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Commonwealth of Massachusetts
Title 5 Official Inspection Form
1' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
64 Beach Plum Lane F
Property Address
Garrett&Jane Douglas
Owner Owner's Name t 4
information is J,
required for every Osterville Ma 02655 February 26, 2021
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered inany
way. Please see completeness checklist at the end of the form.
Important:out forms
A. Inspector Information
filling out forms
on the computer,
use only the tab Thomas Roux
Key to move your Name of Inspector
cursor-do not
use the return Company Name
key. 89 Mayflower Lane
Co
Company Address
East Wareham Ma. 02538
City/Town State Zip Code
774-678-9066 S14531
Telephone Number License Number
B. Certification
I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000);I have personally inspected the sewage disposal system at theproperty 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
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
c Commonwealth of Massachusetts
Title 5 Official Inspection. Form
1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
64 Beach Plum Lane
Property Address
Garrett&Jane Douglas
Owner Owner's Name
information is required for every Osterville Ma. 02655 February 26, 2021
page. Cityrrown 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:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
❑ One or more system components as described in the"ConditionalPass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not`determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑N ❑ ND (Explain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
64 Beach Plum Lane
Property Address
Garrett&Jane Douglas
Owner Owner's Name
information is Osterville Ma. 02655 February 26, 2021
required for every
page. CitylTown State Zip Code Date of Inspection
.C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑Y. ❑N ❑ ND (Explain below):
❑ obstruction is removed ❑Y ' ❑N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR-
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26120 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
r Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _
I
64 Beach Plum Lane
Property Address
Garrett&Jane Douglas.
Owner Owner's Name
information is required for every Osterville Ma. 02655 February 26, 2021
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
[]The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory;for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
El ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-,Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
64 Beach Plum Lane
Property Address ,
Garrett&Jane Douglas
Owner Owner's Name
information is required for every Osterville Ma. 02655 February 26, 2021
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
i
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems:To be considered a large system the system must serve a facility with a design
flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'ate
64 Beach Plum Lane
Property Address
Garrett&Jane Douglas
Owner Owner's Name
information is Osterville Ma. 02655 February 26, 2021
required for every
-page. Cityrrown 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
® ❑ 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?
f
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,.
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Wasthe facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
El ID approximation
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
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
64 Beach Plum Lane
Property Address
Garrett&Jane Douglas
Owner Owner's Name
information is required for every Osterville Ma. 02655 February 26, 2021
page. Cityrrown State Zip Code Date of-Inspection
®.System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 5 Number of bedrooms (actual): 5
DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): +550 gpd
Description:
i
Number of current residents:
3
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
�' F Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
64 Beach Plum Lane
Property Address
Garrett&Jane Douglas
Owner Owner's Name
information is required for every Osterville Ma. 02655 February 26, 2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
I
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: owner
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: Yes
gallons
How was quantity pumped determined? Gauge on the truck
Reason for pumping: Outlet concrete baffle replaced with new PVC tee.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
64 Beach Plum Lane
Property Address
Garrett&Jane Douglas
Owner Owner's Name
information is required for every Osterville Ma. 02655 February 26, 2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
❑ Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of.latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
® Other(describe):
Septic tank and 2 pits in series. }
Approximate age of all components, date installed (if known) and source of information:
septic tank and first pit installed in 1983. New pit added in 1993..
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 2.3
g feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
+10'
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
64 Beach Plum Lane
Property Address
Garrett&Jane Douglas
Owner Owner's Name
information is
required for every
Osterville Ma. 02655 February 26, 2021
page. Cityrrown State Zip Code Date of Inspection
'i D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 1.3'
p g feet
-Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 8'L x 55W x 5.67'H
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
31"
Scum thickness
611
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
16"
How were dimensions determined? measured
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
64 Beach Plum Lane
Property Address
Garrett&Jane Douglas
Owner Owner's Name
information is ryille Ma. 02655 February 26 2021
required for every
Oste rY ,
-page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
i
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle ,
Date of last pumping: Date
Comments(on.pum_ping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
El 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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1, 64 Beach Plum Lane
Property Address
Garrett&Jane Douglas
Owner Owner's Name
information is required for every Osterville Ma. 02655 February 26, 2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
r
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):
Depth of liquid level above outlet invert N/A
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
There was no D-Box found.
�l
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
w Yf 64 Beach Plum Lane
Property Address
Garrett&Jane Douglas ✓
Owner Owner's Name
information is required for every Osterville Ma 02655 February 26, 2021
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 ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Both pits were found and dug up. The first pit was full of water. The second pit was completely
dessicated.
Type:
® leaching pits number: 2
❑ 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
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
+' Subsurface Sewage Disposal System form -Not for Voluntary Assessments
64 Beach Plum Lane
Property Address
Garrett&Jane Douglas
Owner Owner's Name
information is required for every Osterville Ma. 02655 February 26, 2021
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.):
Both pits were found and dug up. The first pit was full of water. The second pit was completely
dessicated.
12. Cesspools (cesspool must be pumped as part of inspection.) (locate on site_plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
-Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
64 Beach Plum Lane
Property Address
Garrett&Jane Douglas
Owner Owner's Name
information is required for every Osterville Ma. 02655 February 26, 2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
�m Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
64 Beach Plum Lane
Property Address
Garrett&Jane Douglas
Owner Owner's Name
information is Osterville Ma. 02655 February 26, 2021
required for every
page.e. 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
- 16A.
ox G.CU��'
• r \
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
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Commonwealth of Massachusetts
kTitle 5 Official Inspection Form
twl
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
64 Beach Plum Lane
Property Address `
Garrett&Jane Douglas
Owner Owner's Name
information is required for every Osterville Ma 02655 February 26, 2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: +10'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Site is elevated. A soil evaluation would have to be done to establish the exact water table elevation.
r"
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
li
k �
Commonwealth of Massachusetts
�s Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
64 Beach Plum Lane
Property Address
Garrett&Jane Douglas
Owner Owner's Name
information is Osterville Ma. 02655 February 26, 2021
required for every ry
-page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached '
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
Commonwealth of Massachusetts �(p(�,69g-6N
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
64 BEACHPLUM LN T
Property Address
DOUGLAS `r
Owner Owner's Name
information is
required for OSTERVILLE MA 9-10-16
every page. City/Town State Zip Code Date of Inspection
i
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: A. General Information
When filling out _ S'-# '.1(��
forms on the 6 0
computer,use 1. Inspector:
only the tab key
to move your DOUGLAS A BROWN
cursor-do not Name of Inspector
use the return
k►ey. D.A.BROWN INC
"�—`I Company Name
P.O. BOX 145
Company Address
CENTERVILLE MA 02632
City/Town State Zip Code
508-4204534 S14297
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
9-10-16
Inspe or'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 is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M s 64 BEACHPLUM LN
Property Address
DOUGLAS
Owner Owner's Name
information is required for OSTERVILLE MA 9-10-16
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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:
AT TIME OF INSPECTION SYSTEM MET ALL MINIMUM PASSING REQUIREMENTS. THIS
REPORT DOES NOT PREDICT THE FUTURE PERFORMANCE UNDER THE SAME OR
INCREASED USE. SEE ATTACHED DOCUMENTATION FOR BEDROOM COUNT APPROVAL OF
5 BEDROOMS.
13) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
r
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4M ` 64 BEACHPLUM LN
Property Address ,
DOUGLAS
Owner Owner's Name
information is required for OSTERVILLE MA 9-10-16
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
I
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
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 64 BEACHPLUM LN
Property Address
DOUGLAS
Owner Owner's Name
information is required for OSTERVILLE MA 9-10-16
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has aseptic tank and SAS and the SAS is within 50 feet of a private water
supply well
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°wM s 64 BEACHPLUM LN
Property Address
DOUGLAS
Owner Owner's Name
information is required for OSTERVILLE MA 9-10-16
every page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system.fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
El ❑ 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.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
GSM , 64 BEACHPLUM LN
Property Address
DOUGLAS
Owner Owner's Name
information is required for OSTERVILLE MA 9-10-16
every page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
❑ ® Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 5 Number of bedrooms(actual): 5
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
wM 64 BEACHPLUM LN
Property Address
DOUGLAS
Owner Owner's Name
information is required for OSTERVILLE MA 9-10-16
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
ACCORDING TO AS-BUILT CARD SYSTEM CONSISTS OF A 1000 GALLON SEPTIC TANK, D-
BOX , AND 2 LEACH PITS
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ❑ No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
2014--------------------------383 2015-----------------------402 GPD SYSTEM NOT DESIGNED FOR
GARBAGE DISPOSAL
Sump pump? ❑ Yes ❑ No
Last date of occupancy: CURRENTLY
OCCUPIED
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
e Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
wM , 64 BEACHPLUM LN
Property Address
DOUGLAS
Owner Owner's Name
information is required for OSTERVILLE MA 9-10-16
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: CURRENTLY OCCUPIED
Date
Other(describe below):
I
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool ,
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 64 BEACHPLUM LN
Property Address
!DOUGLAS
Owner Owner's Name
information is required for OSTERVILLE MA 9-10-16
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
1993 PER AS-BUILT CARD
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron ❑ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000 GALLON PER AS-BUILT
Sludge depth: LIGHT TO MODERATE
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 64 BEACHPLUM LN
Property Address
DOUGLAS
Owner Owners Name
information is required for OSTERVILLE MA 9-10-16
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness -LIGHT
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? WOODEN POLE
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
IF TANK HAS NOT BEEN PUMPED IN THE LAST 3 YRS I RECOMMEND PUMPING NOW AND
EVERY 2-3 YRS FOR MAINTENANCE.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
n rete metal fiberglasspolyethylene other(explain):
co c
❑ ❑ ❑ ❑ ❑
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments
„ 64 BEACHPLUM LN
Property Address
DOUGLAS
Owner Owner's Name
information is required for OSTERVILLE MA 9-lb-16
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
.Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ 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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
<a 64 BEACHPLUM LN
Property Address
DOUGLAS
Owner Owners Name
information is required for OSTERVILLE MA 9-10-16
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0ff
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.):
BOX SHOWED NO SIGNS OF FAILURE OR SOLID CARRY OVER. BOX LOOKED TYPICAL FOR
ITS AGE.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
w W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
GM , 64 BEACHPLUM LN
Property Address
DOUGLAS
Owner Owner's Name
information is required for OSTERVILLE MA 9-10-16
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number. 2
❑ 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 NEWEST PIT ACCORDING TO THE AS-BUILT CARD WAS OPENED AND FOUND TO HAVE
ONLY 6 INCHES OF LIQUID WITH NO CLEAR STAINING OR INDICATIONS OF FAILURE AT
TIME OF INSPECTION.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection. Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM '� 64 BEACHPLUM LN
Property Address
DOUGLAS
Owner Owner's Name
information is required for OSTERVILLE MA 9-10-16
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
64 BEACHPLUM LN
Property Address
DOUGLAS
Owner Owner's Name
information is required for OSTERVILLE MA 9-10-16
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
. t
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M '< 64 BEACHPLUM LN
Property Address
DOUGLAS
Owner Owner's Name
information is required for OSTERVILLE MA 9-10-16
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: GREATER THAN 5 FROM BOTT OF
S.A.S
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
PROPERTY ELEVATION IS VERY HIGH
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 64 BEACHPLUM LN
Property Address
DOUGLAS
Owner Owner's Name
information is required for OSTERVILLE MA 9-10-16
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
'Engineering Dept.(3rd floor) Map /L G Parcel Permit# .
House# Date Issued
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First Floor r91000 square feet 'Second Floor'. square feet
Construction Type
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Zoning District Flood Plain - Water Protection
Lot Size a_C5'<�S Grandfathered ❑Yes ❑No
Dwelling Type: Single Family Two Family p Multi-Family(#units)
Age of Existing Structure_ S _ His House byes 'UNo On Old King's Highway ❑Yes _No
Basement Type: Full ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) GC)c '
Number of Baths: Full: Existing New Half: Existing�_ New
No.of Bedrooms: Existing New
Total Room Count(not including baths):Existing New First Floor Room Count 7' j
Heat Type and Fuel: ❑Gas XOil ❑Electric ❑Other \
Central Air ❑Yes ( No Fireplaces:Existing �i New .Existing wood/coal stove ❑Yes too
Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size)
Attached(size) v ❑Barn(size)
❑None ❑Shed(size)
❑Other(size)
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes )0o If yes,site plan review#
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Current Use Proposed Use
Builder Information
i
Name Telephone Number
Address License#
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Home Improvement Contractor#'
Worker's Compensation#
NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS '
PROPOSED STRUCTURES ON THE LOT.
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE �/al y �14 /L. DATE
BUILDING PER✓1T DENIED F THE FOLLOWING REASON(S)
AsBuilt Page 1 of 2
' TOWN OF BARNSTABLE
LOCATION .6q ���rw/Yit SEWAGE # 9943.2
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INSTALLER'S NAME PHONE NO. G
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NO. OF BEDROOMS PRIVATE WELL OR BLI WATER
BUILDER OR OWNER ,u�n
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:_
VARIANCE GRANTED: Yes o
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First Floor— square feet" Second Floor square feet
Construction Type
Estimated Project Cost S SAL ,oD
Zoning District Flood Plain Water Protection
Lot Size as_S'<S Grandfathered. ❑Yes Q No
Dwelling Type: Single Family '12�, Two Family Q Multi-Family(#,units).. "
Age of Existing Structure 1"21 Historic House ❑Yes '�j(N,o On:Old Kings,Highway ❑Yes �No.
Basement Type: Full Q Crawl Q Walkout. .Q Other
Basement Finished Area'(sq.ft.) 'Basement Unfinished Area(sq.ft)
Number of Baths: Full: Existing New Half:. Existing�_ New
Bedrooms:No.of Total Room Count,notsting New
_
( including baths):Existing New Firsf:Fldor Room Count l
Heat Type and Fuel:, Q Gas XOil Q Electric O Other
Central Air Q Yes. No. Fireplaces:Existing' is New:, Existing wood/coal stove. Q Yes
Garage: Q Detached(size) Other Detached Structures: ❑Pool(size)
Q Barn size . x
Attached(size) - ( )
4
❑None ❑Shed(size).
Y Q Other{sire)
Zoning Board of Appeals Authorization p, Appeal#. Recorded
Commercial Q Yes )'No• If yes,site plan"review# _
r i
Current Use '' Proposed Use,
Builder,Informatiun
Name Telephone Number,
Address License#'
Home Improvement Contractor*
Wo"rker's.Compensation
NEW CONSTRUCTION OR ADDITIONS REQUIRE A'SITE PLAN(AS BUILT)SHOWING EXISTING,,AS WELL AS
PROPOSED!STRUCTURES ON THE.LOT.
ALL CONSTRUCTION DEBRIS,RESULTWG`FROM THIS PROJECT WILL BE TAKENTO r
e ,
r �^SIGNATURE CZ� 9.2 DATE -
BUILDING PERMIT DENIED F THE"FOLLOWING REASON(S)
AsBuilt Page 1 of 2
TOWN OF BARNSTABLE
LOCATION yr-_SEWAGE # 91943.1
VILLAGE (66-
ASSESSOR'S MAP 6 LOT
INSTALLER'S NAME 6 PHONE NO. L 3 -340.5.
foy
i SEPTIC TANK CAPACITY /o0 ,(J
LEACHING FACILITY:(tgpe) 1� (size) I t7Cn +
NO. OF BEDROOMS PRIVATE WELL OR . BLI WATER
BUILDER OR OWNER -¢, y , 4
DATE PERMIT ISSUED: 93
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes Na )
i
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I7' 31,
S9
u
New Pit
http://issgl2/intranet/propdata/prebuilt.aspx?mappar=166018001&seq=1 8/2/2016
TOWN OF BARNSTABLE
LOCATION SEWAGE #
VILLAGE Q ASSESSOR'S MAP Sk LOTr
INSTALLER'S NAME & PHONE NO. G f , ,3 '
SEPTIC TANK CAPACITY cied , / 000 ,J
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PRIVATE WELL OR ?tBLIg2WATER
BUILDER OR OWNER c ..-r
DATE PERMIT ISSUED: 93 r
DATE COMPLIANCE ISSUED
VARIANCE GRANTED: Yes �Io
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L..�-......—J E COMMONWEALTH OF MASSACHUSETTS
�/, _5 OARD OF HEALTH
�� WN OF BARNSTABLE
Appliration for Diinpn!tt1 Hlnrkii Tomitrnrtiun Vami#
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
--------------------------------------------------------------------------------------------------
..... _ �-----------
Location- dress or Lot No.
-� ...............................
-----------------
l5
W rCSS
tistaller Address
T f Building Size Lot............................Sq. feet
�. Dwelling—No. of Bedrooms.-..........................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons.....................--..... Showers ( ) — Cafeteria ( )
dOther fixtures -------------------------------------------------••----------------------....-----............---.............-•---------------------•--'--------•---
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity..........--gallons Length---------------- Width..........------ Diameter...--------.---- Depth................
x Disposal Trench—No. .................... Width.................... Total Length.......--........... Total leaching area....................sq. ft.
Seepage Pit No...................... Diameter.....--............. Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
o a Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I----------------minutes per inch Depth of Test Pit.........----------- Depth to ground water........................
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ---•-----------•-----•--------------------------•-------•------------••---------------.....---------'--•----------------................------------------.
0 Description of Soil........................................................................................................................................................................
x
U
UW ---------•-••---- ---------------------------------------------••--•---•--....----------•-.---•---- ------ .................... ------ - -
Nature of Repairs or Alterations=Answer when applicable.----- . .. .....�dQa.. ....! ......
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environme al Code—The undersigned further agrees not to place the
system in operation until a Certifica;ofmplia e a en issu by the board of health.
.... ;�.. �� .�... .-- .............:......... --- .............. -
qApplication Approved By --------- -------- --.-�-... •................................ .. .................... ..G(..- -'-. 73
Dare
Application Disapproved for the following reasons- -----------------------------------------------------------------------------------------------------------------------------------
... ... . . .... .............................. .... ............................................................................................ ..........:. ........................................
Permit No. ....... .. ..-. , ....2....................... Issued .................................................. Date ....
Dare
THE COMMONWEALTH OF MASSACHUSE17S
BOARD OF HEALTH
TOWN OF BARNSTABLE
Tertifirate of Contylianre
THIS IS,70 CEgIFY Tha the ln&vidual Sewage Disposal System constructed or Repaired
by ------------- ...... --------------7, ---------------------------------- --- ---------------------------------------
--- - ----------------
at ------------- ------------------------ -- ---------- -----------------------------------------------------------------------------------------------------------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ---- 46-3,p--------- dated --------------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY!
DATE------//-.--- ----—----��3.................................................... Inspector -------------------------------------------------------------------------------------------------
--- ----------------------------------- ------------7-------------------- ---
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
FEE........................
Uispasq Workii Tomitrudion '"amit
V
Permission is hereby granted.......... ....................................................................................
to Construct or Repair (6 an Individual
ivi ua SeAa e Disposal System
..
at No.... .................................................................................------- ---
..........................
Street
as shown on the application for Disposal Works Construction Permit Noa:v13Q-.- Dated--- .........
lzl—))... ...................................................
..................6........11.1 . ........
Board of Health
DATE.............. ---------------------------------
FORM 38808 HOODS 6 WARREN,INC..PUBLISHERS
- 2-
THE COMMONWEALTH OF MASSACHUSETTS V
ABOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratinit for Biti-pw3al Hforks Towitxnr#inn Permit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
1,4.
System at: ......... • ••-••--• -•--
e/Le'tLocation:Address or Lot No.
...:.................. .......�. / f�/J��7/C /i,=_-
...............................
Owner Ad Tess
ffliistaller Address'"
Type-A& Building / Size Lot............................Sq. feet
UDwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder-( )
aOther—Type
of Building ---------------------------- No. of persons--------------.------------- Showers ( ) — Cafeteria ( )
dOther fixtures --------------------------------------------------------------------------------------......------------....------------------------.............
W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons.
W Septic Tank—Liquid capacity............gallons Length---------------- Width................ Diameter....------------ Depth................
x Disposal Trench—No. .................... Width.................... Total Length..................... Total leaching area....................sq. ft.
3 Seepage Pit No..................... Diameter-------------....... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by------- -----------------•---••-...----------•--•------••----------------- Date........................................
,.a 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........................
04 -------------------------------•-•----------------------•-••---•-------•------••-••---------.....•-•........................................................
0 Description of Soil.........................................................................................................................................................................
x
U ---------•--------------•-•-----------•-••--------------------------------------------.......----------------------------------------------------------•---------------•------------•-•---------•....--
UW ---------------------------------------------------------------------------------------------------- --------- ----------------
Nature of Repairs or Alterations—Answer when applicable.--------- 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 Complian ,as been issued by the board of health.
Signe `�, ��
----- - -. ............. .......................-----...................------- ----------------------------------------
Date
---------------
ApplicationApproved By .......................... ... . . ?..�G...n . -'-------------------.:.....-.-.._--------------------------------- �`... - --
. , . ..— Dace
Application Disapproved for the following reasons: ........................
--------------- -- ---------------- ---------------------------------------- ---------------------------------------------- ------------------------------- -------------------------------------- ----------------------------------------
� Dace
- Issued Permit No. ------ .... ................... ...................................................... -
Date
SEWAGE PERMIT NO.
L O C T ION,e�±. /f, f-1
VILLAGE
ar Y tit
INSTALLER' NAME i ADDRESS
R U I L 0 E R OR OWNER a
DA T E PERMIT ISSUED _
DAT E COMPLIANCE ISSUED ���
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NO. 2,...-1®.Z. Fes$...... ........
..........
THE COMMONWEALTH OF MASSACHUSETTS
BC)AFM-95 HEAL
'6?4Vj!/............OF....... ...�wl/]Z .7!...:..........................................
Appliration for Biipo5al Works Tonitrurtion Frrutit
Application is her made for a Permit to Construct ( - or Repair ( ) an Individual Sewage Disposal
System at• �.
G� ................ .....-1�//.�.........�!�:..... ...../..:�%.�.�...vzz�( ------.... -
Loca'on A�ddss or Lot _............. �C � —�.. ,! y.0.l.. .......... ......------•-1 . .: ..�! = �••... . ...............
O ey c
Installer Address
dType of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
PaOthe fixtures -----------------------------------•------..... _�......----........._..
Design Flow......: ................................ allons er erson er da Total dail flow.............
W gg P P P Y• Y -...--•----.................gallons.
WSeptic Tank—Liq'uid capacity/ allons Length................ Width................ Diameter..--............ Depth................
Disposal Trench—No. .................... Width_ _................ Total Length.................... Total leaching area....................sq. ft.
x Seepage Pit No......../........ Diameter.....i,....... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
PercolationTest Results Performed bY.......................................................................... Date........................................
aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.......---...........--.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.....................---
----•-----------------------------------••---------•--............................-•--•••--.....---•........................................................
0 Description of Soil........................................................................................................................................................................
x
U ------------------------•-----....-•--•-.....--••--....----------......----...........•..........-•-•--....----.............----•--•-----•-•-•--•-------••---•---•--•-----------•--•••-.........-----•--
W --------------- - ----------------•------------•------------------ •------------------•----........---••-----••---------...---------.........--•------•----•-----------------------•---•-•••---•-•-----
VNature of Repairs or Alterations—Answer when applicable...............................................................................................
----"-----------------------•--------------•--...--•-----...------------------------.....-----..................--•--•---.....--------•---.........------------------------------.................:-----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TL ITIS 5 of the State-Sa de— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been is ed y tfie �ai�o h.
IT. ..................1.
-
A lication Approved B .
Date
Application Disapproved f r t oBowing reasons--------------------•---...................--•---------••----••------------------•------------•---.._...--••-•••.
..--------•---•........................•--•-•--------------.....---..........----•---..................-----•---------......---------------------------------------------•---•-.....-------•----•---•---
Date
PermitNo......................................................... Issued.......................................................
Date
—0�?• Fx$..............................
' THE COMMONWEALTH OF MASSACHUSETTS
BOLA-RCS H EALTte"
Xpli iration for Uigpnsal Workii Tomitrur#inn Urrmit
Application is h made for a Permit to Construct (r or Repair ( ) an Individual Sewage Disposal
y :
r
�- _
Loca—one Add ss or Lot
Installer Address
d Type of Building 2 Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
P" Other. fixtures -----------------------------------------•---- --R-
W Design Flow....... gallons per person per day. Total daily flow............ .................gallons.
WSeptic Tank-Liquid capacity/C?*allons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width_ .. ....... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No........./......... Diameter------ Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ••-••••----•--•---------••..................•-•--•-•.......------------....................•••--......•--.........•-----•-----...----
0 Description of Soil.................................................................................................. ....................................................................
W ......
V Nature of Repairs or Alterations—Answer when applicable................................................................................................
--------•---------•---------•------•-------•--------------------------------------------------•--•------•-••-----------------------------------•--------------------------------------.........---:.....
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLL 5 of the SxEe 5 de— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been is ecl-Fiy tEe�ard'of`hM th.
D e.
Application Approved BY - lr = mil;---��f._1?.........
Date
Application Disapproved f r hollowing reasons:.............................................................
.........•--•••--••--•••--••------•••...............•---•-•--•-•-•---•------•••-•--•---•--••--••••--••------••-•-•-•--•-•••---•------•---------••----•-•---•--•----••.....-•--•--------•-•---•-......---
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
�,..
.t r . ARD HEALTH
.0............. lo.s a r...................
(Irdifiratr of Toutpliatta
S IS CERTIFY, That the Individual Sewage Disposal System constructed (414,
or Repairedby ( )
.. •---•--•-••-----------------•-•------•---•................•............
"� 1 .........
Installer
at... . �. ..... ✓
= -
has been installed in accordance with the provisions of T�T� 5 of T•� State Sanitary Co e a , e'scribed in the
application for Disposal Works Construction Permit No..�"._'...._� . .. .............. dated_!��__-1 ._ ___...... ..............
THE ISSUANCE F THIS CERTIFICATE SHALL NOT BE CONST U AS A GUARANTEE THAT THE
SYSTEM 1All //FU CTION SATISFACTORY.
DATE......ZS .................................................... Inspector-- ...............................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
{ ........................OF..............••.•..•.............................................:...................
No.......................... FE
Diovosal rko �ono#rnr ion rrntit
Permission is hereby granted G��- . 9&....
to Construct ( or r (./) an Irtdividual �ag posal System
atNo. :: = `t J ;c .:........................ --------------------•-------•---------------••----
Street
as shown on the application for Disposal Works Construction Permit Noe. "_ ... '..'f`. .....................
DATE....3 Z f �/ of Health
FORM 1255 A. M. SULKIN, INC., BOSTON
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