HomeMy WebLinkAbout0037 BATES STREET - Health 37 Bates Street,Osterville
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No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered.incomputer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
4plication for Misposal *pstrm Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System R Individual Components
Location Addre s or Lot No. Owner's Name,Address,and Tel.No.
Assessors Map/Parcel 77 —
Installer's Name,Address,anA Tel.No. UAC S--a/z Designer's Name,Address,and Tel.No.
POv O)Q 71 Vhtg�S o�.t5 w►'�s r MkKS
Type of Building:
Dwelling No.of Bedrooms Lot Size 12,1(®_A sq.ft. Garbage Grinder( )
Other Type of Building Fk.S t Xzh,�- z\�No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs,or Alterations(Answer when applicable)Rg%06 Le H.A SP,e�TA-L VI-Bode
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board e t
Si e Date 2(3
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No Date Issued
No. CA, � Fee -
THE COMMONWEALTH OF MASSACHUSETTS Entered in compute _�� ,
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
application for Bisposal *pstrm Construction Permit
Application for a Permit toConstruct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ®I dividual Components
Location Address or Lot No. �� � . Owner's Name,Address,and Tel.No.%01 y`
Assessor's 1vIap/P cel�� iill1MiH y � pia 'q_.M ,
Installer's Name,Address,zWid Tie'No. i *�` l Designer's Name,Address,and Tel.No.'a
Type of Building: "`G
Dwelling No.of Bedrooms Lot Size 17,G11, sq.ft. Garbage Grinder( )
Other Type of Buildini I. , No.of Persons Shower`s Cafeteria
Other Fixturesz.
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
=R` Title ,
" Size of Septic Tank Tte of S.A.S.
Description of Soil .,.:.•ra
Nature of Repairs or Alterations(Answer when applicable) p t
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
m: ..
Compliance has�been issued by this Board •e�_,Jth. t
,
Application Approved by .`� �,.J- .—_..r� Date"
Application Disapproved by Date
for the following reasons r. .
Permit No. �� .�.� '1 Date Issued i t5
� f ,
---------------------------------------------------------------------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
(Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( (y)
Abandoned( )by 1r. X_ Af e.
at "1' 2%ftkcC %A has been constructed in accordance /
with the provisions of Title 5 and the for Disposal System Construction Permit Nc dated / nl
Installer ,,•� Designer
#bedrooms . Approved design flow gpd
The issuance of this permit shall of be construed as a guarantee that the systen9 will fun 'on ned.
Date J//ra ` • - Inspector 1 -
-------------- ------ ----------------------------------------------------------------------------------------- -----------------------
No. -- Fee
THE COMMONWEALTH OF MASSACHUSETTS
,r PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
lnit
Bisposar 6pstem Construction Permit
Permission is hereby granted to Construct( ) Repair( ) Upgrade(�) Abandon( )
System located at 371 9 a ire
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be i ompleted within three years of the date of this pe it.
Date / � ,Approved by
s
tT Town of Barnstable
Inspectional Services
�BARNSrne e `
MASS.
i639. Public Health Division
�0 ,
200 Main Street, Hyannis MA 02601
Office: 508-862-4644 Thomas A.McKean,CHO
FAX: 508-790-6304
CERTIFIED MAIL97015 1730 0001 4988 0749
April 3, 2020
GROSSMAN, DONALD
94 ARDMORE ROAD
NEEDHAM, MA 02494
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5
The septic system located at 37 Bates Street, Osterville, MA was inspected on
03/09/2020 by Brett Hickey, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Conditionally Passes"
under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following:
e The septic tank is leaking.
You are ordered to replace the septic tank within two (2)years from the date you receive
this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
Thomas McKea R.S., CHO
Agent of the Board of Health
e ,
Q:\SEPTIC\Title V Inspection Report Letters Mail ing\Conditionally Passes Letters\37 Bates Street Osterville.doc .
THE tqs,
Town of Barnstable
A. SS
b q 1k. Inspectional Services -Department
ED MP'�
Public Health Division
200 Main Street, Hyannis MA 02601
Office: 508-862-4644
FAX: 508-790-6304 Thomas A.McKean:CHO'
Feb 6, 2007
Rev, 4/26/19
DEADLINES TO REPAIR FAILED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000)
An "x" marked in the ❑ is the failure criteria and associated repair deadline,
_
60 DAY DEADLINE CRITERIA
❑ Discharge or ponding of effluent to the surface of the ground
❑ Pumping more than 4 times during the last year not due to clogged or obstructed
pipe.
❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
❑ Structurally unsound septic tank or SAS
ONE (1) YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation
❑ Any portion of the cesspool within a Zone 1 to a public well
❑ Any portion of a cesspool within 50 feet of a private water supply well with no
acceptable water quality analysis. (This,system passes if the water analysis
indicates the well is free from pollution).
TWO (2) YEAR DEADLINE CRITERIA
❑ Single Cesspool
/Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation
of a driveway due to H-10 components, etc)
❑ Leaching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h)
OT ER
lc.
e(J'Al SQa_ �0Lc
Repair deadline:
Q`.\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc
Commonwealth of Massachusetts i
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0
37 Bates Street ,g
v�
Property Address
Sheila Grossman Z_
Owner Owner's Name
information is required for every Osterville ✓ Ma 02655 3-9-2020>�+.�
'
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 1, q(od
on the computer, Brett Hickey
use only the tab
key to move your Name of Inspector
cursor-do not B&B Excavation
use the return Company Name
key. 374 Route 130
u� Company Address
Sandwich Ma 02563
City/Town State Zip Code
(508)477-0653 S113747
Telephone Number 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 r
2. ❑E Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
F, e •
4. ❑ Fails
Breµ LJIG,Ley, - Digitally signed by Brett Hickey'
It Hickey _-'�Date:2020.03.1207:36a2-0a'oo• 3-9-2020
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.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
t
Commonwealth of Massachusetts
�m Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Bates Street
Property Address
Sheila Grossman
Owner Owner's Name
information is Osterville Ma 02655 3-9-2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) SystemPasses: .
❑ 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:
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):
Septic tank was only 1/2 full at time of inspection showing the tank is leaking
Tank and d-box are H-10 and under driveway.
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
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Bates Street
v
Property Address },
Sheila Grossman
Owner Owner's Name
information is Osterville Ma 02655 3-9-2020
required for every
page. City/Town 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.
r ,-
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:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
r
' 4
c Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
ra
�I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Bates Street
Property Address
Sheila Grossman
Owner Owner's Name
information is Osterville Ma 02655 3-9-2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
r
❑ 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
❑ F. Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ 0 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 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts-
Title 5 Official. Inspection Form r
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Bates Street
v
Property Address
Sheila Grossman
Owner Owner's Name
information is Osterville Ma 02655 3-9-2020
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.)
k
Yes No
❑ E] Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ a Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/day flow
❑ 0 Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ Q Any portion of the•SAS, cesspool or privy is below high ground water elevation.
El ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ a Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ El Any portion of a'cesspool or privy is within 50 feet of a private water supply well.
❑ El 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.]
❑ 0 The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ O 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 god to 15,000 god.
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
1
❑ ❑ 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.cl. •rev.7/26/2018. Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
k
c Commonwealth of Massachusetts
�m Title 5 Official Inspection Form
+ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Bates Street
V
Property Address
Sheila Grossman
Owner Owner's Name
information is
required for every Osterville Ma 02655 3-9-2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to an question in Section C.5 the system is considered a significant
Y Y any Y 9
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 310 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
E ❑ 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?
❑ 0 Has the system received normal flows in the previous two week period?
❑ 0 Have large volumes of water been introduced to the system recently or as part of
this inspection?
El ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
❑ 0 Was the facility or dwelling inspected for signs of sewage back up?
El ❑ Was the site inspected for signs of break out?
0 ❑ 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?
❑ 0 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:
El ❑ Existing information. For example, a plan at the Board of Health.
❑ M 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
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Bates Street
v
Property Address
Sheila Grossman
Owner Owner's Name
information is Osterville Ma 02655 3-9-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
3 3
Number of bedrooms(design): Number of bedrooms(actual):
330/GPD
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Description:
0
Number of current residents: t
Does residence have a garbage grinder? ❑ Yes Q 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 0 No
information in this report.).' ,
Laundry system inspected? ❑ Yes 0 No
Seasonal use? ❑ Yes a No
See below
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
2019- 88,000gallons 2018- 51,000gallons
Sump pump? El Yes ■❑ No
Sept/2019
Last date of occupancy: Date
t5insp.doc-rev.7/26/2018 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 - of for Voluntary Assessments
37 Bates Street
u-
Property Address
Sheila Grossman
Owner Owner's Name
information is Osterville Ma 02655 3-9-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
NA
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:
9 ,
Last date of occupancy/'use: Date
Other(describe below):
3. Pumping Records:
Source of information:, Owner- last pumped 1 year ago
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
ra Title 5 Official Inspection Form =
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments-
37 Bates Street
u—
Property Address
Sheila Grossman
Owner Owner's Name
information is Osterville Ma 02655'• 3-9-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System: E
El Septic tank, distribution boz, soil absorption system
❑ Single cesspool t'
❑ 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: p
1991 per permit
Were sewage odors detected when arriving at the site? r -❑+ Yes ❑■ No
5. Building Sewer(locate on site plan): ;
1 1611
Depth below grade: `
feet
Material of construction: '
❑ cast iron ❑■.40 PVC ❑ other(explain):
Town water
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 f z ;
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Bates Street
V�
Property Address
Sheila Grossman
Owner Owner's Name
information is Osterville Ma 02655 3-9-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
611
Depth below grade:` feet
Material of construction:
X 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
1
Dimensions: 000gallons
Sludge depth: Tank leaking
of
a Distance from top of sludge to bottom of outlet tee or baffle
of of
Scum thickness
n n
Distance from top of scum to top of outlet tee or baffle
n r�
Distance from bottom of scum to bottom of outlet tee or baffle
viewed
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 tank was only 1/2 full when viewed. Tank is leaking.
l5insp.doe•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
' f '
C'
Commonwealth of Massachusetts ,
�d Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Bates Street t '
u—
Property Address
Sheila Grossman
Owner Owners Name
information is Osterville Ma 02655 3-9-2020
required for every
page. City/Town State Zip Code Date of Inspection .
D. System Information (cont.)
7. Grease Trap(locate on site plan):
NA
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: r 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(tankmust be pumped at time of inspection) (locate on site plan):
t NA
Depth below grade:
Material of construction:
a
❑ concrete El metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions
Capacity: gallons
F
Design Flow:
gallons per day
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
4
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Bates Street
u—
Property Address
Sheila Grossman
Owner Owner's Name
information is Osterville Ma 02655 3-9-2020
required for every
page. City/Town 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
s
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):
3
0"
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
The d-box was in poor condition and is H-10 and under the driveway.
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Bates Street
v
Property Address
Sheila Grossman
Owner Owner's Name
information is Osterville Ma 02655 3-9-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on-site plan): t
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: El Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
NA
* 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):
If SAS not located, explain why:
Type:
0 leaching pits number,
(1) 6'x6r pit
❑ leaching chambers number:
❑ leaching galleries number:
* ❑ leaching trenches number, length: -
❑ leaching fields number, dimensions: '
❑ overflow cesspool - number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7126.12018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts.
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Bates Street
u�
Property Address
Sheila Grossman
Owner Owner's Name
information is Osterville Ma 02655 3-9-2020
required for every
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.):
The SAS was in working order at the time of inspection. Pit was dry but does have
heavy root infiltration present.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
NA
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
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
I - -
Commonwealth of Massachusetts
Title 5 Official Inspection Form.
�= l;� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s.
37 Bates Street
Property Address , +
Sheila Grossman
Owner Owner's Name
information is Osterville Ma 02655 3-9-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
- + NA
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
A '
• , 1 y
r
}
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
/J 37 Bates Street
L�
Property Address
Sheila Grossman
Owner Owner's Name
information is Osterville Ma 02655 3-9-2020
required for every
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
Driveway
3
Bates T Q
Al-16' 61.3T
' A2.28' B2.,W
A3.X B3-60'
A B
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
i
Commonwealth of Massachusetts
�9 Title 5 Official Inspection, Form .
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 Bates Street
_u Property Address
Sheila Grossman
Owner Owner's Name
information is Osterville Ma 02655 3-9-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
r
FE1 Check Slope < _
■❑ Surface water
❑■ Check cellar
■❑ Shallow wells
Estimated depth to high ground water: No GW @ 12'feet
Please indicate all methods used to determine the high ground water elevation: R
❑ Obtained from system design plans on record
' -
If checked, date of design plan reviewed: Permit dated: 9-25-1991Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
f
❑ Checked with local excavators, installers-(attach documentation)
l
❑ Accessed USGS database-explain:
" d
You must describe how,you established the high ground water elevation:
A permit on file at the local Board of Health was.used to determine high groundwater.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
i5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
c Commonwealth of Massachusetts
�M Title 5 Official Inspection Form
ii Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
I;
37 Bates Street
V
Property Address
Sheila Grossman
Owner Owner's Name
information is Osterville Ma 02655 3-9-2020
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
QQ A. Inspector Information: Complete all fields in this section.
QQ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
0■ C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6 (Checklist)completed
p■ D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
- DATE:
12/17/96
PROPERTY ADDRESS: 37 Hates Street
Osterville,Mass .
02655
On the above date, I Inspected the septic system at the above address.
This system consists of the following:
1 . 1-1000 gallon septic tank.
2'. 1 -Distribution box.
3 . 1-1000 gallon precast pit packed in stone.
Based bn my Ingroaction, I certify the following conditions:
1 . This is a title five septic system. '( 78 Code)
2. The septic- system is in proper working
• order at the present time.
3 . No repairs needed at the present time.
SIGNATURE: G �(
Name: J. P .Macomber Jr.,
Company: J. P.Macomber & Son-_Inc .
Address
Centqrvi11,e LMass__0.2.632
Phone:___Sa&-175-3338_______ . I
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
•
ISM—
LS. P. MACOMBER & SON, INC.
Tanks-C*upools-le"hfleIds
. Pumped & InsUlled
Town Sewer Connections
x 66' Centerville, MA 02632-0066
773-3338 77:5-6412
v
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
3epartment of
40
�Hvironmental Protection
Trudy Cox*
&. ",Y
David B. Struhs
U.Goal; C4nwr1s*W*f
*
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 37 Bates street Osterville ,Mass " Address of Owner. 7204 MillwoodRoad
Date of Inspection: 12/17/96 (If different) Bethesda,Maryland
Name of Inspector. Joseph P.Macomber Jr. 20815
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 sawage 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-sits u disposal systems. The system:
Passes
_ Conditionally Passes
— Needs Further Evaluation By the Local Approving Authority
Fail
Inspectoes Signature Date:
��I.L � Date:
The System Inspector s 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 pow 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.wd copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
A) SYSTEM PASSES:
have not found any information which indicates that the system violates any of the failure criteria as defined in 310 ChM 15.303.
Any failure criteria not evaluated am 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
inspection.
Iadicaw yes, ao,or not determined(Y, N,or ND). Describ*basis of determination in all instances. If"not determined", explain why not)
N() The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration,.or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a Fonforming septic tank as approved
by tL. Board of Health.
(revised 11/03/95) 1
One Winter Street * Boston, Massachusetts 02108 * FAX(617) 556-1049 * Telephone (617)292.55W
�� Pnnted on Recycled Papa
®
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: Marianna Taylor
Owner. 37 Bates Street Osterville,Mass .
Date of Inspection: 12/17/9 6
B)SYSTEM CONDITIONALLY PASSES(continued)
Sewage backup or breakout or huh static water level observed in the distribution boa is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution boa. The system will pass inspection if(with approval of the Board of
Health):
broken pipe(s)are replaced
obstruction is removed
distribution boot is levelled or replaced
The system required pumping more than four 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
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
,0 n Conditions exist which require Auther 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:
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.
7) 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.
J10 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 Is"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 wail is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or leas than 6 ppm.
3) OTHER
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (oontinued)
PropertyAddreaw 37 Bates Street Osterville,Mass .
owner. Marianna Taylor.
Date of Inspection:12/17/9 6
D) SYSTEM FAILS:
•
I have determined than the system violates on*or more of the following failure criteria as defined in 310 CMR 16.303. The basis for
this dstermiaation is identified below. The Board of Health should be contacted to determine what will be necessary to correct the
failure.
Backup of"wage 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.
Static liquid level in the41stribution box above outlet invert due to an overloaded or clogged SAS or ce"pool.
UA& ►`2�r
Liquid depth in oempoobis leas than 6"below invert or available volume is less than W day flow.
Required pumping more than 4 tunes in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_ 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.
dZ Any portion of a cesspool or privy is within a Zone I of a public well.
,&0 Any portion of a cesspool or privy is within 60 feet of a private water supply well.
40 Any portion of a oe"pool or privy is less than 100 feet but greater than 60 feet from a private water supply well with no
adaptable water quality analysis. If the well has been analysed to be socaptable, 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:
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:
4. the system is within 400 feet of a surface drinking water supply
& the system is within 200 feet of a tributary to a surface&inking water supply
/il!/ 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 AW compliance with the groundwater treatment program
requirements of 314 CMA 5.00 and 6.00. Please consult the local regional office of the Departmant for Author information..
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
PropertyAddrem 37 Bates Street Osterville ,Mass .
Owner. Marianna Taylor
Data of Inspection:12/1 7/9 6 •
Check if the following have been done: `
_2pumping information was requested of the owner,occupant,and Board of Health.
x1lNons of the system components have been pumped for at least two weeks and the cysts=has been receiving
during that period. Large volumes of water have not been introduced into the normal now sates
system recently or as part of this inspection.
2As built plans have been obtained and examined. Note if they are not available with NIATha facility or dwelling was inspected for signs of sawage back-up.
, The system does not receive non4anitary or industrial waste now
ZTha site was inspected for signs of breakout.
All systam components, je;l-ding the Soil Absorption System, have been located on the site.
The&optic tank manboles were uncovered,opened,and the interior of the septic tank was inspected for condition of banes or
tees, material of construction, dimensions, depth of liquid,depth of sludge,depth of scum.
,/The size and location of the Soil Absorption System on the site has been dstormined based on existing information or
approximated by non-intrusive methods.
, The 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 SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
PropertyAddtc*at 37 Bates Street Osterville,Mass .
ow•ncr. Marianna Taylor
Date of lospeuti�L.: 12/17/96
FLOW CONDITIONS
RES I D ENTIAL
D—zm flow: a ons�i
Number of bedroom,:
Number of current reaideau:dAk
Carbaev grinder(yw or no):&
Laundry ooanacted to rpum (yw or no):�
&asota) use (yw or no):�
Water mrter readinp, If available: 144JI -= 7f�OlD
I ` O'Alo13
La,t date or occupancy;
COMMERCLAL NDU9TRIAL
Type of uublishment:
D.u:em flow:"allons/day
Crews trap pnueot: (yea or ao1
LtdustrW Waste Holding Tank present: (yea or no)l�
Nom-"--uury waste discharged to the Title 5 ryetam: dyes or no)&W
Water meter reading, if available: VA
/ _
Lan date of occupancy: A)
OTHER- (Describe) AM
Lan date or occupancy: —
GENERAL INFORMATION
PUMPINGy&CORDS and source of information:
Syrtem pumped u pan or inspection. (yes or nog
11 yea, volume pumped: 4z* �uiu
Reason for pumpiar.. /1JAr
TYPE Ogi9Y9TE.4t
_,Septic taiWdistribuUon bmJsod absorption r)item
Satre ��l ,
Ovrrflow cw-jF4xl
"t)d privy
/00 Shared ryrtem (yes or no) (if yes, attach previous inspection records, if Lay)
L'L
Other (axplrin)
1
e
,4P.?R0)0 MATE GE or tell oomponeou, date u:.+talltxl (if known) and source of information: d
Seware odors nntx-tars .tiF t
�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C• •
SYSTEM INFORMATION (continued)
Property Address: 37 Bates Street Osterville ,Mass .
Taylor
Marianna Ta
Owner: y
Date of Inspection: 12/17/96
SEPTIC TANK:
P&40 Tw�
(locate on site plan)
Depth below grader
Material of construction: Loncrete _metal _FRP—other(explain)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:Z;e •
Scum thickness:7�°�
Distance from top of scum to top of outlet tee or baffle:'��
Distance from bottom of scum to bottom of outlet tee or baffle. l�
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles depth of liquid level in relation to outlet invert, structural
�rity, evidence of leakage, etc.) Pump tank •eve Vy 2-3 years;2nle# & out et teen arm
to lace ;Liquid level at outlet invert iQ. .511;,hank is struaturallyam^
GREASE TRAP.
(locate on site pian)
Depth below grade:;:t��
Material of cons;rortion,�zoncrete metal _FRP —other(explain)
.414 _
Dimensions_
Scum thickness.
Distance from top w.i scum to top of outlet tee or baffe: 4U
Distance from bottom nt -rum t- honnm of outlel tee or trafile.-
Comments:
(recommendation for pumping, condi—n of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, mj Grease trap is not present.
s
(revised 8/15/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
PropertyAddreu: 37 Bates Street Osterville,Mass .
Owner. Marianna Taylor
Date of Inspection: 1 2/1 7/9 6
TIGHT OR HOLDING TANKAZ44,E
(locate on sits plan) e
Depth below
Material of construction:49ooncrete_meta]_FRP—Aber(explain)
Dimensions: AIA
Capacity ns
Design flow: ons/day
Alarm level: J 4
Commeata:
(oondition of inlet tee,condition of alarm end float switches, etc.)
Tight or holding tank not present.
DISTRIBUTION BOX
(locate on site plan)
Depth of liquid level above outlet invert: ,tf
Comments:
(note if laval Had distribution is equal, rvidaaos of solids carryover,evidettcs of leakage into or out of boa,etc.)
Distribution box is level: Has equal distribution;No signs of
solids carry over; No signs of leakage in or out. of the hnx-Nn_.repa xs
needed at the present time _
PUMP CHAMBER:-.dove
(locate on site plan)
Pumps in working order.(yes or no) UA
Comments:
(note oondition of pump chamber,condition of pumps Had appurtanaaoes, etc.)
_P_umn ChamhPr i a ant. nrPQent.t.
(revised 11/03/95) 7
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropeetyAddreue 37 Bates Street Osterville,Mass .
Owner. Marianna Taylor
Date of InrPeotioa: 1 2/1 7/9 6
SOIL ABSORPTION SYSTEM(SAS)
aces"on site Plan,if posaubls;excavation not required,but may be approximated by non-intrusive methods)
e
If not determined to be present,explain:
Type.
1sac.hin8 pits,number,
1whing chambers,number
leachin8 gellsrier,number
leaehin trencher.number,langth.
Lsching fields,number, nsions:
overflow cesspool,number.
Connects:(note condition of veil, signs of hydraulic failure,level of�oadtaaa rcoadutioal c vef a 1 ue ,
Medium sand to fine sand-No si ns o2 jjy 8a—u—1
A11 vegetation is normal. o repairs needed at the presencetime .
CESSPOOLS:
(locate on site plan)
Number and configuration: A>
Depth4op of liquid to inlet invert:
Depth of solids layer
Depth of scum layer:
Dimensions of oesspooL•
Material,of Construction:
Indication of groundwater:
inflow(cesspool must be pumped part of inspection)
I)J
/J
Comments:(note condition of so rigas of ulic failure,level of ponding,condition of vegetation,etc.)
Cesspools are not present.
PRIVY:"V�,
(beats on ad*Plan)
Material.of conatructiaa. Dimensions•_ 41�0
Depth of solids-4(
Comments,(note condition of coil,signs of hydraulic failure,level of ponding condition of vegetation,etc.)
(revised 11/03/95). 8
f
SUBSURFACE 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
isv
DEPTH TO GROUNDWATER
depth to groundwater
rpthod of determinesion or approximation:
4+.
-12 •' ■�n...va�ll
Sbj1f 3r71
THE COMMONWEALTH OF MASSACHUSETTS
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 'Zon of Water Pollution Control
i
r
�1
'rn rr.-ntr/�.-rrtrnrmr•nTRls�nrt r.nlT+t.^.T+r1R►t�rRnRTen�neAv s�'�nen,eT TT"1-rr e—r-:..-•,r•'
� 'TOWN OF Barnstable BOARD OF IIEALTII I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION
`� �•••r^1�T••.•.• -�.t17.�.�TTI.TST.'MI''T.14I T'TlrlC'l/7T.T.TT:�-R'Tr'ItRT.'77nT1Qr9'ATOArl�1RRn�'.7�TR7 ifT ..�rT•Tr-1.�..A
-TYPE OR PRINT CI.EARLY-
PROPERTY INSPECTED
STREET ADDRESS 37 Bates Street Osterville ,Mass .
ASSESSORS MAP, BLOCK AND PARCEL i 141 -111
OWNER' s NAME Marianna Taylor
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph_P-Macomber Jr.
COMPANY NAME J.P.Macomber .& Soil'Ync.
COMPANY ADDRESS Box 66 Centerville,Mass . 02632
Street Town or City State tip
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (508 1 790 - 1578
R
q
CER'rIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
complete as of the time of.-inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one:
IXXXXXX XSystem PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 , 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have conducted has found that the system fails to
protect the public Health and the environment in accordance with Title
5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature Date 12/17/96
_ .�
One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the BOARD OF HEALTII.
* If the inspection FAILED, the owner or"roperator shall upgrade
he aYste
within one year of the date of the inspection , unless allowed ortrequiredm
otherwise as provided in 3,10 ChJR 16 . 306 ,
partd .doc
TOWN OF BARNSTABLE
I
LOCATION J)' 6
WI-4-'S SEWAGE # qj'- /
VILLAGE ASSESSOR'S MAP LOT
INSTALLER'S NAME & PHONE NO. � ��CQ��ti'1
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) az (size) `S Olobveg
4'a
NO. OF BEDROOMS C;Z- PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER 1�
DATE PERMIT ISSUED: Ai 5 " I
DATE COMPLIANCE ISSUED: 6 Iq
VARIANCE GRANTED: Yes No
Ail =
chl
s s
V�
Io.- ..... Fps............................_
Q THE COMMONWEALTH OF MASSACHUSETTS r�V cc A A
'1� ��` BOAR® OF HEALT o I C' 0°�sa p ° °Eo
i1 TOWN OF BARNSTABLE B��oA .
igh s,
Aliji ration for 11iupoiial Works Tonutrn ton rr i
Application is hereby made for a Permit to Construct ( ) or Repair PC an Individual Sewageposa
System at: -
-•-.............
• -31--_.... -------------------------- ----------------------------------------•-- - -------------......_........_•-•-•--•----
Location-A dr s or Lot N
Iq
^Rcaner Ad s
a ------.... ------�0----------------------------------------------- ------------ �'1. ._�_P_�it .
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms.................3_____________________Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons____________________________ Showers — Cafeteria
Q' Other fixtures --------------------------------
W Design Flow............................................gallons per person per day. Total daily flow---------�_310......................gallons.
WSeptic Tank—Liquid capacity/_FDD-_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 00() Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of.Test Pit---_................ Depth to ground water........................
1 ----------------------------------------------------------------------------------------------------.........................................................
0 Description of Soil........................................................................................................................................................... `--........
U ......................................................... ------••--------------------•-•-----------••---------••------••-•------------
W -
x -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------IV=................
NAt9re of Repairs or Alterations— nswer when a hcabl,� v L
.ff
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has een issued by the bo rd of he th.
— Signed -- ---------- ... .......... -. . -`---
te
Application Approved By . ......... . ... . ............................ ......... --
-------V
Application Disapproved for the following reasons: ------------------------ -----------------9
---------------------------- �e
/�........ .....Date
...........
Permit No. - . .... .. .......... Issued ''L.
-- � Date ... ...-...
No.. �..._.l FEB.............................. �,�, f
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratiun for Disposal Works Tonstrurtion rprmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ' an Individual Sewage Dispo al//
System at: '
................_37...... ............................ ..................................................................................................
Location-A dr ss or Lot No
........
111 L t 9 ... �-�-------------------------- -----------o�T .v���� yl/�
wner Ad s
asi. Cam.:..... :... �{7 �t. , 1 ??g�rS r1!¢H. .. � '
Installer Address
Type of Building Size Lot.................... .....Sq. feet
V
�-t Dwelling—No. of Bedrooms................. .......................Expansion Attic ( ) Garbage Grinder ( )
a'4 Other—T e of Building" No. of persons_......................... Showers
YP ------•--------------------- P ( )--- Cafeteria ( )
Otherfixtures -----------•------------- ------------•---------------•-••---••-----•----•-•-••---••-••--•............----•---•---. ------
W Design Flow............................................gallons per person per day. Total daily flow----------3.30......................gallons.
WSeptic Tank—Liquid capacity/-01DD-.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 (5c) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit..............-----. Depth to ground water........................
rZ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....................--.:
a -----------------------------------------------------------•---•--------............----•---•------.......-----------...........----•--....-----•------.••...
Descriptionof Soil ----•---------------•---•---------------------------------------------------------------------------••-•---�-•-•---
Wvwt ......
x ••-•-•-•-•-•-----------------•-•••-------------------------•---------•---..........•--•-•-------•-----•------•----------------•---------•..... --------------------------------------------------
U N�re of Repairs or Alterations—Answer when applicable--..... . 11)b-------QvA�.fk�:.-----.4�1.0 191�..�.....
11 ......... ` o �dl✓ '�OX-----------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual'Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has Keen issued by the board of he h.
Signed .. . . . .. .---. ------------------.- ..:_...GIN
- -
te
Alication A roved B ------------------------------------PP PP Y ....... .. - - - � ... ...../
Application Disapproved for the following reasons: .........°------------------------------------------------------------------------------- --------------------------------------
........... I....... ........ ... ..... -" .......................
....----- --. ---------------------- --------
Permit No. /✓{//Jy -r......- ... Issued -- .......ate
/ ---------------- Dace /
+ C
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
C rortifira#E of Tomplianre
THIS 0 CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by....................V.e�----------- -------------------------- ---------------........--------------.......------------------------------------------------
Installer
at ---------- --- ------ ----- 2-----------. 'PLC ---V------ 0.5..7 v/L��Z.--..... ------.--------------------------- ..........
been installed in accordance with the provisions of TITLE 5 o T e Sta E v ronmental Cod as escr' e i
the application for Disposal Works Construction Permit No- ----------- --�1 ---.�- dated ................. -� - --.
THE ISSUANCE H I I ATE HALL NOT BE ONST ED A A A A E THAT TH
OF IS CERTIFICATE F C S O S GU R
SYSTEM WILL FUNCTION SATISF CTO Y.
DATE /- . /J. 1--------------- Inspector -L% !!': �� -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�,. / TOWN OF BARNSTABLE
No........�........'(. FEE........................
1
Disposal Vor s Tn/nstr w� r
Yg rmit
Permission is hereby ranted-------------------- � C.7------...5 .f ... .....----••--•---------------......----------.................---•--.
to Construct ( ) or Repair ape�dividua�jSewage Disposal System
Street ell / I 1
as shown on the application for Disposal Works Construction Pe>mIt No.. .........,.;... Dated�....... -L......................
..............., ----------------------------- !�� �
Board of Health
DATE............... -�1�...... r•-------
FORM 36508 HOBBS B WARREN.INC.,PUBLISHERS
t