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HomeMy WebLinkAbout0095 ACORN DRIVE - Health 95 Acorn Drive, Osterville -032 mum 'j',p 1"' .10 A is AW 4 t"U, a On IA "A" r U EA-1 Ilk A& A Mm, 'Ve iT & - �1 W "se, q I- p, �q 'i,A? JIM Ofl��,";Ty 1"A"7P(A%qz Ut Ni can', -M 0. V= '. tlll 5F,.1 g -maw V- WNW* �WN q,�r W, U&NO , 3� NIT OT! . A 41T, MA'.'ri v , . "" "'N' 1, AAW 6,S 1. L. �), k , -mill mill 0- ,f0xTT,,1Ft1 e 4j'Q " � ­_1-111t�,, __ ", ""W F _v,?it PAI MW I r t VT_Iektt 06 �el 3' NMI 4A I q, �4 �­­YO mom out F" Rv �X' ON ,fi,rfwl ; P 0 OK� aq, .ly Ap #4�4,� i Rol WO ;pg A�t�i Ev pp Ilz�,�",g'pg, "A M NMI _X gvgxy gg Nit S KAU Ok *9N,71 ,41, im T41 gn, T', y T, "TR "AN"I", SY,I' T4 41977!MN -�*M N� q! tk Imn. WWI A""""S, A15 I Al SOOM V jS j) �,11��11K_ gwy i�p 61 H; t4 V4 AM trx' MAW- W " 'MAUS gll IN 10 �,.Qqmyvs A PAW Who �,I= 1.Nl ,*�,I`i��,;�i �A!; iii"7 -W W Ma, IRV 05 fg_� 2". OWN! �­4XA" 71 E MA!"', RAN U-4 N �,qfoq.�ht,;,TS, c Commonwealth of Massachusetts �d -p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Acorn Drive V Property Address Marshall Berry Owner Owner's Name information is required for every Osterville Ma 02655 4/15/2020 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Company A Lane Co rm Company Address Centerville_ Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com, S14522 sean@smjonestitle5.com License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 4/15/2020 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. / 1 ,c t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 % �., Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Acorn Drive Property Address Marshall Berry Owner Owner's Name information is Osteryille Ma 02655 4/15/2020 required for every page. City(rown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The property located at 95 Acorn Dr Osterville is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and 2 precast leaching chambers. Although the system was found to be in proper working condition at the time of inspection this report does not guarantee future performance under similar or increased usage. 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp doc•rev.7/26/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 2 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form <l. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Acorn Drive Property Address Marshall Berry Owner Owner's Name information is Osterville Ma 02655 4/15/2020 required for every _ _ page. CitylTown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment. t51nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1; j � 95 Acorn Drive Property Address Marshall Berry Owner Owner's Name information is Osterville Ma 02655 4/15/2020 required for every _ page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has 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. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts �x Title 5 Official Inspection Form - r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Acorn Drive Property Address Marshall Berry _ Owner Owner's Name information is Osterville Ma 02655 4/15/2020 required for every _ _— page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 water supply 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 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts �^ Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form Not for Voluntary Assessments 95 Acorn Drive Property Address Marshall Berry Owner Owner's Name information is required for every Osterville Ma 02655 4/15/2020 page. City/Town State Zip Code' Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5.the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 31.0 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ 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? El- ® 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? ® 0 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? ® ❑ as a facility owner(and occupants if different from owner) provided with . on 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•.Page 6 of 18 Commonwealth of Massachusetts :. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 95 Acorn Drive Property Address Marshall Berry Owner Owner's Name information is required for every Osterville Ma 02655 4/15/2020 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date ' t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts ,( Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Acorn Drive Property Address Marshall Berry Owner Owner's Name information is required for every Osterville Ma 02655 4/15/2020 - page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: - Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: ate Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp doc•rev 7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form I;I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `.� 95 Acorn Drive v— Property Address Marshall Berry Owner Owner's Name information is required for every Osterville Ma 02655 4/15/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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).- Approximate age of all components, date installed (if known) and source of information: system installed 11/29/1996 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 1.5 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.): Joints in good condition, no leakage, vented through roof. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Acorn Drive Property Address Marshall Berry Owner Owner's Name information is required for every Osterville Ma 02655 4/15/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: - - - years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallons 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? Tank was pumped day before inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.).- Tank was pumped the day before inspection and should be done again every 2 years for proper maintenance. tank is structurally sound. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Acorn Drive Property Address Marshall Berry Owner Owner's Name information is Osteryille Ma 02655 4/15/2020 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp,doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts . - - Title 5 Official Inspection Form �o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Acorn Drive Property Address Marshall Berry Owner Owner's Name information is required for every Osteryille Ma 02655 4/15/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site.plan): q. o„ 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.): Distribution box was level and in good condition with no rot. Water level was even with outlet invert with no signs of past backup. i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwe alth of Massachusetts p Title 5 Official Inspection Form It Subsurface Sewage Disposal System Form - Not for Vol untary.Assessments u� 95 Acorn Drive Property Address Marshall Berry Owner Owner's Name information is required for every Osterville Ma 02655 4/15/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No*. Alarms in working order. ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): i * If pumps or alarms are not in working order, system is a conditional pass 11. Soil Absorption System (SAS) (locate on site plan, excavation,not required): I If SAS.not located,:explain why: I I _ k I Type: leaching pits number. ® leaching chambers number: 2 El leaching galleries number: 1 ❑ leaching trenches number, length: El leaching fields number, dimensions: El overflow cesspool number: • ❑ Innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•.Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for.Voluntary.Assessments 95 Acorn Drive . Property Address Marshall Berry Owner Owner's Name information is required for every Osterville Ma 02655 4/16/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of,soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching facility was video inspected from d-box and was found dry with a stain line 6 from bottom. 12. 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 El Yes - ❑ No Comments (note condition of soil,,signs of hydraulic failure, level of pond ing, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth.&Massachusetts q - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 95 Acorn Drive ... Property Address Marshall Berry Owner Owner's Name information is required for every Osterville Ma 02655 4/15/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate:on site plan): Materials of construction: I' Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): q. R. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•.Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection .Form - Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments 95 Acorn Drive Property Address Marshall Berry Owner Owner's Name information is required for every Osterville Ma 02655 4/15/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately �PollE as. Z3 AZ 02 2z f�3 37 ro p. N l:b a`f 36'e t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•.Page.16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 95 Acorn Drive Property Address Marshall Berry Owner Owner's Name. information is required for every Osterville Ma 02655 4/15/2020 page. City/Town State Zip Code Date of Inspection D. System Information' (cont) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water.elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) El Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater was established by accessing town:of Barnstable groundwater contour maps: p. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface.Sewage Disposal System Form - Not for.Voluntary Assessments 95 Acorn Drive Property Address Marshall Berry Owner Owner's Name information is required for every Osterville Ma 02655 4/15/2020 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section: ® B. Certification:Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached w. For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15 Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•.Page 18 of 18 Commonwealth of Massachusetts W Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 95 Acorn Dr Property Address Bank Owned (Contact David Holt@Today Real Estate 1-800-966-2448) Owner Owner's Name information is Osterville MA 02655 9-20-14 required for every i page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector.: • ���►T �U I Shawn Mcelroy Name of Inspector Upper Cape Septic Services z Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town ' State Zip Code 17508-495-0905 S13971 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 Evaluation by the Local Approving.Authority 9-20-14 Inspector's Signature Date - =The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of 1411MIth 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. ..""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•3113 Title 5 Official pe ' n Form:Subsurface age Disposal System•Page 1 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 95 Acorn Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Osterville MA 02655 9-20-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E I 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: System is in good condition with no sign of failure. 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 ass inspection if it is structural) sound not leaking and if a Certificate of P P P Y � 9 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 ,M 95 Acorn Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is Ostervllle MA 02655 9-20-14 required for every _ 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: ❑ 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 I ❑ 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 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 95 Acorn Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is Osterville MA 02655 9-20-14 required for every page. City[Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3/13 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 95 Acorn Dr Property Address Bank Owned (Contact David Holt cLD Today Real Estate 1-800-966-2448) Owner Owner's Name information is Osterville MA 02655 9-20-14 required for every _ page. Cityrrown State Zip Code Date of Inspection B. Certification (cost.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you 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. gins•�It Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 95 Acorn Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Osterville MA 02655 9-20-14 _ page. Citylrown 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): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms). 220 t,❑ •;.r, Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 1- Commonwealth of Massachusetts Title 5 Official Inspection Form ~ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �HM 95 Acorn Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is Osterville MA 02655 9-20-14 required for every _. page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 2014Date 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: t5ms•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 95 Acorn Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Osterville _ MA 02655 9-20-14 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: N/A 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) t5ms•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 95 Acom Dr Property Address Bank Owned (Contact David Holt c@ Today Real Estate 1-800-966-2448) Owner Owner's Name information is Ostervllle MA 02655 9-20-14 required for every 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: 1996 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: f 611 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.): Good condition. Septic Tank (locate on site plan): 8" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years K age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal Sludge depth: 12" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 95 Acorn Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is Osteryille _ MA 02655 9-20-14 required for every _ — 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 20"- Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping. Date t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 I Commonwealth of Massachusetts m W Title 5 Official Inspection Fora, Subsurface Sewage Disposal S stem.Form -Not for Voluntary Assessments. - 9 p Y rY ,M 95 Acorn Dr Property Address ., Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is Osterville MA 02655 9-20-14 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction:- ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day . Alarm present: ❑ Yes ❑ Nor Alarm level:.. Alarm in working order: r - ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is.copy'pttached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 95 Acorn Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Osteryille MA 02655 9-20-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from chambers. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form,-Not for Voluntary Assessments WA 95 Acorn Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name I information is I required for every Osterville MA .02655 9-20-14 page. City/Town I State Zip Code Date of Inspection D. System Information (cont.) - Type. i ❑ leaching pits number: i ® leaching chambers f number: 2-500 s leaching galleries / number: i leaching trenches number, length: • i , ❑ leaching fields number, dimensions: . ❑ overflow cesspool number: ❑ I' 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.): Leach chambers in good condition and empty at inspection with no sign of back-up from chambers: j . �I y a I Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration l Depth—toip of liquid to inlet invert Depth of solids layer Depth of scum layer ..; Dimensions of cesspool - C 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 4 , f I I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 95 Acorn Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Osterville MA 02655 9-20-14 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.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts m f Title 5 Official Inspection Fo:rrr 4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 95 Acorn Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) - Owner Owner's Name information is required for every Ostefville MA 02655 9-20-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) _ Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately C'e k �' t5ins•3t13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' M 95 Acorn Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Osterville MA 02655 9-20-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water _ f ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed- Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °7M 95 Acorn Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Osterville MA 02655 9-20-14 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 T4DVd�T' .BiT5��BLYA SBWAGt vac D e�� l a, sFssGn°s 1 :i.ox 15TlR LE�CZ'5 D1AAli �ME Y+Y0 ..— AFAC NO.OF 0 1 CAW 9�p�sEteac�a��RSr��acc:I3et��cera t�aa . .. Mflxl numl cljus�;t1 aj000jldw:ltejabW Ca tlac ouarribi Leuc:hin Nac lily . ...-.�u- .�---w Vic`' �a1v�94'�V'�tce Sup�+ly;�'laNt did i.(,as,i�ete�Ixacal.tly l3f t�ty delis gist , 7rcrs8 ari e�l�,at awlt as ERR£eet of lanshia FRO ity) — �.cturiy�"�/et.9atat9 ad�d.Leaa�li�at,l�aca�Ily(YE,uriy wctl�nclti exist r�iti���a 3Q0 fc.a2 a#`lenat�in�Pi►cil�ry) -�-�� � �uc�►�l�hc�d:try,....,:,� r � ,�.,,,,.�...,....�, ' � L G D � n � TOWN OF BARNSTABLE LAtATION PVC- r oSEWAGE # q VILLAGE 0 S�r J �� � . �C� 11 ASSESSOR'S MAP & LOT r INSTALLER'S NAME&PHONE NO. LI 1 SEPTIC TANK CAPACITY /-5,0 O //` �f4 LEACHING FACILITY: (type) 9--SOD S<Q, Uwt((('(Size) -� �y as NO.OF BEDROOMS BUILDER OR OWNER PERMUDATE: t f a ko COMPLIANCE DATE: II 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 Edgeetland and LeachngFacility(If any wetlands exist iF 00feetofleachingfacility) Feet Furby k BAc k f 1 1• 4 y, TOWN OF BARNSTABLE . �� f UPCATION - m� SEWAGE # f� VILLAGE (2, 9rL/ZZ&' e 5 ASSESSOR'S MAP & LOT 'toAME&PHONE NO 1 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 6�XF v ek (size) NO.OF BEDROOMS BUILDER OR OWNER DATE: `9A 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 any wetlands exist within 300 feet qf leaching fac' ty Feet Furnished bv t fa No. '` Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZIppfication for Migogar *p6 em Con6truction Permit Application for a Permit to Construct( )Repair( )Upgrade )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Dc.vZ, Owner's Name,Address and Tel.No. Assessor's Map/P 1S�+2r ��`c, �• `a�: �e���11 . 6 ® Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. "k k-0 •j�.2 v^:c.It.S �r�-r—��a..' ��.s- +n..�.idcLS lSoEy Mct.�,� ��° AIICS`ryQe-P;M"- 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 Soils -- a� Nature of Repairs or Alterations(Answer whe applicable) -�,,. -rz � Date last inspected: A 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 S of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is e. by this Board of Pealth. Signed Date /1 2 2- 9 Application Appoved by r Date Application Disapproved for the following reasons Permit No. Date Issued //—A vZ -96 r ' NO' - '� �i Fee�.��.67 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: I / I Yes - PUBLIC HEALTH DIVISION -TOWN ORBARNIS•14ABLE., MASSACHUSETTS ZIpprication for Migozar pgtemc oi�gtru�t o ern i ° Application for a Permit to Construct( )Repair( )Upgrade )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. f Owner's Name,Address and Tel.No. Assessor's Map/P ^ � ,� �r i , 0 — OJvS R A C0 � AS�rJ`� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.' C�'k �ro•�- �--�r:cBLS 106'rna',w s I• M(tS��e�.M4 t Oa�y � c-a�P-vv.,,t Type of Building: Dwelling No.of.Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building Cafeteria( ) 1 Other Fixtures i Design Flow gallons per day. Calculated daily flow I gallons. Plan Date umber of sheets Revisio Date Title Size of Septic Tank Type of S.A.S. 1 Description of Soil .y.... r Nature of Repairs or Alterations(Answer when applicable) M K:s :L c-e ss s oe. I . per< LAD — '. Date last inspected: 'Agreement: # w The undersigned agrees to elits a the and maintenance-of the afore described on-site sewage disposal system in accordance with the provisions of Title of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is Pd >y this Board of Health. Signed Date Application Approved by r Date "t.2-9 Application Disapproved for the following reasons 4 i Permit No. Date Issued //-A oZ -'9G .' ---------------------------------- THE COMMONWEALTH OF MASSACHUSETTS . BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( )Repaired(J o)lTpgraded( ) Abandoned( )by _� r-t wa �a n,c..1t-S, ` at -' - has�been constructed in accordance with the provisions of Title 5 and the for Disposa?System Construction Permit No. t dated ✓., ;�A"^ 9 6 Installer ( ., \ � tie 1-4.. c l,..k 1 Designer The issuance of this permit s all not be construed as a guarantee that the will function a !dVd.e Date �� Inspecto -- �—�---------------------------- No. Fee$ CJ"aa vm THE COMMONWEALTH OF,MASSACHUSETTS PUBLIC HEALTH DIVISION -:BARNSTABLE., MASSACHUSETTS 0 iqoar *pgtent Cott6truction permit Permission is hereby granted to Construct( )Repair( )Upgrade(1,.,<Abandon( ) System located at da c �-w .r: ,,-. 0.s 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 It. Date: Q9j , IL 110k (_ Approved y CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I ,-,�, —.��,�1�� . hereby certify that the application for disposal works construction permit signed by me dated tio,� concerning the property located at l<C' meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in now and/or change in use proposed • There are no variances requested or needed. SIGNED :( e�•S,� 1 �4 DATE: O0IJ LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. �� vim-o..a � 'L^� y' '� ' , r 0 0 Y 1. �. I a + •F' f � �'� 1 o ` + P 7^ f r� I t/ I *l .. � ...a .... ,t 9 `. 1;'� �1 S f r ` - -- - --- _------ - .._ V 1 DATE: _ 9/27/96 PROPERTY ADDRESS: .95 Acorn Drive Osterville ,Mass . 02655 4 . On the above date, I Inspected the septic system at the above Address. This system consists of the following: -1 . 2-6'x8 l block cesspools . ''> SSESSOt PARCM MY. Based bn my In e-:�ction, I certify the following conditions: 1 . This i.s not a title five septic system. 2. This is a sewage system. 3 . The sewage system is in failure .. 4. The system. should be upgraded to a title five septic system. 81GNATUR!--: Name:-J . P . Macomber -Jr... i Company:_J• P . MacoMber & Son-_Inc . , Address:_-B-e-x-66......I...... _-Centerville LMa�;�__02632 Phone:--- SCZ-7-7-9-3338------- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tanks-Cesspool&-LeachfIvIds . Pumped & InsUII&d Town Sewer Connections P.O. Box 66 ' Centerville, MA 02632.0066 775.333,8 773-6412 r- V.. . U .Q6% Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection W111 larn F. WWeldGwrn Trudy Cox* 8_ 10t Aryoo Paul Celluool David B.Struhs U.Gowmor Cyr • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION PropertyAddreaa: 95 Acorn Drive Osterville ,Mass . Address of Owner. Date of Inspection: 9/2 7/9 6 (If different) NameofInspocwr.. Joseph P. Macomber Jr. Company Name,Address and Telephone Number. J. P.Macomber & Son INC . Box 66 Centerville ,Mass . 02632 508-775-3338 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes — Conditionally Passes — eeds Further Evaluation By the Local Approving Authority /FD ails Inspector's SIgnature: 2� / G 6<lL'G`� Date: The System Inspector submit a copy of this inspection report to the Approving Authority within thirty(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 Department of Environmental Protection. The original should be sent to the system owner Ind copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspoction. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exMtration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One Winter Street • Boston, Massachusetts 02108 • FAX(617) 5545-1049 • Telephone (617) 292-5500 �� Pnnled on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontlnued) Property Address 95 Acorn Drive Osterville ,Mass . owner. Judy Bright Date of Inspection: 9/2 7/9 6 BJ SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced �L/1 The system required Pumping more than four times a year due to broken or obstructed pipe(s). The system will peas inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: /XC' Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: 4,"L Cesspool or privy is within 50 feet of a surface water E0 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is leas than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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 6 ppm. 3) OTHF41 The System consists of 2-61x8l block cesspools All no ' s to paragraph C section 2 (revised 11/03/95) 2 CERTIFICATION (continued) PropertyAddre'ss: 95 Acorn Drive Osterville,Mass . Owner-' Judy Bright Date of Inspection:9/2 7/9 6 D] SYSTEM FAILS: • I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 16.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an 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. ,f.L!,v4 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. !O Liquid depth in cesspool is less than 6"below invert or available volume is less than M day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped V2) Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I of a public well. Any portion of a cesspool or privy is within 60 feet of a private water supply well. %S�L> Any portion of a cesspool or privy is less than 100 feet but greater than 60 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: 1-10 The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply th 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.. (revised.11/03/95) 3 i S 'A'AGL DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Addressz- 95 ;Acorn Drive Osterville ,Mass . Owner. Judy Bright Date of Inspection: 9/2 7/9 6 Check if the following have been done: ` ,Pumping infor mation was requested of the owner,occupant,and Board of Health. X/None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. 4L/�As built planslhave been obtained and examined. Note if they are not available with N/A ZTbe facility orl dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow The site was uupected for signs of breakout. All system components,eluding the Soil Absorption System, have been located on the site. �csv<��The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods, 2The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE 51:WAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 95 Acorn Drive Osterville ,Mass . Owner. Judy Bright Date or 9/2 7/9 6 FLOW CONDITIONS RES I D ENTL4L Design flow: q'e Number of bedrooms: Number of current residents:.z Garba,&e grinder(,yea or no):46 Laundry connected to system (yea or no):4t�=-� Seasonal use (yes or no):-,&�� Water meter readings, if v ble: ' �1 �y�.� day. �.��r'�,a✓, Last date of occupancy: /-l COMMERCIAL INDUSTRIA''L• Type of establishment: 4 Design flow:_Id_'�ons/day �— - Grease trap present: (yea or no)& Industrial Waste Holding Tank present: (yes or no)-111/thti Non-sanitary waste dischargod to the Title 5 syswin: (yea or no) 1 '� Water meter readings, if available: �►%{� Last data of occupancy: OTHER: (Describe) f� Last date of occupancy: ---- GENERAL INFORMATION PUMPING�tECORDS c td soun;e of information: System pumped as part of inspection: (yes or no)� If yes, volume pumped: /:4 O n6 oils Reason for pumping .S Y �✓�7^ T✓ �`;c /� TYPE OF SYSTELf Septic WLIJdistributloil box/soil absorption ryuteiu 3inblo cwrpacl Overflow oe"pool Privy Shared system(yes or no) (if yes, attach previous inspection records, if any) 2ff Other(explain) APPROXIMATE AGE of all components, date in,tali�i (if known) and source of information: Sowago odors dots ted when arriving at the sire: ty a or :;o) (revised 11/03/95) 6 ' ` ' SUBSURFACE biSYUSAL SYSTEM INSPECTION FORM p�R.T [ (cun(ioucd) Property Address: q5 Acorn Drive OsterriTIo 'Mass . Owner; Judy Bright Date of Impectivo4/27/46 ' ' ` SEPTIC TANK: (locate on site plan) Depth be|m, grade�V,# Material oJ construct iuo�y#concrete _metal __FKp __vo.c'�^v|^"v Dimensions:— A)A _—_ _....... ��--'—__ Sludge depth ' Divanc m bottom uf outlet tee o, ��/� '`«\�_ Scum thickno s: ���1_-— Distancehummpp(avmmmpo(owdameo, LuDc-_=�� � — u� Diyu�r from bottom of scum to bottom of outlet xz mu,'�.` fz� Comments: (recommendation for pumping, condition of inlet and outlet tc"� of buNc^ depth o( |Quid 1pvel in ,c/aiun to outlet invert, wm#ucd ' Vit evidence of leakage, > ICKEASFTKAP. (locate un site plan) . Depth below � material o/cuost"'rtione6,,�_unoce __frco| __FK" __"�:�.�^v|��w � Scum w/c^oc� xvzr Distance from top * u�mm top u(outlet tee o/ buNc:-11~,_�� D.yaoe from bottom * .o'� rmmop o/ nv/+l ',r n �6//', Comments: � (recommendation for pumping, mnd-~nu/ inlet and uuU6 `=` o' LuNc\ depth o( |iguid level in relation m outlet invert, structural leakage, . � . ` -' | ^ - | / ` / � � h � � °.�"ou o/zwos� r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 95 Acorn Drive' Osterville ,Mass . Owner. Judy Bright Date of Inspection:9, 2 7/9 6 TIGHT OR HOLDING TANK&A/e,, (locate on site plan) • Depth below grads:,k Material of construction:,Q1concrete_metal_FRP_other(explain) hl I Dimensions: AJA Capacity: A fit) gallons Design flow• QUA aallons/day Alarm level: A)1 Comments: (condition of inlet tee,condition of alarm and float switches, etc.) DISTRIBUTION BOX:ti!''V (locate on site plan) Depth of liquid level above outlet invert: Z' Comments: (nota,if level and distribution, equal, evidence of solids carryover,evidence of leakage into or out of box,etc.) JS PUMP CHAMBER:4-ezf)N (locate on site plan) Pumps in working order:(yes or no) rill Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) (revised 11/03/95) 7 i r "UR ACE SEWAGE DISPOSAL SYSTEM INSPECTION b'ul:ia PART C SYSTEM INFORMATION (oontinued) 95 Acorn Drive Osterville,Mass . 0' , Groner. Judy Bright Data of 9/27/96 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,it poaaible;excavation not required, but may be approx—ted by non-intrusive methods) • If not determined to be present,explain: I Type: leaching pits,number:A, 4I i�- leaching chambers,number. leaching galleries,number: leaching trenches,number,length: leaching fields, number,dimensions overflow cesspool, number:_ Comments: (note condition of&oil,'signs of hydraulic failure level of ponaing,condition of vegetation,etc.) Medium to fine sand: No signs ok Hydraulic failure or pon ing; All Vege a ion is normal. CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert:I Depth of solids layer: L Depth of scum layer: Dimensions of cesspool:_ I' X Materials of construction: iw,tom_ 7l Gy�e Indication of groundwater: inflow(oaupool must be.pumped as part of inspection) �C" Medium o `nef sand;o 1gns oFNV rn 'fg1cdi'?ailure oW)pondin g3 Ali vegetation is norma PRIVYt Aljll,,U 1, I Materials of construction: Dimensions' Depth of solids d Co ts:*to condition of soil,,signs of hydraulic failure, level of ponding, oondition of vegetation,etc.) i (revised 11/03/95)• g SUUBURYACE SEWAGE DISPOSAL SYSTEM INSPECTION ,FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE L_'SPOSAL SYSTEM: include ties to at least two permanent references landmarks. or benchmarks locate all wells within 100 ' ' Centerville .Osterville Marstons Mills Water Company 428-6691 ' <... %'-s A c o eit/ �; s DEPTH TO GROUNDWATER -20 ' + depth to groundwater m.Qtkod of determin ion :or approximation: We"T � 'L` '3 s - e,P = s'�t,� ' ' t .54' AC°Q'rn''Dr'v,e ., '95-10 wa er was . „'�:�•�ver.. �xr�oun erg ., •,�..y�_ -._:T,_ -�: a:� _ -. ---- t ' r a w z s � Un s � . ..__THE COAM- ONWEALT_H ,OF. MASSACWSETTS _. DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby ; authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. June 8, 1995 Acting Director of the ion of Water Pollution Control I'OWN OF Barnstable WARD OF HEALTH S1111SURFAU SNAGE DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION -TYPE OR PRINT CI,EARLY- STREET ADDRESS . 95 Acorn Drive Osterville ,ma.ss . ASSESSORS MAP , BLOCK AND PARCEL # OWNER' s NAME Judy Bright NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Son Inc. COMPANY ADDRESS Box 66 Centerville ,Mass . CERTIFICATION STATEMEN'r I certify that I have personally inspected the sewage dispos�j system at this address and that tile information reported is true , accurate, and complete as of the time of -inspection . Tile inspection was performed and any recommendations regarding 6pgrade , maintenance I and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems , Check one : CXXXY,XXLX Sys teui PASSED The inspection 14hich I have conducted has not found any information which indicates that tile system fails to adequately protect public criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . The inspection which I have conducted has found that -the system fails to protect tile public health and the environment in accordance witil ritle 5 , 310 CHR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form Inspector Signature . Date 10/1196 One coPY of this c�-rtification Must be Provided to the OWNER, the BUYER ( where aPPlicable ) and the DOA11D OF JILCAL'111. * If the inspection FAILED' rk� r� o owner ' ' within one year of the date e o� the i «pe- r�t�r shall «P�rud= ' tbm mYntmm otherwise as provided in 30 CH -� 5 . »oPmoti«o ' unless ullowed or required ` ~: ` ' . '