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HomeMy WebLinkAbout0032 ACORN DRIVE - Health 32 Acorn Drive Oster_ville P A = 120 026 • o p , d n J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 32 Acorn Drive r Property Address Marion Frank Owner Owner's Name information is t� MA 02655 10/14/2015 t01 1 required for every Osterville page. City/Town State Zip Code Date of Inspection is aF'1 Inspection results must be submitted on this form. Inspection forms may not be altered in an 4ryr. way. Please see completeness checklist at the end of the form. Important:When A filling out forms ..General Information w 9/3b3 on the computer, use only the tab 1. Inspector: key to move your cursor.-do not James Ford use the return Name of Inspector key. MIACompany Name P.O. Box 49 Company Address Osterville MA 02655 CitylTown State Zip Code 508-862-9400 S 12482 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further E al ation by the Local Approving Authority 10/19/15 Insr1th ature Date Thinspector shall submit a copy of this inspection report to the Approving Authority(Board ofDEP)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. ****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. t5ins•3/13 G'U Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Acorn Drive Property Address Marion Frank Owner Owner's Name information is required for every Osterville MA 02655 10/14/2015 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/ always complete all of Section D A) System Passes: ® 1 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: i i B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by . the Board of Health, will pass. Check the box for"yes "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Acorn Drive Property Address Marion Frank Owner Owner's Name information is required for every Osterville MA 02655 10/14/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced . ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Condition's 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 (Sins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Acorn Drive Property Address Marion Frank Owner Owner's Name information is required for every Osterville MA 02655 10/14/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier; if any) determines that the system is functioning in a y g manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑" ® Backup of sewage into.facility or system component due to overloaded or clogged SAS or cesspool I ❑ ® 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 1/2 day flow 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °�M a 32 Acorn Drive Property Address Marion Frank Owner Owner's Name information is required for every Osterville MA 02655 10/14/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No Required pumping more than 4 times in the last year NOT due to clogged or El ® 99 obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑' ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , a 32 Acorn Drive Property Address Marion Frank Owner Owner's Name information is required for every Osterville MA 02655 10/14/2015 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate 'yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 •l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 I , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 32 Acorn Drive Property Address Marion Frank Owner Owner's Name information is required for every Osterville MA 02655 10/14/2015 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: unavailable Sump pump? ❑ Yes ® No Last date of occupancy: currently Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Acorn Drive Property Address Marion Frank Owner Owner's Name information is required for every Osterville MA 02655 10/14/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: pumped in 2013 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ® Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the'DEP approval. ❑ Other(describe): l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 , r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 32 Acorn Drive Property Address Marion Frank Owner Owner's Name information is required for every Osterville MA 02655 10/14/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: system installed - unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: cover to grade feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ® other(explain) cesspool acting as a septic tank If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: - t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 32 Acorn Drive Property Address Marion Frank Owner Owner's Name information is required for every Osterville MA 02655 10/14/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 1 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The liquid level was up to the outlet pipe. Grease Trap (locate on site plan): Depth below grade: n/a feet Material of construction: ❑ concrete ❑ metal ❑fiberglass , ❑ polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage-Disposal System Form - Not for Voluntary Assessments 32 Acorn Drive Property Address Marion Frank Owner Owner's Name information is w required for every Osteryllle MA 02655 10/14/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, ton, structural integrity, 9 Y, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): N/a Dimensions: 4 Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): i Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No !Sins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 r Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Acorn Drive Property Address Marion Frank Owner Owner's Name information is required for every Osterville MA 02655 10/14/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert n/a 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(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption.System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 15ins•3/13 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments AM 32 Acorn Drive Property Address Marion Frank Owner Owner's Name information is required for every OSterville MA 02655 10/14/2015 page. Citylfown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 - 1000 gal. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: 1 ❑ 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 liquid level in the overflow cesspool was up to the outlet pipe. The cover was 2" below. The leach pit had 6"of liquid on the bottom. There was no sign of failure The cover was 2' below. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration . Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ® No l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 32 Acorn Drive Property Address Marion Frank Owner Owner's Name information is required for every OStefVllle MA 02655 10/14/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/a r e r t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 32 Acorn Drive Property Address Marion Frank Owner Owner's Name information is required for every Osterville MA 02655 10/14/2015 page. CitylTown E State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: Z hand-sketch in the area below ❑ drawing attached separately ' � J 3 a 3 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Acorn Drive Property Address Marion Frank Owner Owner's Name information is required for every Osterville MA 02655 10/14/2015 page. City/Town State Zip Code Date of Inspection D. System Information (Cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells . Estimated depth to high ground water: 30+/- feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: Topo and water contours map ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: see above Before filing this Inspection Report, please see Report Completeness Checklist on next page. (Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 IL r . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ''�.. 32 Acorn Drive Property Address Marion Frank Owner Owner's Name information is required for every OSterville MA 02655 10/14/2015 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 f Commonwealth of Massachusetts t. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments 32 Acorn Drive Property Address Marion Frank ` Owner Owner's Name information is required for every Osterville MA 02655 10/10/13 page. CitylTown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness;checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor- not James Ford i use the return urn - key. Name of Inspector ,n Company Name P.O. Box 49 Company Address Osterville MA 02655 City/Town State Zip Code 508-862-9400 S 12482 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector.pursuant.to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails i ❑ Needs Further valuation by the Local Approving Authority 10/15/13 Inspe or's Signature Date The tem inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 DER The original should be sent to the system owner and.copies sent to the buyer, if applicable, and the approving authority.. ****This report only describes,conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 . r Title 5 Official Inspetulne Sewage Disposal System•Page 1 of 17 ' Commonwealth of.Massachusetts Title 5 Official.ilnspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v 32 Acorn Drive Property Address Marion Frank Owner Owner's Name information is required for every Osterville MA 02655 10/10/13 page. City/Town State Zip Code Date—of-1 n—spe�cfion B. Certification (cont.) r Inspection Summary: Check 'A,B,C,D or E/always complete all of Section D A) System Passes: . ® 1 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. Tfesystem, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for.."yes",.',no" or"not determined" (Y, N, ND)for the following statements. If"not determined,",please explain': The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank;is replaced with a complying septic tank as approved by the Board of Health. 9 , *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the,tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 4 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Acorn Drive Property Address Marion Frank Owner Owner's Name information is required for every Osterville i MA 02655 10/10/13 page. CltyFrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage;backup or break out or high static water level in the distribution box due to broken or obstructed,pipes)or due to a broken, settled or uneven distribution box. System will it pass inspection if(with;approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is,leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s)..The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(sr)�r�replaced ❑ Y ❑ N ❑ ND (Explain below): El obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): F , 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: • E ❑ Cesspool or privy 11 is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 i . tt Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 32 Acorn Drive Property Address Marion Frank f Owner Owner's Name information is Osterville required for every MA 02655 10/10/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont) f 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. ElThe system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. I; ❑ The.system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine:distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of p ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, prov4ded that no other failure criteria are triggered. A co of the anal be attached to this form. 99 copy analysis must 3. Other: j D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or;"No"to each of the following for all inspections: Yes No ` I ❑ ® 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 ''Y2 day flow 15ins•1113 J �` Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official) Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '^GSM 32 Acorn Drive Property Address # Marion Frank I Owner Owner's Name information is Osterville MA 02655 10/10/13 required for every _ page. City/Town ! State Zip Code Date of Inspection B. Certification (cont.)' Yes No ` d ; ❑ ® 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 po gion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The 9..ystem is a cesspool serving a facility with a design flow of 2000gpd- 10,o00gpd. ❑ ® 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 syste n';owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. .. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Areal= IWPA)or a mapped Zone II of a public water supply well If you have answered "yes',tq any question in Section E the system is considered a significant threat, or answered "yes" in Secti6n'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. 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I i : e b .1' r' . 1 Commonwealth of Massachusetts v Title 5 Officiagi Inspection Form Subsurface Sewage Disposaf!System Form - Not for Voluntary Assessments �N 32 Acorn Drive Property Address Marion Frank Owner Owner's Name f, information is required for every Cisterville MA 02655 10/10/13 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have'been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ 0 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'lacility 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 thoi septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimen§ions, depth of liquid, depth of sludge and depth of scum? ® Was tfe facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approxima'tion of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: , •' Number of bedrooms (design):. 3 Number of bedrooms (actual): 3 DESIGN flow based on 316 WR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 t Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 ji i f Commonwealth of Massa1chusetts W Title 5 Official lnspection Form Subsurface Sewage Disposal;`System Form Not for Voluntary Assessments 32 Acorn Drive Property Address Marion Frank Owner Owner's Name information is required for every Osterville MA 02655 10/10/13 page. City/Town State Zip Code Date of Inspection D. System Information{ Description: f Number of current residents- 11 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected F El Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd))` Detail: , unavailable t s Sumpump? P ❑ Yes 0 No Last date of occupancy: currently Date r Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310.,CMR 15.203): Gallons erda G fi P y(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present?. ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 l; Commonwealth of Massachusetts Title 5 Official; .Inspection Form Subsurface Sewage Disposal'system Form -Not for Voluntary Assessments 32 Acorn Drive Property Address Marion Frank Owner Owner's Name information is required for every Osterville i MA 02655 _ 10/10/13 i` page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use`: Date Other(describe below): k General Information Pumping Records: Source of information: ii never pumped - per owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: y ; gallons How was quantity pum pled.determined? Reason for pumping: maintenance Type of System: ❑ Septic tank,.distribution box, soil absorption system ❑ Single cesspool ® Overflow cesspool ❑ Privy u ❑ 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 Jcontract(to be obtained from system owner)and a copy of latest inspection'of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 R Commonwealth of Massachusetts Title 5 Official, Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Acorn Drive ) Property Address i Marion Frank 4 Owner Owner's Name information is required for every OsterVllle MA 02655 10/10/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: installed - unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: I ❑.cast iron ® 40,PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade:. i. cover to grade feet Material of construction: ❑ concrete El 'metal. ❑fiberglass ❑ polyethylene ®other(explain) cesspool acting as a septic tank t If tank is metal, list age: years 41 Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'wM 32 Acorn Drive Property Address Marion Frank Owner Owner's Name information is required for every Osterville MA 02655 10/10/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) } Distance from top of sludge to bottom of outlet tee or baffle Scum thickness ,i 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.): The liquid was up to the outlet pipe. The cesspool was pumped after the inspection. The cover was to fade. ,. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): N/a Dimensions: ` Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 1 f �i Commonwealth of Massachusetts W Title 5 Officia.1 Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 32 Acorn Drive Property Address l Marion Frank Owner Owner's Name information is required for every Osterville MA 02655 10/10/13 page. City/Town State Zip Code Date of Inspection e ' D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): i' i�. it - Tight or Holding Tank(tank must be pumped at time.of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): N/a Dimensions: Capacity: gallons Design !Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): rl *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Officiallnspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments k 32 Acorn Drive 'j Property Address Marion Frank Owner Owner's Name information is required for every Osterville MA 02655 10/10/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if prese�trmust be opened)(locate on site plan): Depth of liquid level above outlet invert N/a 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.): u i I f _ } Pump Chamber(locate ontsite plan): Pumps in working order: El Yes ❑ No Alarms in working order: `° ❑ Yes El No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): N/a r r, If pumps or alarms are not in working order, system is a conditional pass. I. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 5 } b. I: f .. Commonwealth of Massachusetts, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Acorn Drive Property Addressis Marion Frank Owner Owner's Name t informati for every on is required Osterville MA 02655 10/10/13 page. City/Town State Zip Code Date of Inspection D. System Information cont.) -�( 1 Type: ® 1� 1 - 1000 gal.leaching pits -; number: ❑ leaching chambers number: ❑ leaching galleries number:. ❑ leaching trendies number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: 1 "t ❑ 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 liquid in the overflow cesspool was full up to the outlet pipe. The cover was to grade and it was pumped. The leach pit had'6" of liquid on the bottom.There were no signs of failure. The cover was 2' below ` r r; Cesspools (cesspool must•be:pumped as part of inspection) (locate on site plan); ,i Number and configuration;" '.'' N/a Depth—top.of liquid to inlet.invert. Depth of solids layer Depth of scum layer a. Dimensions of cesspool [ 'µ Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 I • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Acorn Drive Property Address Marion Frank Owner Owner's Name information is required for every Osterville MA 02655 10/10/13 page. CltylTown State Zip Code" Date of Inspection D. System Information, (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i . Privy(locate on site plan): Materials of construction: ' Dimensions +i Depth of solids. a Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/a h I e. `I 4 I ' t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I Commonwealth of Massachusetts N W Title 5 Official' Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ",M a 32 Acorn Drive # ' Property Address Marion Frank Owner Owner's Name information is Osterville MA 02655 required for every 10/10/13 page. CityrFown State Zip Code Date of Inspection D. System Informatioh (cont.) Sketch Of Sewage Disposal.System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 1 . L 1 3� I� a a3 ay . 3 ay ys k t5ins-3/13 R Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I !I Commonwealth of Massachusetts Title 5 Official -inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 32 Acorn Drive s Property Address Marion Frank Owner Owner's Name information is required for every Osterville " MA 02655 10/10/13 page. City/Town State Zip Code Date of Inspection D. System Informatiow(cont.) Site Exam: ❑ Check Slope k, ❑ Surface water ❑ Check cellar ❑ Shallow wells. Estimated depth to high ground water: 30' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site('abutting property/observation hole within 150 feet of SAS) ® Checked with Iocal'Board of Health- explain: Using topo and water contours maps ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USES database -explain: You must describe how yo' established the high ground water elevation: see above ' ' h Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i ,'. Commonwealth of Massa6husetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Acorn Drive Property Address Marion Frank Owner Owner's Name information is Osterville MA 02655 10/10/13 required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist z ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file a t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No... �............. F�$.....$...15.,.QQ.._ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ..............Tam..................OF.........$ nstable...................................................... Appliration for Disposal Works Tonstrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair (x ) an Individual Sewage Disposal System at: 32 Acorn Drive,..Osterville. -�'-.._.0265.� .. ........... ....... ......._......- - •--........... .........._..._._......---•••-----...---------- Location-Address or Lot No. Thomas Warren 32 Acorn Drive: 0sterville, MA____02655. Owner Address aA & B Cesspool_ S_ ervic_e 128 Bishops Terrace, Hyannis, MA 02601.._ Installer Address Type of Building Size Lot...... ..................Sq. feet Dwelling—No. of Bedrooms.............................................Expa2 ion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons..................._........ Showers ( ) — Cafeteria ( ) dOther fixtures -----------------------------------•------------------•------•----•••--------•-•-----•----•--•------•----•••......•-•-----•---.... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter-_-__-__-___-_ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes er inch Depth of Test Pit......._............ Depth to �' . ground water--_-_--____-_-__-----_ P P P frq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ----•---------------------------------------------------------------------------•---•--•-•-----•---•...................................... --------------•---- 0 Description of Soil----.Sand----------------------------------•------...........-•---------••--•-----•••••-----•-•--•-•---------•----------------------•......•.....------------•.--- V -------------------••------••••--------•---•.._......------•---•------------------••--•--•----•--•--•--------•-••--•-------------•---••-------------••--•------------------------•---....----••......•-- W ---•--------------------------------------------------------------------------------------------------------------------------------------------------------------••-------------------.............._. U Nature of Repairs or Alterations—Answer when applicableim-stallati.on...af...a._1,0Q0..gallan,...pm-cast, stone. pa�k�a leas- R�.t- �oV�x lara).� Agreement: The undersigned agrees to install the aforedescribed Individual Sewage sal System in accordance with the provisions of TITLE5 of the State Sa ?s / �e— he and n d agrees not to ce the system in operation until a Certificate of Compliance d by th I Signe .1 �`-....`.. -- ---•--------- - ---i.......... 61264�... Date Application Approved By................................................................................................ 84 .. 6/_26� Date Application Disapproved for the following reasons:.............................................................................................................. ...................................................•---.......------.....-----------------------..........- Date Permit No.--.-• L-•---•.......-- -. Issued..........6I26,§:.......................•--- ........................ Date No. �- . ----------•--- FER...A...1.5..00..._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............. g.1 ...................oF........13axns-tabl.e....................................................... _ ... ppliratinn for Disposal Works Toustrnrtiun- .erntit Application is hereby made for a Permit to Construct ( ) or Repair (x ) an Individual Sewage Disposal System at: 32 Acorn Drive, Osterville, MA 02655 ................----............................................................................ •••---•••••---••••-----•••-----•••....••••-•-•-...••-••••-••-••--•--•••-•.....--•-.............••. Thomas Warren Location-Address 32 Acorn Drive Osterville MA 026 -- p i-.... ...•.-- -• -5 -•1 A & B Cesspool of Servi CeOwner Address a ..................p 128 Bishops Terrace H is 14A 0260 --------------------........•------ Installer Address UType of Building Size Lot............................Sq. feet �-� Dwelling—No. of Bedrooms...................3 ......................... Attic ( ) Garbage Grinder ( ) P4 Other—T aype of Buildin g ---------------------------- No. of persons_____._.....____.______._.__ Showers ( ) — Cafeteria ( ) d Other fixtures -------------- W Design Flow............................................gallons per person per day. Total daily flow............................_...............gallons. W Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total"leaching area....................sq. ft. Seepage Pit No------_------_-_- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ W Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 •--•-•------------------•-••-•-•-•'-•--•--•-•-------•••-••-•--•.....___......___............................................................................. D Description of Soil...``,pan45. .................................. V .......................•-••--------•••------•......-••-•-•--•---•----•-•••--•-•-•-••-----.---•-----•-....••••---•-•------•--••-•---•-••......--•- W UNature of Repairs or Alterations—Answer when applicablentallatioA_.of._a-- -,OQO•-� ]�o ,.--p --�A.St., stone packed_leach--pit__.(overflow).• ----------------------------------------------------------•------------..................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Di s osal System in accordance with the provisions of TI TIE 5 of the State Sani Code—The undersigned f -rfl /agrees not to place the system in operation until a Certificate of Complianc as�6�i > by th o, h.'Si ne '/�r�/�_ _ Application Approved BY ----•.-- 184 --....�---------•------••-_.. ..--••----••........................... - ---• �. Date Application Disapproved for the following reasons:------•----------------------------------------------------------------------------------------------------•-- 6/26/84 -6at- Permit No....-•� --••--••-•-----•---•------•----•--••--...... Issued-------------•• 6 Date Date THE COMMON WEAL[H OF MASSACHUSETTS r` 'e BOARD OF HEALTH Town Barnstable ........... . . .... ..................OF.....:........................ . ......................................... (Intifiratr of Toutpliattrr T I TO C IFY That i idual ewa e Dis sal S. stem onst to ( ) or Repaired (X ) by..A .� esspoo ervi'ce, i s�iops er�,ce, yann�is, NX ( 0 ------------------•---•---......--------•--•---•-----......----.............._................._.... 32 Acorn Drive, Osterville, YA 026551n=tathomas Warren at...................................................................................................... has been installed in accordance with the provisions of T�4LF 5 of The State Sanitary Cot/�� wribed in the application for Disposal Works Construction.Permit No......................................... dated-----------..................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WIL F�frd�CTION SATISFACTORY. DATE..... .�1 ..................................................... Inspector. .... THE COMMONWEALTH OF MASSACHUSETTS \ BOARD OF HEALTH Town Bazn .......................oF......................._...........stable..... .1500 No......................... FEE..._._.................. Disposal Works Tnnstrnrtinn rrntit A & B Cesspool Serviced Permission is hereby granted -• -- -- .................. ---------------- to Co u t (( ) r•Re ai X l a IIndiv,�dd al S Di osal Sy em �COrn IYrivep bsge�lnJ.1e, Ml O �55j - Rols arren atNo..................................................................... r - ----------••--------------•---------•------•---------- Steet as shown on the application for Disposal Works Construction Permit No'.:_r ............ Dated.....6/26/84 DATE................................................................................ Board of Health FORM 1255 A. M. SULKIN, INC., BOSTON r 4J 7 'own of Barnstable # `�71°° 1•� Department of.Rei ato Services � ,. Date '� Public Health Division 200 Main S eet,Hy nis MA'02601 itisp ♦e , 1/ ' Fee Pd. +Date Scheduled ' Time i Soil Suitability Assessment for nwaPe_D' . al - - Witnessed By: Performed By: -- LOCATION& GENERAL INFORMATION Owner's Name: 'r�On k _ Location Address 3.2. A cA-;m -D- �W E J _. • 0 1�� i Address . �C'�� • �N -" SzvGs- � � Engineer's Name Assessor's Map/P$tcel: (� - NEW CONSTRU�,`I'lON REPAIR i Telephone# � " ►7 Land Use ��A� l � Slopes(%) �c Surface Stones pJ ft Drinking Water Well —"'7 —ft Distances from: Open Water Body�—ft Possible Wee Area -- Drainage Way ft Property Line —LL—ft Other ft SKETCH:($treet name,dimensions of lot,exact locations of test holes&perc tests locate wetlands in proximity to holes) m r1v Y,� rJ 4. i W \K Z- CAS+ 17� co , a) a rrrr, Depth to Bedrock Parent material(gedlogic) `—� I :PP Weeping feom Pit Face Depth to GroundwaWr. Standing Water in Hole: E � C stimated Seasonal;High Groundwater Cl�)e �' t TION FOR SEASONAL HIGH WATrR TALE D 'I.�RN1IN ,A i -. •fin. Depth tc soli tn®tt'"' Method Used: in. Dep tt. Depth dbperved standing in obs.hole: in, Groundwater AdjusthUnt Depth toiweeping from side of obs.hole M.factor,.,m-!A�•drnundwflter Level Index Well# Reading Date Index Well level • � 1-1�9-0 'lt'lnra_t�-Q PERCOLATION T ''ST . Date � e i1 ` Observation i Time at 9" J.1L.t1- - -- Hole# Time at 6" Depth of Pere `—�--- i Time(9M,661) �1�_.._^^_ Start Pre-soak Time.® End Pre-soak Rate MinAnch Site Failed; = Additional Testing Needed(YIN) Site Suitability Asse,�sment: Site Passed„L�---- ; / Observatiot Hole Data To Be Completed on Back original: Public H41th Division ------ you must first notify the ***If percolj#0 test IS to be conducted within lOWeedk prior to eginning* Barnstable Noservation Division at least one(1) P Ar.. 'DEEP OBSERVATION HOLE LOG Hole# f Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Struc M Stones,Boulders. Consistency, rav 1 DEEP OBSERVATION HOLE LOG. Hole# Z Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) e. LS 10 a MeA ^si s 8 a Gs DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Stmct0re,Stones,Boulders. Consislgncy, Gra ;DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture; Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. ositn rn t Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes . Within 500 year boundary No._V ..-Yes�..� Within 100 year flood boundary NoJYes , Depth of NatubBy occurrine Pervious Material Does at least folir feet of naturally occurring perviopl material exist in all areas observed throughout the area proposed Or the soil absorption system? �S If not,what is the depth of naturally occurring pervious material? Ce_ I certify that on. (date)I have passed the soil evaluator examination approved by the Department of> nviro ental do and that the above analysis was performed by r4a consistent with 'the required traini ,e` 's d x err nce described in 310 CMR 15.017. Signature Date Q:\SEMCUPERCMRM.DOC UVCOMMONWEALTH OF MASSACHUSE-TTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL .1 1SE PE 1 AB 8.20TT 0Z TOWN LTH DEPTABLE TITLE 5 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 32 Acorn Drive Osterville, MA 02655 Owner's Name: Teresa Warren , Owner's Address: Same Date of Inspection: _September 6, 2002 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Map: 120 Osterville, MA 02655-0049 Parcel: 026 Telephone Number: (508) 862-9400 Lot: 7 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000): The system: ✓ Passes - Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fail Inspector's Signature: Date: September 8, 2002 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: 32 Acorn Drive Osterville, MA Owner: Teresa Warren Date of Inspection: September 6, 2002 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: I 2 Page 3 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 32 Acorn Drive Osterville, AM Owner: Teresa Warren Date of Inspection: September 6. 2002 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: 32 Acorn Drive Osterville, AM Owner: Teresa Warren Date of Inspection: September 6, 2002 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: 32 Acorn Drive Osterville, AM Owner: Teresa Warren Date of Inspection: September 6, 2002 Check if the following have been done: You must indicate."yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner, occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period,? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection ? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS, located on site'? ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 32 Acorn Drive Osterville, AM Owner: Teresa Warren Date of Inspection: September 6, 2002 FLOW CONDITIONS RESIDENTIAL - Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: 1 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system (yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL q 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-per treatment plant Was system pumped as part of the inspection (yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box, soil absorption system Single cesspool ✓ Overflow cesspool Privy Shared system (yes or no) (if yes,,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: A pit was added approximately 10 years aQo-per owner. Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 32 Acorn Drive Osterville, MA Owner: Teresa Warren Date of Inspection: _September 6, 2002 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 siteplan) (Cesspool acting as a septic tank Depth below grade: To.grade Material of construction: concrete metal _fiberglass _polyethylene ✓ other(explain) Cesspool 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'Wx 6'6"Tx 10'bottom to,grade Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle: 6' Scum thickness: 1" 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.): Liquid was up to the outlet pipe. No outlet tee was present. The cover was to Trade. 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 um in : P P g 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 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: 32 Acorn Drive Osterville, MA Owner: Teresa Warren Date of Inspection: September 6, 2002 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.): . I 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: 32 Acorn Drive Osterville, MA Owner: Teresa Warren Date of Inspection: September 6, 2002 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type " ✓ leaching pits,number: 6'x 6'-1000 gal. leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number, dimensions: ✓ overflow cesspool,number: 1 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 overflow cesspool was S'Wx 6'T x 10'bottom to grade and had approximately 6'of water in it. The pit had approximately 1'ofwater. The scum line was at the same level. There were no signs of failure. The bottom to grade was approximately 10'. The cover was approximately 2'below grade. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 32 Acorn Drive Osterville, AM Owner: Teresa Warren Date of Inspection: September 6, 2002- Map: 120 Parcel: 026 SKETCH OF SEWAGE DISPOSAL SYSTEM Lot: 7 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. 1A r k A , - 3y B (31 - Aa- a3 A3- ay a 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: 32 Acorn Drive Osterville, AM Owner: Teresa Warren Date of Inspection: September 6, 2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30 +/- feet Please indicate (check) all methods used to determine the high ground water*elevation: Obtained from system design plans on record- If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: The bottom of the leach pit to grade was approximately 10'. Using the Barnstable topographic map and the Cape Cod Commission water contours map, the maps were showing approximately 30'+l-to ground water at this site. P 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 wili function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection andlor this report. 11 TOWN OF BBARNSTABLE . LOCATION Go r �J(, SEWAGE # VILLAGE O STe,r.y, c. ASSESSOR'S MAP & L OTiaglL �O INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY w S S LEACHING FACILITY: (type) ' (size) NO.OF BEDROOMS l - BUMDER OR OWNER rZ S A W Arrez\ PERMIIDATE: 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 o leaching facility) J Feet Furnished by ► I1 S ul l0 d/ �-+ Al - Aa- 93 rya- ay A3- ay yt a