nL M i '30. 0 6rov�� w,aT. love,l (SAS bTA4"1oN A�R F�It+�s q$1 GArAq e- work Shop 00 S-foroo4q CPR CoTVACI c GArAge $ -5 sTorAgt .� y-f3�• No. % L Fee t THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes d� PUBLIC HEALTH DIVISION —TOWN OF BARNSTABLE, MASSACHUSETTS ltwv�ppfication for 30i5pogaz *p!gteut Cori.5tructiou per utit Application fora Permit to Constj( )Repair(tijUpgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 4RB S l• Owner's Name,Address and Tel.No. ds�er-%j- ner1� F4nr�;..� Assessor's Map/Parcel p I 6 � �fT\r 5 C ps K,- A\ c Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. . 3e c C VIA — 03.6� 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 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature/off Repairrs�or Alterations(Answer when applicable) to -1 J✓& I od ^n 3131 ," _ J cv I/Cc c33C 3 +. - T►1 3 r d-F l91,.�t .3 18 s u�C Go�x•��� 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 Certifi- cate of Compliance has been iss ed by Board o alth. Signed . Date NU u> J,1 g Application Approved by Date (- Application Disapproved for e f to lowing reasons Permit No. `�71 Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired Upgraded( ) Abandoned( )by fir at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. - " dated Installer_ s -cc 1C,c c \ , s�r Designer The issuance of this permit shall not be construed as a-guarantee that the system will function as designed. Date_ _ !�- ^ 1 Inspectors --------------------------------------- 1 19 FPP. TOWN OF BARNSTABLE E LOCATION A ��`^ SEWAGE # VILLAGE ke+'�.<<c ASSESSOR'S MAP & LOT A IX INSTALLER'S NAME&PHONE N0. SEPTIC TANK CAPACITY ACC C�l Q LEACHING FACILITY: (type)C,/TC .330'= (size) NO.OF BEDROOMS BUILDEROROWNE_R ,l(�r1A�0 f fA�Oi�nZ PERMI'TDATE: Gov j i��j S COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 ye �• I J 7 � _ JI Q8l (SAS STAB-IoN 5 A i ft I i GArAq e- work+ Shop' 00 GArA C STo�A`1 t 9kr CoTraq c S saa`2eo Iep C � t I I © ® U N0.. ................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratilatt for Dtnpmial Work.5 Towitru n it Application is hereby made for a Permit to Construct ) or IZcpair ( ) an_,Individual Sewage Disposal System at: _5�j'tlq�r 10,4) t Location-�(_'i'Nress --- or Lot N.' - ------ ................ ...— / Owner r ...........................................Address ------------------------------------------- p Installer Address d Type of Building Size Lot----------------------------Sq. feet NDwelling— No. of Bedrooms.-_--_------________________________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) P-' Other fixtures ................................. Design Flow................----------------------------gallons per person per day. Total daily flow............................................gallons. N Septic Tank—Liquid capacity------------gallons Length________________ Width---------------- Diameter---.------------ Depth................ 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. I----------------minutes per inch Depth of Test Pit._._...___-__-__-_._ Depth to ground water------------------------ ", Test Pit No. 2----------------minutes per inch Depth of Test Pit.........._..._..._. Depth to ground water------------------------- ---------------------------------------------------------------------------------------------------- :-------------------___-------•-•----•-----•------------- 0 Description of Soil---------------------------------------------------------------------------------------------------------------•--•--••-•--•------------------•----------------------- x U ---------------------------------- - --------•-------------------•--------------------•--•------------------------------• ---------------------------------..._..---------------- W ---------------- ----------------------------------------------------------------------------- = -----------------•--------_ . UNature of Repairs or Alterations—Answer when applicable..._ .r... _. . ...... ..... ... Agreement: The undersigned agrees =o install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issydbhe and of he lth.- -Signed __. = . !�i(/l ----- --- ... Dare .. Application.Approved BY = � - - `--�� �� Dace Application Disapproved for the following reasons: ... ..... ............ .. .. ..................................................................................... ....................... .......... ..----..--......---.--..-- ------..........__.................... .-- .. . ..---..---- . ............................................................... .............--..............--.--..... G� Dare .........J--�---�----�..-g.�......---.-- Issued Permit No. .. ---- --------...v---".........-'.r,..:'�.-�--��--- Dale THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Gex#tfiratt Of C�uzn ii zri>c>e THIS ISr�'/`TQ CERTIF�Yn,jhat the Individual Sewage Disposal System constructed ( ) or Repaired ( �� bL y .. tr,. ._i /Ins/c.tller .. ..... ..... .S. ti C v' at ........ /. �F. ....... �...... ............ .. .. try has been installed in accordance with the provisions.'of TI"tLE 5 of The State Environmental Code as described in �� . f. S---- the application for Disposal Works Construction Peimlt No. ._...:.. :��_. -., -:--d-3- dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS'A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ----- ---- --- ------ Inspector .-- nATF :... -... . AsBuilt Page 1 of 1 TOWN OF BARNSTABLE IL ST` LOCATcOF1 . _ �. SEWAGE # VILLAGE OST^C(V�IL� ASSESSOR'S MAP&.LOT 0 N INSTALLER'S NAME&PHONE NO. 4TTI-� i SEPTIC TANK.CAPACITY S-OD LEACHING FACILITY: (type) a�. ' $4D`GAr. Ghe,M6e.(�sixe) 3 S7'O/� No.OF BEDROOMS I '. ' I i BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: I Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet ....I 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�.facibty) �^ ) Feet Furnished by�A-VC G+i0✓) r4 Cf� Al - 03 � 4 A3- 41901 163- q9' (0 O � l a O ' 3 http://issgl2/intranet/propdata/prebuilt.aspx?mappar=l 17026&seq=1 9/26/2013 f '. LOCATION 18 < al 4 SEWAGE # Z��✓"- ��� VILLAGE ASSESSOR'S MAP & LOT/1 7 Z C INSTALLER'S NAME &PHONE NO. C2- M Z/i4z/re .. 50S.-305-1�o' SEPTIC TANK CAPACITY a LEACHING FACII.=: (type)��� 3 o r (size)- I. k 4 5 f S '. NO.OF BEDROOMS _ j BUU-DER OR OWNER PERMITDATE:. !Z - 19 -O COMPLIANCE DATE: Separation Distance Between the: �i Uet��n 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.Faciliry (If any wetlands exist ' within 300 feet of leaching facility) `U Feet Furnished by �J 3 . :,I z 1 A 5= 34"g5 Town of Barnstable-Health Department Page 1 HAZARDOUS MATERIALS INVENTORY SITE VISITS DBA: Mera Image Fax: - ; Corp Name: Mailing Address i Location: .981 Main Street,Osterville Street: mappar: City: Contact: :Christopher Mera State: Ma TeVephone: 781-953-2851 Zip: 00000 Emergency: Person Interviewed: .......................................... Business Contact Letter Date: .............. Category: Inventory Site Visit Date .......- Type: Follow Up/Inspection Date: ......... .... _. ❑ public water ❑ indcor floor drains ❑ outdoor surface drains ❑ license required ❑ private water ❑ indoor holding tank mdc ❑ outdoor holding tank mdc ❑ currently licensed ❑ town sewage ❑ indoor catch basin/drywell ❑ outdoor catch basin/drywell expir - - ❑ on-site sewage ❑ indoor on-site syste ❑ outdoor onsite system date: compliance: Sk u;nx - Page 2 Town of Barnstable-Health Department HAZARDOUS MATERIALS INVENTORY Chemicals: ❑ Zero Toxic Waste Materials ❑ gty's>25 Ibs dry or 50 gals liquid but less than 111 gals ❑ gty's 111 gals or more Waste Transporter: Fire District: Last HW Shipment Date: Waste Hauler Licensed: No ........_ __..: 4� i HOSTETTER REALTY 770A MAIN STREET OSTERVILLE, MA 02655 PHONE: (508)420-0644 FAX: (508)428-1974 May 23, 2007 Town of Barnstable Public Health Division 200 Main Street Hyannis, MA 02601 Attn: Thomas McKean, R.S. Re: 981 Main Street, Osterville, MA Dear Mr. McKean: ' We are in receipt of your notice of septic system,non-compliance relative to the property named above. Please note that a new system was installed in December 2005. A copy of the Compliance Certificate is enclosed. Feel free to contact me if there are additional concerns. Thank you for your consideration. Sincerely, AC -J 3 udy�cAbee ; Administrative Assistant :. N w r �" THE COMMONWEALTH OF MASSACHUSETTS ?r�;k BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the O site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded Abandoned( )byj��1 k at- qZ �� �, has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated ' 5 !s Installer �C�s�V^� Designer B,-cZ+vt0. tQk #bedrooms L� Approved design flow Y gpdI The issuance of this permit sh 11 not be construed as a guarantee that the system wi =c * ned. Date ) f� Inspector 1�y{ , i i i i fr �F, 11 4 �! OC Q TOWN OF BARNSTApBL.E c�a ^A� L CATION a I mAIA VT-- FAILMAWEMON YMLAGE; C�S`T'e�✓� ASSESSOR'S MAP & LOT O�Co INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY2PUO I LEACHING FACILITY: (type) (size) NO. OF BEDROOMS I BUILDER OR OWNER —IA/C�.�p I 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 cm site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 1 300 feet of leachin�g facility) r Feet Furnished by �er-t - C� STA�an a 3� i - i i J£e . 1 4 I e , QAc,k GAe-,aq 4t_:: TOWN OF BARNSTABLE LOCATION 9 a MAID S7- FAUDUTECInON VILLAGE C�ST2f✓+ , ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY CQ Ss pfip I . j LEACHING FACILITY: (type) (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 leachin�facility) Feet Furnished by I1S GG�ty✓� TOWN OF BARNSTABLE Q LOCA PION 9 D / A MAo �' SEWAGE # 1 -7 I VILLAGE o`T_-Cl✓� ASSESSOR'S MAP &.LOT INSTALLER'S NAME&PHONE NO. i SEPTIC TANK,CAPACITY S� LEACHING FACILITY: (type) GU 14tC 33D S (size) NO. OF BEDROOMS. BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Dist4nce 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) j� 1 Feet Furnished by d - A ' co !s'.9 -3 0 01. i a � l3a- 16 . to h3- i3 Aq- a dl f r . A TOWN OF BAR LOCATION ;�v1 - . D INSPECTION VILLAGE O ST.eivi SEWAGE # _ I. INSTALLER'S N ASSESSOR'S MAP& LOT 07 OaCQ — AME dt PHONE NO. I SEPTIC TANK CAPACITY — rJl� I LEACHING.FACILITY: (type) NO. OF BEDROOMS /, (size) BUILDER OR OWNER. — D j .1 PERMITDATE: — COMPLIANCE DATE: Separation Distance Between the: �eet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Rriwate Water Supply Well and Leaching Facility Feet Feet on,site or within top feet of leaching.facility) many wells exist Edge of Wetland and Leaching FacilityFeet within 300 feet of leachin 'facility) ,(��y wetlands exist Feet Furnished by ^S e �h. Feet FN Y h. -4 No. 4066_4gl, l � '+ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for Migonl 6p5tem Construction Verrait Application for a Permit to C r c ) Repair( ) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. 1W &-ti4 Owner's Name,Ad ress and Tel N fd5_f ew vI t t GGca-r�G� Assessor's Map/parcel 11 7 6 7 6 '57-L> 395 07 S0F3-77r-073 Installer's Name,Address,and Tel.No. Designer's Name, ddress and Tel No. /�G ht Z'n -r T f r l c��Cc,� Qs /03 �3/Gy pug cQ . �r�tf� 4c e1 i 6 �tS �au�i ��•� a-rH4 0 a r G 26 Z pe of Building: Dwelling No.of Bedrooms Lot Size $'3f 700 sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures `` Design Flow(min.required) -1 z® gpd Design flow provided 5� gpd Plan Date e 0 - 2—$—a S Number of sheets Revision Date /Z— Title 5e a,11 gyp' -- j¢/ AU4`i 05{teria lie Size of Septic Tank SdO G Type of S.A.S. y�0e, G wryeJe(l 5 t,c, Description of Soil Nature of Repairs or Alterations(Answer when applicable) °Tc I k ��-i 5 T7 pt Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Q Sign (f r-L Date /0— —g GS Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. Date Issued 4:,, off- �. .�y� ,,,, .W�r ,�� Fir ,: h n. _ l _ , _� 4.• �i�-� �" �t ,'.`fU 4 �' ,r�. f "� 'K ;�.. 'i� /22, No. � Fee — — ' a --THE COMMONWEALTH OF MASSArCHUSETTS - Entered in computer: Yes PUBLIC HEALTH-DIVISION - TOWN OF BARNSTABLE, MASSACHUS TTS !9� 2ppttcation for Mi5po5al 6pg;tm Con!5tructton berm tt Application for a Permit to C s rfct ) Repair O Upgrade O Abandon O ❑ Complete System ❑Individual Components Location Address or Lot No. / Gg GH S^f. Owner's Name,Address,and Tel.No. V1 l(Xf �r cGc�v� -l(a,.LL-2-u Assessor's Map/Parcel l/-/ 8 * Installer's Name,Address,and Tel.No. �v g-3 0 S- 4457 Designer's Name,Address and Tel.No. Sv - 7 7 3 /mac M �t'n /7r� Gc.�6l��- QSsoc. :a-/of e u r !w.. G Z , d 2 V Z ( e of Building: Dwelling No.of Bedrooms Lot Size $3, 700 sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) '9//0 gpd Design flow provided gpd Plan Date /y - Z S Number of sheets Reyision Date l Z- v a Title f" af � -- IV/ /�G! .S-r. 05 fVG Ile s Size of Septic Tank /SyU G Type of S.A.S. 5-0c+ 6 66- cvc(f 5 w # i f ,Description of Soil .5 p�ltiL� s furl Ga 7. n Nature of Repairs or Alterations(Answer when applicable) ^t c it /N eX I S T�i�, C'���,tx f0 s L> r� r�v�l is Date last inspected: Agreement: v The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. 1 F . Signedl /�-- y Date l`3 -7 b S Application Approved by /�� / ^ /1 e Date Application Disapproved by: Date for the following reasons +u Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( ) Abandoned( )b M, T at Q a,1* ST t 031�1q�1,ly has been constructed in accordance with the provisions of Title.5 and the for Disposal System Construction Permit No. Qco 6 dated 1,91 I( 15 . Installer e `-A.P Designer RV-,CX,-yNQ v-"*, #bedrooms L-1 Approved design flow 4410 gpd The issuance of this permit sh 1 not be as a guarantee that the system wt fun:c a oes�ed. Date / �6/W Inspector _ ------------�--------------------=----.�.,—, r--,---- No. ✓ 1� 1 Fce / THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS Digpogal J�pgtemt Construction Permit Permission is hereby granted to Construct 1) Repair ( ) Upgrade ye-�( /Bandon ( ) System located at q3J �,��_ / /K J 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: Construction r ust be completed.within three years of the date of.thV',IV-.m Dat-, !/ Approved by % No... r - .. Fs$"F©.....®........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � TOWN OF BARNSTABLE Apphratiuu for Mire 3 al Wor1w Tait ttraa�n amit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ..........9,Y/...../Nri�..... 3 --------------------------------•-------.----------........ � Location- ress ry�//�� �/ or Lot No. ............. V(_I�/�1_.......)1X_:--- - 1y /--•--.._..-----...--•------•--....-----------..____.---.....---•--................................ W Owner l Address Installer Address UType of Building O Size Lot............................Sq. feet Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' 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 ( ) aPercolation Test Results Performed by-----------_- ------------------------------------------------------•-- Date.....---....-------------------------- Test Pit No. I................minutes per inch Depth of Test Pit-------_------------ Depth to ground water........................ (14 Test Pit No. 2................minutes per-inch Depth of Test Pit__._____-.--____---- Depth to ground water........................ a --------------------------------------------------------------------------------•---------------------------.... .------------------------ •... -.... ..-------- 0 Description of Soil................................. -......... •--------- .------- -..-------- -------------------------------------------------------------------------------......._.....__. x V .----------------------------------------------------•------------------------------------.........--------------...-------------------------------------------------------•--•--•-•-.-------•--•-------. W --------------------------------------------------------------------------- ------------------------------- r --- --U Nature of Repairs or Alterations—Answer when applicable._ .. 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 CompliancMbe sued b he and of he Ith. Signed ....... ... ------------ Application.Approved By ----------� Date Application Disapproved for the following reasons: '-" ........................................ .... ............ .............. -------------------------------- ----------------------------------------------------------------------------------------------- ---------------------- -----------....---------------------- ....... ' .._...._.......... qDare Permit No. ---------J --- . ...g.3........... Issued --------------------3--- ..- 5........... Date ................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE ._ .- Appliration for Dhip t ial lVarkB Towitr r i�an rruti Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: t -7 in�1 J r Location-address ( or Lot No. roe? k.r _.__..... ..------•-_-�`-•OA--•----• ��~?� -' ................................................................................................ Owner Address E. Installer Address") ° UType of Building Size Lot___________________________Sq. feet Dwelling—No. of Bedrooms-------_____________________________--------Expansion Attic ( ) Garbage Grinder ( ) `4� Other—Type of Building ____________________________ No. of persons------------ _--------------- Showers ( ) — Cafeteria ( ) Other'Tixtures . 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 ( ) a ► Percolation Test Results Performed by--------------=-=-=---- ��" <,g' = ,,- Date---------•••. �.. 1.4 Test Pit No. 1________________minutes per inch Depth of-Test Pit.................... D`e"pth to ground'`water........................ lam`, 44 Test Pit No. 2................minutes per inch Depth of Test Pit___________________ Depth to ground water........................ -„------------------------------------------------------------------•--•------------------•----------------------------___---________-•-•---- 0 Description of Soil........................................................................................................................................................................ U .__--_.._._-•-••--•......_.••••--••----•-••--•---••......--•-••-----••----••-----••-•--••-----.._._-•-•--....---••-••------•----___-•------•---•-••----•---•-----••---•--•-•...----•-•--•-••------•----• W -------- -------- �" --=---------- U Nature of Repairs or Alterations—Answer when ....... -_.-••-••.--.•-•--•••--•-......-----•._..._-•----••-••----•--•---•••---••••___.__-•------•••-•••--• - ` Agreement: i The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate.of Compliance has bee, issued by-the of health. Signed ----- --- ------------ Date Application.Approved By ........... -.--. _ . ra - -------............ ...._.-.... ------------- .::: ..= .-.-.. s Date Application Disapproved for the following reasonr- ----------------- ------------ ------------------------------------------------------------------------------------------- - - - ------------------------------------------------------------------------------------- --------- --------------.------- ---------------------------------------- It _Date Perm No. ?�... . �> ��--- --------- Issued .....................�...----� `�5---.......... Date 4 - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Cer#ifirate of Conyliance THIS IS,TO.C` �RTIFY&That the Individual Sewage Disposal System constructed ( ) or Repaired '""ev 'd/<a` _ 'deiz --------- ----- -------- - - i r by ....--... .�� .u K , Inst Jtrt + � t >---- .-t A --- - at .... .. .�. - --- ` --- --- a has been installed in accordance with the provisions,ofTITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. _ �7: dated .-_-: --.- .��- -- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS•A-GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE_-....... - 7 .... ----------------_ Inspector ---- ------------ - ---- -:-- .+ice THE COMMONWEALTH OF MASSACHUSETTS BOARD OF kHEALTH TOWN OF BARNSTABLE C? I�- FEE •'--•. ................. �t ns l Dry lo tn�rti�tt vrrmtt Permission is hereby granted____ ... =- to Construct ( ) or Repair ( ,;�) an Individual Sewage Disposal Systemf 1 atNo........ ._ 1...........:.%° ,f-`--------•-•------- -••---- ........ rl.... `-�---- � ) f �f"44 1�l t 1 .Street C/ f� 43-- Dated.....= �.`t._..__.... as shown on the application for Disposal Works Construction Permit No_________________ Q• ' -----•------••-------••-•---••---------•--••---- DATE.............. -�--=-•�`�. .............................. Board of Health FORM 36508 HOBBS lit WARREN.INC..PUBLISHERS AsBuilt h Page 1 of 1 "-"'-TOWN OF BARNSTABLE LOCATION 106y Sr SEWAGE # VILLAGE ASSESSOR'S MAP&.LOT //7 O INSTALLER'S NAME&PHONE NO. SEPTIC TANK.CAPACPI'Y SGD LEACHING FACILITY: (type) n I� No.OF BEDROOMS BMDER OR OWNER PERMITDATE- COMPLIANCE DATE: l� i 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 lI within 300 feet of leachi facility) Feet I Furnished by 1 A Sac . f CAI c93 AZL'AUL- � 4 r 3 1 ttp://issgl2/intranet/propdata/prebuilt.aspx?mappar=l 17026&seq=1 9/26/2013 COMPLETE • ■ Complete items 1,2,anld 3.Also complete A.Sign re item 4 if Restricted Delivery is desired. X �� � --. ❑❑Addressee■ Print your name and address on the reverse so that we can return the card to you. B. R&Ived by(Printed Name) C. D to of Delivery ■ Attach this card to the.back of the mailpiece, / or on the front if space permits. v j2, 1. Article Addressed to: D. Is delivery address different from item 1? ❑Yes If YES,enter delivery address below: ❑No 3. Service Type 0 Certified Mail 0 Bpess Mail ❑Registered- a Retum Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery!(Extra Fee) ❑Yes 2. Article Number(Transfer 6om service fabeo 11+ i t i 7 3 ]6$0 0;0 4 5 4 5 8'.i, €5 4`8 4 i I PS Form 3811,February 2004 Domestic Return Receipt 102ss5-02-M-IW UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid USPS Permit No..G-10 • Sender: Please printyour name,address; and ZIP+4 in,this box.• d l Town of Barnstable ?ealtc?Division 200 Main Street Hyannis,MA 02601 I I I {4 { Certified'Mail#7003 1680 0004 5458 5484 IKE rO�ti Town of Barnstable o� Regulatory Services • nntuvs-rasLE. M^S Thomas F. Geiler, Director Arf 0 A Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Se ember 4, 2007 Daniel Hostetter Richard Callahan 770A Main Street Osterville, MA 02655 v NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II— MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE CODE CHAPTER 170. �! The property owned by you located at 981A Main Street Osterville, was inspected on August 31, 2007 by Meredith Morgan, Health Inspector for the Town of Barnstable. This inspection was conducted'on the basis of the rental registration in accordance with Chapter 170 of the Town of Barnstable Code. a The following violations of the State Sanitary Code were observed: 105 CMR 410.190—Hot Water. Temperature observed at 10717. 105 CMR 410.351 —Owner's Installation and Maintenance Responsibilities. Front right stove burner is inoperable. 105 CMR 410.500—Owner's Responsibility to Maintain Structural Elements. Living room windows observed to be rotting. The following violations of the Town of Barnstable Code were observed: 1§ 70-10—Smoke Detectors and Carbon Monoxide Alarms. No smoke detector on second floor. QAOrder letters\Housing violations\Rental ordinance\981A Main Street.doc I You are directed to correct the violations listed above within twenty-four (24) hours of your receipt of this notice by installing smoke detector on second floor in .accordance with Mass State Fire Codes. You may request a hearing before the Board of Health if written petition requesting same is received within ten(10) days after the date the order is served. Non-compliance will result in a fine of $100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have any questions regarding the above violations, please contact the Town Health Division and ask to speak with the inspector who performed the inspection. P RDE OF TH BOARD OF HEALTH Thomas A. McKean, R.S., CHO Director of Public Health Town of Barnstable Cc: Meredith Morgan, Health Inspector COMM Fire Department QAOrder letters\Housing violations\Rental ordinance\98 I A Main Street.doc FORm30 �l�w HOBBS&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS BO . D�OFELYA � H COW A� W UK;biV EPARTMENT 'p ADCESS • 4�M svey`0 Address 7 b dI-e Occupa t Floor Apartmen o. No. of Occu is No. of Habitable Rooms No.Sleeping Rooms No.dwelling or rooming units o.Sto 'es /G Name and address of own n paia6±i Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceilin : �•� Hall Lighting: b _ Hall Windows: HEATING Chimneys: Central Q Y o ❑ N Equip. Repair TYPE: 0 1L Stacks, Flues,Vents: PLUMBING: Supply Line: Q fJ l ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wirin : DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom(1). Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Ga Elect.: Stack , ,t s, en s,ftties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted , Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR. (See Over) "THIS INS ECTION T IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTI d E R " INSPECTOR TITLE r A. DATE ME G ,� P.M A.M. THE NEXT SCHEDULED REINSPECTION Ili P.M. 410.750: Conditions Deemed to Endanger or Impair Health.or Safety The following conditions,when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well=being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always haveathe potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include sliall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure,to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of,the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and'temperature, both hot and cold,to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A),410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents onto the creation or spread of disease. (J) The presence of leadbased paint on.a dwelling or dwelling, nit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns,-shock,accident or other dangers or impairment to health or safety. a (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3) or any defect which renders them inoperable. (3) ,Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. i(P) Any other"violation of 105 CMR 410.000-not enumerated in 105 CMR 410.750(A)through-(0)shall be deemed to be anon- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. M Ibis lon _ - `�"°� � f Town of Barnstable P��sr�Teti o� Regulatory Services + BARNS-CAi3LE, Thomas F. Geiler�Director� 9 MASS. 16,9. A Public Health Division �jEO MA'S Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 September 4, 2007 Attn: COMM Fire Health Inspector Meredith E. Morgan conducted a rental inspection in accordance with Chapter 170 of the Town of Barnstable Code. In accordance with the State Sanitary Code, 105 CMR 410.482, the Health Department is required to notify the Fire Department if there is a smoke detector violation, or possible smoke detector violation. The following property had possible smoke detector(and\or CO detector) violation(s): 981 Main St. Osterville Apt. A Assessors Map-Parcel: (117-026): Smoke detector lacking on second floor. Meredit E. organ -Hea th Inspector f Q:`.Order Ietters\Housing violations\Rental ordinance\\Fire ViolationsTIRE TEMPLATE.doc 1 tNME Tatio Town of Barnstable y Regulatory Services BARNSTABLE, Thomas F. Geiler,Director 9 MASS. g `bp i639• A�• Public Health Division rFD MA'S Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Richard P. Callahan Date: March 1, 2005 Centerville Village Apt Rlty Tr. %Hostetter,Daniel Osterville,Ma. 02655 NON-COMPLIANCE WITH STATE ENVIRONMENTAL CODE TITLE V. The septic system owned by you located at 981 (Rear) Main St. Osterville was inspected on, 1111/2001.byJames M. Ford a Massachusetts licensed septic inspector. The.inspection of your septic system showed that your system has failed under the.guidelines of 1995 TITLE 5 (31.0 CMR 15.00) due to the following: Single Cesspool: Our records show that the system has been in a failed state for more than two years. 'You:•are .ordered to.hire a professional engineer or registered sanitarian to prepare:a.plan.of ::proposed replacement septic system component(s). This plan is to be submitted-.to- the-,Jown of Barnstable Public Health Division Office(Regulatory Services, 200 Main Street, Hyannis),within (90) days receipt of this letter. The plan will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title V. You are a lso o rdered t o u pgrade o r r eplace t he s eptic s ystem w ithin s ix months (180) days o f y our receipt of this letter. Any person aggrieved by any order issued by the local approval authority may appeal to any c ourt o f competent jurisdiction as provided for by the laws of the Commonwealth. You have the option of requesting an adjudicatory hearing pursuant to 310 CMR 15.422 Failure to comply with this order will automatically result in a public hearing scheduled before the Board of Health. PE E HE OARD OF HEALTH Thomas A. McKean,R.S., C.H.O. Agent of the Board of Health CC: Board of Health iifa;iea_septic_iett� THE Tpw�O Town of Barnstable ti Regulatory Services * BARNSTABLE, Thomas F. Geiler,Director MASS. o� 9� 1639• ��� Public Health Division AT�o A� Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Richard P. Callahan Date: March 1, 2005 Centerville Village Apt Rlty Tr. %Hostetter, Daniel Osterville,Ma. 02655 NON-COMPLIANCE WITH STATE ENVIRONMENTAL CODE TITLE V. The septic system owned by you located at 981 (Rear) Main St. Osterville was inspected on, 11/1/2001 by James M. Ford a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: Single Cesspool. Our records show that the system has been in a failed state for more than two years. You are ordered to hire a professional. engineer or.registered sanitarian to prepare:a plan.6f:: ; i proposed replacement septic system component(s). This plan is to be submitted to the Town of Barnstable Public Health Division Office (Regulatory Services, 200 Main Street,Hyannis),within (90) days receipt of this letter. The plan will bring the septic system into compliance with 310 CMR 15.00,The State Environmental Code, Title V. You are a lso o rdered t o u pgrade o r r eplace t he s eptic s ystem w ithin s ix months (180) days o f y our receipt of this letter. Any person aggrieved by any order issued by the local approval authority may appeal to any c ourt o f competent jurisdiction as provided for by the laws of the Commonwealth. You have the option of requesting an adjudicatory hearing pursuant to 310 CMR 15.422 Failure to comply with this order will automatically result in a public hearing scheduled before the Board of Health. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean,R.S.;C.H.O. Agent of the Board of Health J./failed_s eptic_letters c ,,TOWN OF BARNSTABLE LOCATION o O l�l�!'� SEWAGE VILLAGE , 0 S T6(V' INSTALLER'S NAME&PHONE NO•. -Do wo D- N . SEPTIC TANK CAPACITY LEACHING FACILITY: (type) GAS C1��S VA e NO.OF BEDROOMS 7 NCO- � BUILDER OR OWNER D0+^ I�ArC.t�G Q,,(L �R-r(vkll I PERMiTDATE: COMPLIANCE DATE: 3 I Separation Distance Between the: ©��� Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet f Private Water Supply Well and Leaching Facility (If any wells exist j 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 facility) Feet Furnished by 1�n Se Gr(o r1. �J �d r Al �, S7-7 C 3 - l W TV 11 V 1 1!!'11I1 I J 1 A1.)AA. LOCATION 1 8 ,n'IGL! SEWAGE # ZG�i�✓' 6 I j VILLAGE •0cSr yclle ASSESSOR'S MAP & LOT f! Z b INSTALLER'S NA)viE&PHONE NO. c.Z-rl'�z it e . off-385 J40', SEPTIC TANK CAPACITY l3� gcZl. LEACHING FACILITY: (type) r 3 3 0 vr-r,: (size) /2. 3 45,5 '. NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: fZ ' l - COMPLIANCE DATE: �-17 ' 05 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility �' S Feet Private Water Supply Well and Leaching Facility (If any wells exist / on site or within 200-feet of leaching facility) /Jl� Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) `0 — Feet Fumished by i 3 2 1 � J Z= 3lp ' 6 N 3 = 46 ,low 5= 34',5 t' f7 ' vest/541 r7 No. 7 " I'L Fee�_ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION —TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for Migogal *pgtem Congtruction Permit {y Application for a Permit to Comm t( )Repair(Vf TUpgrade( )Abandon( ) ❑Complete System ❑Individual Components 179/ Location Address or Lot No. 4;ib Owner's Name,Address hand Tel.No. 'tV� Assessor's Map/Parcel V6 (N 3'C . Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. os cr`.11c RA - 0a6ss 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 gallons per day. Calculated daily flow gallons. 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 a pbic abl 940,00 P 1 J 79// Od ^n 5 c,,acc 330' s,.:Tl� 3+ a l kjL `s1-4 a C —3 lf3 s iv-c cld.c-:, 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 Certifi- cate of Compliance has been i by ' Boar alth. Signed��� Date NU L,, J g Application Approved by Date 1(—• Application Disapproved for a following reasons Permit No d 71 Date Issued No. H M' Fee a e9 t THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS es 01pplication for �Biopaal *pztem Con.5truction Permit Application for a Permit to Construct( )Repair(►-')'Upgrade( )Abandon( ) []Complete System ❑Individual Components Location Address or Lot No. `y R .S Owner's Name,Address and Tel.No. \ Assessor's Map/Parcel e " \`c V�Xlf tv o Installer's Name,Address,and Tel.No. _ Designer's Name,Address and Tel.No. 3cv1Zf k-\cx CL.`V, C) ASS Typejof Building: Dwelling No.of Bedrooms IV Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day.I Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil f R Nature of Repairs or Alterations(Answer when applicable) a ,of 3 %; iR 31P c 31 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 Certifi- cate of Compliance has been issued by thi Board o alth. <Signed Date A i S Sf Application Approved by Date Application Disapproved for Re follo ing reasons w,r Permit No. Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired(✓f Upgraded( ) Abandoned( )by _ .11 t<c- at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 7 1 dated _ Installer_�?)c -cc. Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector (T . --------------------------------------- No. /Y Fee THE COMMONWEALTH OF.MASSACHUSETTS-' PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS_ 'Wi5p0al *pgtem Construction Permit Permission is hereby granted to Construct( )Repair( /)Upgrade( )Abandon( ) System located at C_ � ,A&A;4 S7` to 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:Construction must be completed within three years of the date of this permit. Date:_ /�— ( - q Approved by rn c.. s 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - i.VO �i CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL � e� , o a 6 WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated /4/ou, 41�ffj , concerning the property located at Q. J �P meets all of the following criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There are no wetlands within 100 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W.Elevation +the MAX.High G.W. Adjustment. _ DIFFERENCE BETWEEN A and B � SIGNED DATE: xleu. [Sketch proposed plan of system on back]. q:health folder:cert 4 � 8 (A w:t�► 3` o`�S�o�c. r e� ` Town of Barnstable Regulatory Services Thomas F. Geiler,Director + BARNSTABM 9� MASS. � Public Health Division p'fD"AD'�A Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: Sewage Permit# <�- -3 l Assessor's Map\Parcel /l 2 Designer: et-50C . Installer: M . Di �yre Address: 1&45 / . 50 Ae-4C Address: /03 ��y �=�--n�,t �Q, k3o. C°6uter-w lie MA . 6 Z6 37- On 12111 6 6- ( , ki e.Lw was issued a permit to install a (date) (installer) septic system at tv' I Am Sf. 0 (�15ta'ti (e based on a design drawn by (addre s) / Out-, Ily-�, r ��aC , dated lo- 28-oS t-e-Y, /� -11-0,5-j (designer)' I 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. I 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. M - �P�IH OF "'OS •9 (Installer's Signatur ) aa� DANIEL E. eyGN o BRAM CIVIL N •— � � ,No.3268, (Designer's-Signature) ®NAL (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. . CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form 3-26-04.doe I r� TOWN OF BARNSTABLE Loc&ION 92 A I lA14 S r SEWAGE # 1� -7 19 re VILLAGE os ,,,y; ''C' ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY S-OZ) _j_ LEACHING FACILITY: (type) _CL)Ar— 33�-S (size) J NO. OF BEDROOMS BUILDER OR OWNER b0/1 I4ArCJl-� 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 leach g facility) '"'��' Feet Furnished byCGt /0r1 �Or A ' 9 3 O a � �3- 13 At4- a� !3y- 30 TOWN OF'BARNSTABLE f G 19 ;.Oi✓r':ai 1C i1 SEWAGE # 99 7 VILLAGE ®S ier�.•-��c ASSESSOR'S MAP & LOT ` INSTALLER'S NAME&PHONE NO.' , 1/AC llt:170f iY;2?- 9/ SEPTIC TANK CAPACITY /31�O Cal D LEACHING FACILITY: (type)Cvl cC 330 = f/-�® (_S� (size) NO.OF BEDROOMS '' rr BUILDER OR OWNER `)VX A-19 I�tAMk 1^! ' PERMITDATE: )Jdv. fi i i j J COMPLIANCE DATE:_JI Separation Distance Between the: Maximum Adjusted Groundwater Table and 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) Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet!?,,t Furnished by .' '" hit 13 XV • +All " C OTPA9e, �� , TO`'` 'OF B It 4 D INSPECTION LOCATION �A SEWAGE # $- e/V� Q& ASSESSOR'S �17 Ca(p VILLAGE O SSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. l SEPTIC TANK CAPACITY C�ss(JUO 1 LEACHING FACILITY: (type) (size) NO. OF BEDROOMS I 11 JJ BUILDER OR OWNER -JO+^ PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachin ,facility) j Feet Furnished by= e,4 /—Jd G �� �e. �,��-k ,� . � �3 � (3Ac,k GAr-Age_. 'TOWN OF BARNSTABLE p� � LOCATION -1431 �MAI^ ST FAILMOPE�a ON VILLAGE ns-ner✓, ASSESSOR'S MAP & LO Co INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY C¢,Ss Pu0 I LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER 'JOB nA��t^p PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted,Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) �„� Feet Furnished by G lo^ GAS STA�,on as 1 I r- Gins TOWN OF BARNSTABLE LOCAT$DN ` o ' MAV\ JT SEWAGE # q!5-' ;�E3 VILLAGE O ST"e(✓j k ASSESSOR'S MAP & LOT 7 O INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY Slra LEACHING FACILITY: (type) 6A I. Ckgm, ,size) 3 57'One- NO. OF BEDROOMS BUILDER OR OWNER "bOr PERMPTDATE: 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 1 facility) Feet y Furnished b _LnC Gf 10�'1 �Or� Ai - c�3 A;L- • Q A3— '119 G3- 419 O a p a . OWN O B LE LOCATA,�N 9V SEWAGE # VILLAGE ( ASSESSOR'S MAP & LOT !l 7 6)Z INSTALLER'S NAME&PHONE NO. a (!- y-�? --,,�� SEPTIC TANK CAPACITY .5©0 i LEACHING FACILITY: (type`506 �iz CJ we- NO.OF BEDROOMS ~ BUILDER OR OWNER % PERMTTDATE: �� �� COMPL CE DATE: ISeparation Distance Between the: Maximum Adjusted Groundwater Table and 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 5r��t t ,. s IL xe4l � ;;TOWN OF BARNSTABLE LOCATION SEWAGE #, VILLAGE OS—rerV S _�. SOR"S MAP`& LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 3 ' Cgsspo-DL NO. OF BEDROOMS 7 I� BUILDER OR OWNER '_00►N AA 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 facility) - .37 Feet Furnished by �J �d r A� " t3 l- a0 A K. Aa' `1 cl u TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE C3,!7--ru1,/I e ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 6`' (2• M ',I/i 4z4re 5;0 3f5J4o7, SEPTIC TANK CAPACITY 56 U qa-,t' LEACHING FACILITY: �rP.L4�.�1'' 3 3 o � � �, size (type) ��"'.r-`� (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: l Z - l q-O a 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) A-) J Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) // `� Feet Famished by C�- c ��l T�-f r e Q� � �!' 34`5"- r✓�5p• Poi' " 5= 34'8 " r7q 2 = t2 ' 31 �� N 5 = •�8' FAILED INSPECTION COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ®1/ �1 TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 981 Main Street(rear garage) Osterville, AM 02655 Owner's Name: Don Harding Owner's Address: Same Date of Inspection: October 26, 2001 Name of Inspector: (Please Print)James M. Ford v `j, 6 2001 Company Name: James M. Ford N® Mailing Address: P.O�rv'lle Box 4MA 02655-0049 T�WHEALTH DEFT BLE 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 CMR 15.000). The system: Passes Conditionally Passes Need4PVrther Evaluation by the Local Approving Authority ✓ Fails Inspector's Signature: Date: November 1, 2001 The system inspector shall sub . a copy of this injection 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 nand 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 1 IL Page-2 ofi y a;, ws OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 981 Main Street(rear garage) Osterville. MA Owner: Don Harding Date of Inspection: October 26, 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 CUR 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 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 981 Main Street(rear garage) Osterville. M4 Owner: Don Harding Date of Inspection: October 26, 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)(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 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. 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: 981 Main Street(rear garage) Osterville. AM Owner: Don Harding Date of Inspection: October 26, 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 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. *NOTE: Single cesspools fail in the Town of Barnstable: E. Large System: To be considered a large system the system must serve a facility with a design now 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 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 981 Main Street(rear-ara-e) Osterville. MA Owner: Don Hardin- Date of Inspection: October 26, 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? n1a 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: 981 Main Street(rear gara e g ) Osterville. MA Owner: Don Harding Date of Inspection: October 26, 2001 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no): [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use(yes or no): Water meter readings,if available(last 2 years usage(gpd)): Sump Pump(yes or no): Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Garage/work shop Design flow(based on 310 CMR 15.203): d Basis of design flow(seats/persons/sgft,etc.): -- Grease trap present(yes or no): No Industrial waste holding tank present(yes or no) No Non-sanitary waste discharged to the Title 5 system(yes or no): No Water meter readings, if available: Total for all buildings: 2000- 77,000 gals.; 1999- 135,000 gals. Last date of occupancy/use: Approximately 35 years ago OTHER(describe): The single cesspool was disconnected approximately 35 years ago-per owner GENERAL INFORMATION Pumping Records Source of information: None on file 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: Unknown 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: 981 Main Street(rear-ara-e) Osterville. MA Owner: Don Hardin- Date of Inspection: October 26. 2001 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: None (locate on site plan) Depth below grade: 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: 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP: 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 f I� Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 981 Main Street(rear garage) Osterville. MA Owner: Don Harding Date of Inspection: October 26, 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: allons/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: None (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: 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: 981 Main Street(rear garage) Osterville. MA Owner: Don Harding Date of Inspection: October 26, 2001 SOIL ABSORPTION SYSTEM(SAS): None (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: 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.): CESSPOOLS: ✓ (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: 1 Single cesspool Depth-top of liquid to inlet invert: -- Depth of solids layer: Dry Depth of scum layer: -- Dimensions of cesspool: 5'W x 6'T x 8'bottom to grade Materials of construction: Brick Indication of groundwater inflow(yes or no): No Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): The cesspool serviced the front and rear garages many Years ago. A new system was installed for the front building and the plumbing was removed from the rear building approximately 35 years ago-per owner. 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 �I. Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 981 Main Street(rear garage) Osterville. MA Owner: Don Harding Date of Inspection: October 26 2001 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. .f GAS STAho^ Ofd �,ess pw I I � O y I � O F A,r pu^^ps work '5�op I ggc,k G�r4q�. 10 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 981 Main Street(rear garage) Osterville, AM Owner: Don Harding Date of Inspection: October 26, 2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30'+1- feet (Adjusted High Ground Water Level is 25.3) 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: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: The bottom ofthe cesspool to grade was approximately 8. Using the Barnstable topographic map and the Cape Cad Commission water contours map the maps were showing approximately 30'+1-to ground water at this site. Using the Cape Cod Commission Technical Bulletin the high groundwater adjustment for this site(MI W 29 Zone C 9101)was 4.7'. This report has been prepared and the system 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 system, the inspection and/or this report. 11 Coss a rq��vs� I 30,o Gr�VndW�QrG/ h.L I (SAS bTA4-1oN O AIK F.Iivs q81 GArAq t q8i -/-� y- peg, �,Ar�gt C, CoTT-,Alg c i GArrw°It °I$► '� cr STorAq� _� �'1'�3�• f 'L, - .ram ""®a=•'"'a - ,....:. -,_.. j j 2 z�3" LAYER OF 3� '" PEASTONE AFIRST PIPE LENOT OVER 3/�„ _ I 1/1" DOU5LE TOP OF FOUNDATION TO �E SET LEVEL_ WASt1ED STONE T AT HOLE LOCH = 1 FOR MIN. 2' DATE:- FIN 13H GRADE TEST j5Y:: EL= /� S" ERG RATE z / M / Zo.a 6CH 40 4„ PVG %„ TOP @ EL.� ,6 s YAP L�r , 4 PVC, /3 Q a IS"' SGI1 40 o 00000 ( ) 500 COAL_ DRYWEI I �� � f"f--7 O Bw S `\ C��(/S/. ) 0 0 0 0. ° oo O -TOM @ 1L. /3r �p'� /b/xS/�i N5TALL OAS f5AFPL.E\ ^i Al, 3 j' I N OUTLET TEE /s, v 90 O� DIST. SOX Z sy ASSv �, /57.3 Z SEPARATION �� 1500 GALLON y 7z i5!o a SEPTIC TANKrc�_G" STONE SASE BOTTOM OF TEST PIT @ ELEV. 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