HomeMy WebLinkAbout0023 BEACH PLUM LANE - Health 23 BEACH PLUM LANE
OSTERVILLE
A= 166 -036
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No. 4210 1/3 BGR
ESSELT'E
10%
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Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
263 Starboard Lane
v Property Address i^ t
Thomas Casey -
Owner Owner's Name/
information is r, l
re uired for everyOsterville V Ma 02655 10-3-1$ y
q '
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 A. Inspector Information filling out forms
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
uy 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
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
Brett Hickey �^�� 10-3-18
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.ozio:mie.io.oa a"un
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.
t
t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 16
__ CI
c Commonwealth of Massachusetts
i1-10 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
263 Starboard Lane
v�
Property Address
Thomas Casey
Owner Owner's Name
information is Osterville Ma 02655 10-3-18
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) 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 cesspool and leach pit in series were dry and in working order at the time of inspection.
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. A
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):
J •
•
f
. t
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments
263 Starboard Lane
V
Property Address
Thomas Casey
Owner Owner's Name '
information is Ostervil►e Ma 02655 10-3-18
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.
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
v
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
v
263 Starboard Lane
Property Address
Thomas Casey
Owner Owner's Name
information is Osterville Ma 02655 10-3-18
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
❑ 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
❑ 0 Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ O 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
r'
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .
263 Starboard Lane
V�
Property Address
Thomas Casey
Owner Owner's Name
information is Osterville Ma 02655 10-3-18
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
❑ O Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ 0 Liquid depth in cesspool is less than 6"below invert or available volume is less
than '/z day flow
❑ ❑ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ 0 Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ 0 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.
❑ 0 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.]
a The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ a 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
❑ a 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 'r Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
a.
Commonwealth of Massachusetts
�m Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
263 Starboard Lane
L
Property Address
Thomas Casey
Owner Owner's Name
information is Cisterville Ma 02655 10-3-18
required for every
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 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
❑ El 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?
❑ ❑ Have large volumes of water been introduced to the system recently or as part of
this inspection?
El El available
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?
Q ❑ Was the site inspected for signs of break out?
El ❑ Were all system components, excluding the SAS, located on site?
E ❑ 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?
❑ O 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:
❑ 0 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
0 ❑ approximation of distance is unacceptable) [310 CMR 15.302(5)]
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
r
Commonwealth of Massachusetts
�- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
~ �f 263 Starboard Lane
u� Property Address
Thomas Casey
Owner Owner's Name
information is Osterville Ma 02655 10-3-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
No design plans - 4
Number of bedrooms(design): Number of bedrooms(actual):
NA.
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Description:
x
0
Number of current residents:
Does residence have a garbage grinder? ❑ Yes E] No
Does residence have a water treatment unit? ' [I Yes Q 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 R] No
Seasonal use? 0 Yes ❑ No
See below
Water meter readings, if available(last 2 years usage(gpd)):
Detail: -
"'2016-29,000gallons 2017-6,000gallons""
Sump pump? ❑ Yes ❑■ No
ry Sept-21
Last date of occupancy: Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
i
Commonwealth of Massachusetts
,P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
263 Starboard Lane
Property Address
Thomas Casey
Owner Owner's Name
information is Osterville Ma 02655 10-3-18
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:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Owner- last pumped over'4 years ago
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: x
a
t5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts '
+� Title 5 official Inspection Form
1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
263 Starboard Lane
u _
Property Address
Thomas Casey
Owner Owner's Name ,
information is Osterville Ma 02655 10-3-18
required for every
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
m r n if attachprevious ins inspection records if an❑ Shared system (yes o o) ( yes, ttac p y)
❑ 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:
0 Other(describe): s`
Cesspool and leach pit in series,
Approximate age of all components, date installed,(if known) and source of information:
Unknown due to lack of record A
Were sewage odors detected when arriving at the site? . ❑ Yes ❑■ No
5. Building Sewer(locate on site plan):
2161�:'
Depth below grade: E 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.):
`
t5insP.doc•rev.7/26/2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 9 of 18
•.a r t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
263 Starboard Lane `
u� Property Address
Thomas Casey
Owner Owners Name
information is Osterville Ma 02655 10-3-18
required for every
page. City/Town. State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
NA ,
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
M
t
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) _ ❑ Yes ❑ No
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):,
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
I
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments,
263 Starboard Lane ,
u� Property Address n .
Thomas Casey
Owner Owner's Name
information is required for every Osterville Ma 02655 10-3-18`
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
I
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 M 1
Date of last pumping: 'Date V
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):
NA
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
c Commonwealth of Massachusetts
1, Title 5 Official Inspection Form .
~ ii Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
263 Starboard Lane
Property Address
Thomas Casey
Owner Owner's Name
information is Osterville Ma 02655 10-3-18
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
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):
NA
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.):
t
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
.Title 5 Official Inspection Form
11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
263 Starboard Lane
V�
Property Address
Thomas Casey
Owner Owner's Name
information is Osterville Ma 02655 10-3-18
required for every
page. City/Town 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 0 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. (1) 6'X6'
El leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
i� Title 5 Official Inspection Form
�- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
263 Starboard Lane
Property Address '
Thomas Casey
Owner Owner's Name
information is Osterville Ma 02655 _ 10-3-18
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 leaching was in working order and was dry with no high staining at time of inspection.
12. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
' ^ 1 (in series with pit)
Number and configuration
dry
Depth—top of liquid to inlet invert
n o
Depth of solids layer
• " rr n
Depth of scum layer
Dimensions of cesspool
block
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.):
Cesspool was dry and in working condition at the time of inspection.
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
f
t
c Commonwealth of Massachusetts
�- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
263 Starboard Lane
v� Property Address
Thomas Casey
Owner Owner's Name
information is Osterville Ma 02655 10-3-18
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.):
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
Dis Disposal System Form -Not for Voluntary Assessments I� Subsurface Sewagep y ry .
263 Starboard Lane
u—
Property Address
Thomas Casey
Owner Owner's Name
information is Osterville Ma 02655 10-3-18
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
Asbuilt Ground water
\Y_ V
I
2,
Rear
Porch8'
6'x6'pit
A B
>12
A1.20'6" B1.23'
A2-3XV 82.47'
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
. r
Commonwealth of Massachusetts ,
Title 5 Official .Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
263 Starboard Lane
V
Property Address
Thomas Casey
Owner Owner's Name
information is Osterville Ma 02655 10-3-18
required for every
page. City/Town State Zip Code Date of Inspection ,
D. System Information (cont.)
15. Site Exam:
■❑ Check Slope
❑■ Surface water y
■❑ Check cellar
■❑ Shallow wells
>4 below SAS
Estimated depth to high ground water: 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
El 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:•
A hand hole was augured 4'below the dry cesspool and pit and no ground water was encountered
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7126/2018 Title 5 Ofhdal 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
263 Starboard Lane
Property Address ~
Thomas Casey
Owner Owner's Name
information is Osterville Ma 02655 10-3-18.
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:
❑� A. Inspector Information: Complete all fields in this section.
0■ B. Certification: Signed& Dated and 1, 2, 3, or 4 checked S;
X■ C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6(Checklist)completed
0■ 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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
r
r
t
x` Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
263 Starboard Lane
Property Address
Thomas Casey
Owner Owner's Name
information is required for every Osterville Ma 02655 10-3-18
page. Cityrrown 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
I
Asbuilt Ground water
2'
Rear
i
i
Porch 8'
--- - --= -- 6'x6'pit -. .-
i
>12
A1.20'6" B1.23'
OA2-33'6" 82-47'
i
I
' I
>41
t5insp.doc-rev.M6=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEIVED
FEB 2 12001
TOWN OF BARNSTABLE
TITLE 5 HEALTH DEPT.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 263 Starboard Lane
Osterville, MA
Owner's Name: Vincent Morton
Owner's Address:
Date of Inspection: February 14, 2001
Name of Inspector:(Please Print) James M. Ford
Company Name: James M. Ford _' ;k e
Mailing Address: P.O. Box 49
Osterville,MA 02655-0049
Telephone Number: (508)862-9400
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection: The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Co ditionally Passes
N Further Evaluation by the Local Approving Authority
Fai
Inspector's Signature: Date: February 15, 2001
The system inspector shall su a copy of this inspection report to the Approving Authority(Board of Health or,
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP: The original should be sent to the system owner and-copies sent to,the,buyer,if applicable,and the approving,
authority.
Notes"and COmll]"`entS
.J
"This report only describes conditions at the time of inspection and under the conditions of use at that
• time. This inspection does not address how the system will perform in the future under the same or different.
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
Page 2 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 263 Starboard Lane
Osterville. MA
Owner: 1 t Vincent Morton
Date of Inspection: February 14, 2001
- Inspection Summary: Check A,B,C,D or E/.ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303.or in.31:0-CMR.15.304,.exist—Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaire&-The system;upon completion of the replacement or repair,as approved-by the Board of Health,will pass.
Answer yes,no or not determined_(Y,N,ND)-iri the . for the following statements..-If"not determined",please
explain. ,
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level inthe dis
tribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
_.__. . _._._...___pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
y
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM
PART A
t.t' 1:�!" ° CERTIFICATION (continued)
Property Address: 263 Starboard Lane------- - = - -
-� t
Osterville. MA
Owner: Vincent Morton
Date of Inspection: February 14, 2001 t
C. Further Evaluation is Required by the Board of Health: '
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance-with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail.unless the Board of Health(and Public'Water Supplier,if any)determines:thit 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. r
The system has a septic tank and SAS and the'SAS is within a Zone 1 of a public water supply:
The system has a septic tank.and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
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Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 263 Starboard Lane
Osterville. AM k i
Owner: Vincent Morton - -
Date of Inspection: February 14 2001
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than 'V2 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`orprivy is within a:Zorie l'of a.public we1L;
_ ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. T -
_ ✓ Any portion of a cesspool or privy is less th`an,100'feet but greaterahan'50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP.certified laboratory,for coliform bacteria,and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A co of the analysis must be attached to this form.]
gg PY �
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System:
To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000
gpd-
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
a
Page 5 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM
a.. .{ PART B
CHECKLIST
263 Starboard Lane
Property Address:
Osterville, MA
Owner: Vincent Morton : ' ... .__ `. ;' ". -
Date of Inspection: February 14, 2001
Check if the following have been done: You must indicate`dies"or"no"as to each of the following:
Yes No i a
✓ Pumping information was provided by the owner,,occupant,,or Board of Health
✓ Were any of the system components pumped out in,the previous two weeks?
✓ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
n/a Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or-dwelling inspected,for,signs of sewage back up?
✓ _y 'Was the site-.inspected for'signs_ofbreak out
✓ Were all system components,excluding the SAS,located on site?'
✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
✓ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
✓ Existing information. For example,a plan at the Board of Health.
✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)].
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Page 6 of 11
- N
OF
FICIAL INSPECTION FORM T FOR VOLUNTARY ASSESSMENTS O
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
'SYSTEM INFORMATION '
Property Address: 263 Starboard Lane
Osterville, MA
Owner: Vincent Morton
Date of Inspection: February 14, 2001
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): n/a Number of bedrooms(actual): . 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: 0
Does residence have a garbage grinder(yes or no): Yes
Is laundry on a separate sewage system(yes or no): No .[if yes.separate inspection required]- , ;
Laundry system inspected(yes or no): No
Seasonal use(yes or no): Yes
Water meter readings,if available(last 2 years usage(gpd)): 2000-123,000 gals.; 1999-139,000 gals.
Sump Pump(yes or no): No
Last date of occupancy: Unknown
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR-15.203):—-.._ gpd_____..
..
Basis'of design flow(seats/persons/sgfft,etd.)'.
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available: TM
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:Pumped on July 7195-per treatment plant
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption system
Single cesspool
✓ Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records,if any) .
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner) _ . ,f • } , ;_
Tight Tank Attach a copy of the DEP approval
Other'(describe)'
Approximate age of all components;date installed(if known)and source of information:
Unknown
Were sewage odors detected when arriving at the site(yes or no): No
6
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Page 7 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
,SYSTEM:INFORMATION (continued)
Property Address: 263 Starboard Lane r s � c} ' ,;, ;" •�:,;, ,.
Osterville. MA
Owner: Vincent Morton
Date of Inspection: February 14, 2001 w
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):
Distance from private water supply well or suctiori line: r
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: None (locate on site plan) ,
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attache a copy of
certificate)
Dimensions:
Sludge depth: '. `� 4 r'
Distance from top of sludge to bottom of outlet tee or baffle: ;> A
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: concrete metal _fiberglass. _polyethylene =other
(explain):
Dimensions:
Scum thickness:
k,.Distance.from top of scum,to.top,of outlet tee or baffle: r:,,;c, ,�,x t
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping: r..,
Comments(on pumping recommendations,inlet and outlet tee or baffle condrhon,structural integrity,liquid-levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
'SY-STEM!INFORMATION (continued)
Property Address: 263 Starboard Lane
Osterville. MA
Owner: Vincent Morton
Date of Inspection: February 14, 2001
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material.of construction: concrete metal _fiberglass _polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
-DLSTRIBUTION'BOX::'-'''None-(if present must:be-opened).e(locate on site.plan), ,, r ti
,,3.
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
.... '•,L.._. _. ., 'tit" .. •:'� _ +;. ,,.r' .. _ ._.. ... .,. ... • - ' .r.` _,. ,.. . .ss`: , �..`.f..,rl s
8
Page 9 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
P".SYSTEM'INFORMATION (continued)'
Property Address: 263 Starboard Lane 't.'_ r: `�`� .r; ;,.. ,-;�•p, .:u
Osterville, MA
Owner: Vincent Morton
Date of Inspection: February 14, 2001
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 1 -6'x 6'
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number.
_-•-- -- -- Innovative/alternative-system._..,Type/name of technology
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.):
The pit was dry The scum line ivas'P up from the'bottom..There were no signs of failure.-The bottom�to grade was
approximately 9' The cover was 30"below grade. Recommend installing risers to bring cover within 6'ofgrade.
CESSPOOLS: ✓ (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: I with overflow
Depth-top of liquid to inlet invert: --
Depth of solids layer: 12"
Depth of scum layer: --
Dimensions of cesspool: 6'W x 6'T x 8'6"bottom to grade
Materials of construction: Block
Indication of groundwater inflow(yes or no): No
Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
The cesspool was dry. The outlet tee was present. The cover was 24"below grade. Recommend installing risers to bring cover
within 6"ofgrade
PRIVY: None (locate on site plan)
Materials of construction:
Dimensions: '
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
9
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Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
_ ' PART C
J`SYSTEM INFORMATION(continued)
Property Address: 263 Starboard Lane
Osterville, M4
Owner: Vincent Morton _
Date of Inspection: February 14, 2001
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
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Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
.SYSTEM,INFORMATIQN(continued)
Property Address: 263 Starboard Lane.. _ °At5� lsyw,t r __ , .;;, '►t,s,� •,I
Osterville. MA
Owner: Vincent Morton
Date of Inspection: February 14, 2001
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
✓ Accessed USGS database-explain: topographic and water contours maps
"
s
You must describe how you established the high ground water elevation:
The bottom ofthe pit to grade was approximately 9' Using the Barnstable topographic map and the Cape Cod Commission water
contours map the maps were showing approximately 40'+/-to groundwater at this site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a
warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees,
either expressed,written or implied, relating to the system, the inspection andlor this report.
11
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property &0 S_�PAIOAzn L(:Nr.e RECEIVED
owner' s name RECEIVED
Date of Inspection �J�7 ,�1�lCis JUL 1 8 1995
PART A HEALTH DEPT.
CHECKLIST TOVM OF BARNSTABLE
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of
Health.
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.
As built plans have been obtained and examined. Note if they are not
available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
The site was inspected for signs of breakout.
All system components, excluding the SAS, have been located on the
site.
CV_upocl,
J/ The septle 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.
_ 7 The size and location of the SAS on the site has been determined 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 SSDS.
tr ,
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
number,-,of.
Y nunumber,-,of. bedroomss" i
.j_ number_-.of currentl`"residents
_YES garbage grinder, yes or no
`tS laundry connected to system, yes or no
'YES seasonal use, yes or no
If nonresidential, calculated flow:
Water meter readings, if available:
a 7 y
I- ciq 'f Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
0'nct
yes System pumped as part of inspection, yes or no
if yes, volume pumped -yDC'4A
Reason for pumping:
�5 A</' Zns/Jc-C77C-j
Type of system
Septic tank/distribution bQx/soil absorption system
,/Single cesspool /icy%�S A,
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection
records, if any) n
Other (explain)_ U)ycr'T!oL�7
Approximate age of all components. Date installed, if known. Source of
information:
�S
C2�G���a � ('eSS,PGc��— IGCr�
1q(Zc`
hoc Sewage odors detected when arriving at the site, yes or no
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK:
(locate on site plan)
depth below grade: fi
material of construction: -concrete metal FRP other(explain)
dimensions:
sludge depth
_S, distance from top of sludge to bottom of outlet tee or baffle
,r scum thickness
?B„ distance from top of scum to top of outlet tee or baffle
distance from bottom of scum to bottom of outlet tee or baffle
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet invert, structural integrity,
' evidence of leakage, recommendations for repairs, etc. )
(�) ou fc D i n 0loj c ic, p2k. ,o yC/:
,-hot
DISTRIBUTION BOX:��/L
(locate on site plan)
depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc. )
PUMP CHAMBER:
(locate on site plan)
pumps in working order, yes or no
Comments: \
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs, etc. )
r
10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) :
(locate on site plan, if possible; excavation not required, but may be
approximated by non-intrusive methods)
If not determined to be present, explain:
Type
leaching pits and number �t'ec•��I p"
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool , number
Comments:
(note condition of soil , signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs, etc. )
l /v0 T F C.y �r��c% �kJ J,l �3 �r'� A T 7/YI d i/1 i!I C%i n
CESSPOOLS (locate on site plan) 45
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 (cesspool must be pumped as
part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs, 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, recommendations for maintenance or repairs, etc. )
11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 '
GArA e- 13Ack
A
e \\ Q, L
- PST
-g opt. �
r
DEPTH TO GROUNDWATER
jo� _ depth to groundwater
method of determination or approximation:
y S, Ge0 O,�CCA� V2UeY
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12 '
SUBSURFACE SEWAGE DISPOSAL C SYSTEM INSPECTION FORM
P
FAILURE CRITERIA
N or ND) Describe basis of
Indicate yes, no, or not determined (Y, . why not)
determination in all instances . If "not determined' ,
explain
_ Backup of sewage into facility?
Discharge or p
onding of effluent to the surface of the ground or
surface waters?
N Static liquid level in the distribution box above outlet invert?
Liquid depth in cesspool <61, below invert or available volume< 1/2 day
flow?
Required pumping in 4 times or more in the last year?
_ 9
number of times pumped
Septic tank is metal? cracatanklly ufailure imminent?substantial
infiltration? substantial exfiltration?
Is any portion of the SAS , cesspool or privy:
below the high groundwater elevation?
,A// _ within 50 feet of a surface water?
)/ within 100 feet of a surface water supply or tributary to a surface
water supply?
_/_ within a Zone I of a public well?
within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the ) •
within 50
feet of a private water supply well?
from a
private water
less than 100 feet but greater than 5.0 feet f P
/y le f the well
1 sis. I
ter alit analysis?1 well with no acceptable water quality supply of well water analyse
has been analyzed to be acceptable, attach copy
for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
I
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13
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspector
BRUCE MACALLISTER
Company Name SHORELINE CONSTRUCTION
Company Address 67 FOND STREET
OSTERVILLE; MA 02655
Certification 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
manitenance of on-site sewage disposal systems.
je,* one:
I have 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.
I have determined that the system fails to protect public health and
the environment as defined in 310 CMR 15 . 303 . The basis for this
determination is provided in the FAILURE CRITERIA section of this
form. ✓/ 0o
Inspector ' s Signature .�'2r�cc % C,
Date Jo�j Sj 1ctRs
Original to system owner
Copies to:
Buyer ( if applicable)
Approving authority