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Home My WebLink About0036 BONNIE BRIAR DRIVE - Health 36 Bonnie Briar Drive, Osterville I A Pt j x I /Y/P Commonwealth of Massachusetts Title 5 Official Inspection) Form Subsurface Sewage Disposal S stem Fc,rm - Not for V'o!untary Assessments Property Address �- �� iles -rev- Ow ner Owner's Name / J7 information Is S�2✓V!<l ✓✓ /�� 0°Z 6SJ� /j required for every page. City/Town State Zip Code Date df 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. Importatforms When fling out f A. General Information on the computer, use only the tab 1. Inspector., key to move your �/ cursor-do not //� Cti Y h' / U 1�e-Ili use the return tame of Inspects key ,L.. rt/VI Company Name /�10 Company Address atyfrown / �O_?�q State Zip Code C o� o� Telephone Number License Number' B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems, I am a DEP approved system Inspector pursuant to Section 15.340 of Title 5(310 qWR 16.000). The system: 91"Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspect is 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 gpo 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. tSns-3h3 Tibe 50rfidai InspeCbonF=subsuiace sewage cisposat System-Page 1 of 17 �O - US y� Commonwealth of Massachusetts Title 5 Official Inspection Form Sudsurrace Sewage Disp63al System Form - Not for voluntary Assessments 19 , �So �p yl✓l r� ,�l G y ,�✓I✓�i Property Address �ves � Ow ner Cw ner's Name ris equirfreedforevery 5 ✓�/l�� O� 6 �s q page. Cityrrown State Zip Code Date of Inspedtion B. Certification (coM.) Inspection Summary: Check A,B,C,D or E I always com plete all of Section D A) System asses: 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CM 15,304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. 9"not determined," please ex0ain. 1 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 Healt h. *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 ❑ NO(Explain below): t5ns,3M 3 Title 5 0 0cial Ins pectlm F onn Su bsufam Se`%Qe Disposal$y5WM•Page 20117 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments l� O v1✓f/� �✓l Gi � OC/ �l�i� Property Address k l�'eS � ' Ow ner O,v ner's Name information is 0 S -ipe t° /� oc�C S / required for every page, 31 crown State Zip Code Date-A Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a mannerwhich will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 15na 3M3 Title$OffciallrepectionFomSubsufaceSowage0lapasalSyftm-Paae3ofV Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments n 26 61004ip_ 61-Ir[G-K Property Address Ow ner Ow ner's Name Information is required for every page. CihNTown State Zip Code Date of Ins •tbn B. Celrtifrcabon (coat.) 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other. D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all Inspections: Yes No ❑ �.�� Backup of sewage into facility or system component due to overloaded or . clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ 5�,� Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ LJ' m Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t9na•Y13 Tide60fficiaf Ins pectianFarm Subsurface SewageDlspoAs System-Page 4of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , Property Address S / Ves V- ON ner Om ner's Name inform dfo OS for page Cityfrown State Zip Code Date of Ins*Wn B. Certification (cunt.) 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 Wthin 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 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 f :i-k I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered'yes'to any question in Section E the system is considered a significant threat, or answered 'yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department: 15ins W3 TiO50f jai IfSpe=nFam 5U0W1aDe$eV%0oisPQs0 System-Page 5of 17 I Commonwealth of Massachusetts ti Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments dookilf dr1 G V— oG/// vtl Property Address ON Her Orr Hers Name D S � - i/�L� � (J 0' S X/ infomlation is � ( -e _ required for eve y State Zip Code Date Inspection page, Qtyfrown C. Checklist Check if the following have been done, You must indicate"yes"or"no"as to each of the following: Yes - ❑ 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): Number of bedrooms (actual): ?O DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): J t5ins 3113 TItle50fficidInspectimfomtSubsufWeS0vA90DisposalSyswm-PageAof17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address I yes fie✓ ouv ner Ow nets We hfom-stion is S- /I'li required for every page. Citylrown State Zip Code We df inspection D. System Information Description: 1O00 fir' lh� 4rL 7!✓ 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: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 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: 15na.3h13 {, - Title 50f al USpecbon F am SubsWxe Sewage Disposal Symem-Page 7of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form 19 -Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �to &,,t.: , �y r Property Address S' Ives�e✓ infomyation is D$ ✓t�l { // Od C-J SS __. J required for every State Zip Code Date of spection page. Cky/Town D. System Information (cont.) Last date of occupancy/use: pate Other(describe below): - 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 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 VA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (descri be): i Yiuesomdal trgpac6onForm Subsu we SevgpDi$po$o S)Ssm'foe 8of 17 tins 3n 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage/Disposal System Form -Not for Voluntary Assessments ✓G— Prop"Address Ow ner ON ner's Name II�,, ' Ile- page. information is required for every 05-11 ✓Wt �oZ Cityrrown State Zo Code Date of hispectim D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: pQ�y� ✓� aL /la/� Were sewage odors detected when arriving at the site? C1 Yes No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron. E 40 PVC ❑ other(explain): . Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, eudence of leakage, etc.): Septic Tank(locate on site plan): ( z / T . Depth below grade: feet Mater al,&construction: M/ crete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: yeas Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t9ns,3113 Title 5 OMcial Ins pectlon F arm Subsi oace Savage Disposal Symm•Page s or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Ow ner Ow ner's tSlameinfo Wn is required for every page. City/Town State Zip Code Date o spec D. System Information (cont.) Septic Tank(cont.) e/ Distance from top of sludge to bottom of outlet tee or baffle Scum thickness d 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.): rrvt o eS l oC Con Grease Trap (locate on site plan): Depth Wow grade: feet Material of construction: ¢ ❑ concrete ❑.metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t9m y13 T&50fficial InspecOonForm Subsurface SevaGeDisposd Stem-Plgo 10of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments / to ��ovi✓lr� �l � ►�` U�/1 i�.� Property Address �ve5�r ON ner ON ner's Name Ile informatbn is O S �-Q,i 4-1( l e Dot G'63- required for every 1�9e, City/Town State Zip Code bate of Inspection D. System Information (coat.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, eudence 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 On,3'13 TlUo50l&3al ImpeceanFarm SubsLowe Sewage Disposal System•Page 11 d 17. t i' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Volunttaa�ry.Assessments 19 _?*(:, ov�K �S�t Ar �C/�t Iti Property Address oN nor Ow ner's Name t cy information is OS4__el�_ required for every page. CityRo,n State dip Code Date or inspectbn D. System Information (coat.) DlWbutlon Box (if present must be opened) (locate on site plan): Z__ 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.): O � L2✓� Sp! //o Lc t 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) pocate on site plan, excavation not required): If SAS not located, explain why: I Sur,•Y13 Ti0e5Officfel Ins pec bon Form Suburfa0e S0w0960i6paeel system-Page 12 d 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments 3 lJ �O✓7�� /..�i� a /' �il t�C..� Property Address S l ves-fie,-- Ow ner Owner's Name infornation is QS ✓�! �/� �o� 6 9 required for every page. Ckylrown State Zip Code Date of in lion D. System Information (cont.) Type: leaching pits � number: ❑ leaching chambers number: ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields ' number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): (/ cJ r ✓1.S �� ` C/�Gt 1. �I G c.r !�l"'G. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan).- Number and configuration Depth—top of Ilqui d to inlet Invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No i tgns,3M3 T 950f6dal1mpec6cnFonm SutxirlamSewa®eNsposat System•Pape 13d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage/Disposal System Form -Not for Voluntary Assessments t'lug ✓� vC� Property Address lve54ek" 0,v ner CW ner's Name �,•/ required for every n is 0 S' "" -e / ' IT page. C#ytrown State Zip Code Date of ns ctlon 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.): t91s-W 3 Title SOMdal ins pecdcn F mrt Subsirface Sewage Disposal System-Page 14 d 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2(� Property Address Ives Ow ra Ow ner's Name �j rrretim required revery �S ✓(/! f /7 0� &S-3, page. City/Town State Zip Code Mite peotlon D. System Information (cunt,) Sketch of Sewage Disposal System; Provide a view of the sewage disposal system, including has to at least two permanent reference landmarks or benchmarks, Locate all wells within 100 feet. Locate where is water supply enters the building. Check one of the boxes below. hand_sketch in the area below ❑ drawing attached separately Swing Ties: A- Tank In-21.5' B- Tank In-13.59' A-D-Box-30 B-D-Box-27.75 A-Leach Pit -40' B-Leach Pit -38' 78§�1`fiitae4g Exist;-louse _ B A I r Septic Tank 0 (1000 Gal.) Water Line Box Leach Pit i 0 BONNIE BRIAA DRIVE y r.. Commonwealth of Massachusetts Title 5 Official Inspection `Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 �AN yI/e e� A✓ Property Address Owner ON ner's Name J_ ' requirirtfoed�forevery page. City/town State Zip Code Date f In peeWn D. System Information (cont.) Site Exam ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells /� , 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 ❑ served site(abutting property/observation hole within 150 feet of SAS) Checke with local Board of Health -expj in: / / // ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: o74ovv7 0-14, �eG�Li G"i� ?�'� �✓E /may/ Before filing this Inspection Report, please see Report Completeness leteness Checkist on next page. One•3n 3 Title 5 Jf6aa1 Impeckn Form SubsWace Sewoge Disposal Syetem•Page 16 d 17 } Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments Property Address Ow nor QN neft Name information is required for every Me. Cdy/rown 7Gte Zip Code Date of peo m E. Report Completeness Checklist a Inspection Summary: A, B, C, D, or E checked �/s L7 Inspection Summary D(System Failure Criteria Applicable to All Systems)completed t� S em information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file f f t$pi•3rts rise 5OMeW 1mPw6mF0m SubmOaw SWMWDi 0Wd SW"-raps 17 d 17 PS COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION ti C O,,M Sva TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION �� Property Address: #36 Bonnie Briar Drive Osterville,MA - Owner's Name: Jason White Owner's Address: #36 Bonnie Briar Drive Osterville,MA Date of Inspection: 07/61/05 Name of Inspector: (please print) Mr.Carmen E. Shav Company Name: CAPEWIDE ENTERPRISES,LLC Mailing Address: P'.O.Box-_763 Centerville,MA 0632 Telephone Number: (508)-428-4028 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: XX Passes Conditionally Passes VA OF Needs Further Evaluation by the Local Approving Authori 9�y Fails - M CARMEN N z E. �. Inspector's Signature: Date: 7/01/05 o SHAY o Zj F9TIf\ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10, gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments 2.5' Liquid observed in Leach Pit. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 , OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: #36 Bonnie Briar Drive Osterville,MA Owner: Jason White Date of Inspection: 07/01/05 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated Below. Comments: B. System Conditionally Passes: One or,more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: #36 Bonnie Briar Drive Osterville,MA Owner: Jason White Date of Inspection: 07/01/05 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within_ 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: #36 Bonnie Briar Drive Osterville,MA Owner: Jason White Date of Inspection: 07/01/05 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No XX Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool XX Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool XX Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool XX Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow XX Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped . XX Any portion of the SAS,cesspool or privy is below high ground water elevation. XX Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. XX Any portion of a cesspool or privy is within a Zone 1 of a public well. XX Any portion of a cesspool or privy is within 50 feet of a private water supply well. XX Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large 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• 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 11 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. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: #36 Bonnie Briar Drive Osterville,MA Owner: Jason White Date of Inspection: 07/01/05 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No XX Pumping information was provided by the owner,occupant,or Board of Health XX Were any of the system components pumped out in the previous two weeks? XX _ Has the system received normal flows in the previous two week period'? XX 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) XX _ Was the facility or dwelling inspected for signs of sewage back up'? XX _ Was the site inspected for signs of break out XX _ Were all system components,excluding the SAS, located on site ? XX _ 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? XX _ 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 XX _ Existing information.For example,a plan at the Board of Health. XX _ 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)) Page 6 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: #36 Bonnie Briar Drive Osterville,MA Owner: Jason White Date of Inspection: 07/01/05 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3. DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 3 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no):_ Seasonal use: (yes or no): Yes Water meter readings, if available(last 2 years usage(gpd)): 117,000 gallons—2003/112,000 gallons 2004 Sump pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: 2004-per owner Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM XX Septic tank,distribution box,soil.absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1980-orieinal,- per Owner&BOH Records Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #36 Bonnie Briar Drive Osterville,MA Owner: Jason White 4. Date of Inspection: 07/01/05 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction:_cast iron _40 PVC XX other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) ' Depth below grade: 14"to Ton of Tank Material of construction: XX concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):,_(attach a copy of certificate) Dimensions: 5'deep x 5'wide by 8' long (1,000 gallons) Sludge depth: 4.0' Distance from top of sludge to bottom of outlet tee or baffle: 2' Scum thickness: 1/4 inch scum laver noted Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 17" 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.): Structural integrity of tank was ok. No evidence of cracks, leaks, or water infiltration/exfiltration. 4" PVC Tee present at inlet end. Outlet baffle present and in good condition. Liquid level equal with outlet invert. GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: . Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): T•., . . r 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION(continued) Property Address: #36 Bonnie Briar Drive Osterville,MA Owner: Jason White Date of Inspection: 07/01/05 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no) Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D-Box Present—onw outlet,no evidence of significant carryover. PUMP CHAMBER: (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.): r Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #36 Bonnie Briar Drive Osterville,MA Owner: Jason White Date of Inspection: 07/01/05 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not-located explain why: Type XX leaching pits,number: 1 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.): No evidence of hydraulic failure of septic tank or of leach either leach pit. 2.5' Liquid observed in leach pit. Cover located and removed as part of inspection. No Riser present. Top of leach pit is 24" below ground. 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 or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) w Materials of construction: r Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): I Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #36 Bonnie Briar Drive Osterville,MA Owner: Jason White Date of Inspection: 07/01/05 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. Swing Ties• A- Tank In—21.5' B- Tank In—13.59' A—D-Box-30 B—D-Box—27.75 A—Leach Pit —40' B—Leach Pit —38' Exist House A B O Septic Tank Q (1000 Gal.) Water Line , , D-Box Leach Pit 0 I BONNIE BRIAR DRIVE Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE_SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #36 Bonnie Briar Drive Osterville,MA Owner: Jason White Date of Inspection: 07/61/05 SITE EXAM Slope Surface water -'/:mile+/- Check cellar -Yes Shallow wells—None Estimated depth to ground water 20' 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: XX 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) XX Accessed USGS database-explain: You must describe how you established the high ground water elevation: Checked with Quadrangle of USGS Map. Per USGS MAP PLATE 2: Elev.of Ground=40 Feet Elev.Of Groundwater=8 Feet - Elev.Of Bottom of Leach Pit 32 Feet Therefore: 32—8-24 feet separation between Bottom of Leach Pit and Groundwater. Groundwater Adjustment using Index Well MIW-29 : 2.0 feet W Adjusted Groundwater Separation=24' -2=22 feet between bottom of pit and adi.groundwater Grade=Elev.40 feet Pit#1 Septic Tank ` Bottom of Pit=Elev.32 feet I Adj. Groundwater=Elev. 33.6 Commonwealth of Massachusetts ' Executive Office of Enviroranental Affairs Dept. of Environmental Protection One winter Street, Boston,Ma. 02108 John Grad D.E.P. Title V Septic Inspector P.O. Box 2119 TeatickerM�`OZ-5,36 WILLIAM F.WELD (5,08) 5646813''•,p Governor IN o ARGEO PAUL CELLUCCI Lt.Governor RfAvr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM coo CERTIFICATION oPART A G l 3 1997 HEq T�EPTAB� Property Address: 36 Bonnie Briar Dr.Osterville Address of Owner: Date of Inspection:7/21197 (If different) ` Name of Inspector:John Grad Debs A I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) £ y Company Name, Address and Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true;accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X Passes This inspection is based on criteria defined in Title V — Conditionally Passes code 310 CMR 15.303.My findings are of how the system is Needs F h Evaluation B the Local Approving Authority perrorminq at the time of the inspection.My inspection does — y pP g tY not imply any warranty or quarantee of the longevity of the Falls septic system and any of its components useful life. Inspector's Signature: Date: 8/11/97 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B.C, or D: A] SYSTEM PASSES: X I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: _One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exhlbation,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04127/97) One Winter Street 9 Boston,Massachusetts 02108 • FAX(617)556-1049 9 Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 36 Bonnie Briar Dr.Osterville Owner: Debs Date of Inspection:7/21/97 _ Sew.a4e backup or.breakout.or hiah.static water level observed.in.the distrihution box is due to a broken. or obstructed pipe(s)or due to broken, settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipets)are replaced obstruction is removed Cj 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. . The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. — The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must Indicate either"Yes"or"No"as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage in facility or,system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged cesspool. SAS is in hydraulic failure. (revised D4/27/97) A, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 36 Bonnie Briar Dr.Osterville Owner: Debs Date of Inspection:7/21/97 D] SYSTEM FAILS(continued) 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). Numbers of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further Information. (revised 04127/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 36 Bonnie Briar Dr.Osterville Owner: Debs Date of Inspection:721/97 R Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: —7— — Pumping information was requested of the owner,occupant, and Board of Health. X None of the system components have been pumped for at least two weeks and the 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. x — As built plans have been obtained and examined. Note if they are not available with N/A. X — The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. _X_ — The site was inspected for signs of breakout. X All system components,excluding the Soil Absorption System,have been located on the site. x The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions, depth of liquid, depth of sludge, depth of scum. X _ The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different-from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. X Existing information. Ex. Plan at B.O.H. X Determined in the field(If any failure criteria related to Part C is at issue, approximation of distance is unacceptable)115.302(3)(b)J (revised D4127/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 36 Bonnie Briar Dr.Osterville Owner: Debs Date of Inspection:7/21197 FLOW CONDITIONS RESIDENTIAL: d./bedroom for S.A.S. Design flow: 330 g-p Number of bedrooms: 3 Number of current residents: 0 Garbage grinder(yes or no): Yes Laundry connected to system(yes or no): Yes Seasonal use(yes or no): Yes last two 2 year usage d - Water meter readings,if available:(as O y g (gp )' Sump Pump(yes or no): No Last date of occupancy: summer use COMMERCIAL/INDUSTRIAL: Type of establishment: n/a Design flow:0 gallons/day Grease trap present: (yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system: (yes or no) No Water meter readings,if available: n/a Last date of occupancy: We OTHER: (Describe) nla Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System has not been pumped in the last year. System pumped as part of inspection: (yes or no)No If yes,volume pumped: 0 gallons Reason for pumping: n/a TYPE OF SYSTEM X Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool ° Privy Shared system(yes or no)_(if yes,attach previous inspection records,if any) I/A Technology etc. Copy of up to date contract? Other: APPROXIMATE AGE of all components,date installed(if known)and source information: 1982 Sewage odors detected when arriving at the site: (yes or no) No (revised 04127/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 36 Bonnie Briar Dr.Osterville Owner: Debs Date of Inspection:7/21/97 SEPTIC TANK: X (locate on site plan) Depth below grade: 6" Material of construction:X concreate_metal_FRP_Polyethylene_other(explain) If tank is metal, list age 15 . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: L B'6'H 5'7'W 4'10' Sludge depth:3" Distance from top of sludge to bottom of outlet tee or baffle: 24' Scum thickness:0 Distance from top of scum to top of outlet tee or baffle:6" Distance form bottom of scum to bottom of outlet tee or baffle: 0 How dimensions were determined: Measured 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,etc.) Septic tank and all components are structurally sound.Recommend pumping septic system every two years for maintenance. GREASE TRAP:_ (locate on site plan) Depth below grade: n/a Material of construction: _concrete_metai_FRP_Polyethylene_other(explain) Dimensions: n/a Scum thickness:n/a Distance from top Of scum to top of outlet tee or baffle:n/a Distance from bottom of scum to bottom of outlet tee or baffle:n/a Date of last pumpingn/a 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,etc.) n/a BUILDING SEWER: (Locate on site plan) Depth below grade: 16" Material of construction:_cast iron X 40 PVC_other(explain) Distance from private water supply well or suction linOowri _ Diameter: 4' I;vamments: (conditions of joints,venting, evidence of leakage,etc.) s 4 (revised 04127/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 36 Bonnie Briar Dr.Osterville Owner: Debs Date of Inspection:7/21197 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: We Material of construction:_concrete_metal_FRP_Polyethylene_other(explain) Dimensions: n1a Capacity: n/a gallons Design flow: n1a gallons/day < Alarm level:_n/a Alarm In working order?_Yes No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) n1a DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert: Liquid leveI v ith bottom of pipe. Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.) D-box is structurally sound PUMP CHAMBER: (locate on site plan) Pumps in working order.(yes or no)No Alarms in working order(yes or no)_Yes Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) n1a (revised D4127/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 36 Bonnie Briar Dr.Osterville Owner: Debs Date of Inspection:712t197 SOIL ABSORPTION SYSTEM(SAS):X (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present, explain: n/a Type leaching pits,number: 1,000 gallon leach pit leaching chambers,number:n/a leaching galleries,number: n/a leaching trenches,number, length: n/a leaching fields, number,dimensions:n/a overflow cesspool,number:n/a Alternate system: n/a Name of Technology:_nta Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) The overflow is structurally sound and functioning propedy It was empty at the time of the inspection. CESSPOOLS:_ (locate on site plan) Number and configuration: n/a Depth-top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: nla Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection) n/a Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) n/a PRIVY:_ (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) n/a (revised 04127/97) I " G SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 36 Bonnie Brier Dr.Osterville Owner: Debs Date of Inspection: 7/21l97 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) El AA HB 3G be 37 ytp• 9 of 10 (revised 0427/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 36 Bonnie Briar Dr.Osterville Owner: Debs Dale of Inspection: 721r97 Depth to Groundwater 12+ Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers x Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS Maps and Charts f (revised 0427197) page 10 of 10 ION #3G E W A PERMIT NO. LOCATION SEWAGE VILLAGE J �-5 ca9 nzt�- , - INSTA LLER'S NAME i ADDRESS -K 41z"f , I UILDE R OR OWNER DATE PERMIT ISSUED 86 DATE COMPLIANCE ISSUED �z _.z � -�� w.o. • � �� `�� 3' t f� .3`� G � N ( �. .._._. 6 Fss.... ................... THE COMMONWEALTH OF MASSACHUSETTS, /� BOAR® F H�� ......a%-.(�$/C' ...OF..... .. . .... .....-•.............................. .Appliraation for Uiipootal Works Tonotrur#inn Prrutif Application is hereby made for a Permit to struct ( or Repair ( ) an Individual Sewage Disposal System at: -------------------------- ............. t2�... ovation-Addres 0r o 421 Ow r Address a ..... ................. .......... •--------•-------------•••--- -- .....---•------------------....--•---•----------------•-------•--••------• --......-•---- Installer '` Address �y Type of Building `� Size Lot..JS =a_._�?-_...Sq. feet Dwelling—No. of Bedrooms.........................--......_.•.........Expansion is ( ) Garbage Grinder ( ) a`4 Other—T e of Building —Type g ............................ No. of persons..................-- ...... Showers-fZ — Cafeteria ( ) Otherfixtures ..---•-•--•...............••--•- -------•---......------------•----------••-•--- ---------------...._.. W Design Flow............................................gallons per person per day. Total daily flow-----------u_.___......................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.....A)........ Depth below inlet.................... Total leaching area--. ------ ------- sq. ft. Z Other Distribution box ( ) Dosing ) a Percolation Test Result Performed by.......�.(.�...... .f.P a.l!�- ---------- ------------------ Date.... Test Pit No. l_.."... minutes per inch Depth of Test Pit.................... Depth to ground water..---......--........... (14 Test Pit No. 2.... >Minutes per inch Depth of Test Pit.................... Depth to ground water....-----...•------.-..- -r------------------------•-------•--.------------•--.- ---per j•----- -----............-•-..._..-•-•--......._............-•---•-- O Description of Soil. 6 s w --------------------------- U 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 LI L I1 5 of the State Sanitary Code— he undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issu y the boa f lth. Signed--••-r ..._"_ '`!..................-----•--•_-- Application Approved By-------- f'--• ••--- .•. ---------------•--.........--•-----.. �_. `� ....-------- � � Date Application Disapproved for the Jollowing reasons:-••----•------•-----------------------------•------•------------------------------........................... .....................................••----•------•-----------.......-•----------....-----•-•---•---•--------•--....--- •-------------•------------------------------•--------•------------••---•--- �^�,�_�� Date PermitNo.......................................................- Issued .................................................. 30 N0�11L(D 6 2_G ........................... THE COMMONWEALTH OF MASSACHUSETTS 1-1= ,---,-' BOARDVADF HMH�, .� OF..... ... ............... .... ......... .................................. Appliration for %qposal Works TOmitrurtion Prrutit Application is hereby made for a Permit to. Gonstruct or Repair an Individual Sewage Disposal SZy a,:..... .............If ,,it. 1 1. .7............... .............. .... . .. .........!.....c'...6v .... -----�.,l ----------------------*...... ocation-Addre s ................................. or .. .. ........... ...a. ............A,............. . ........e ........ `ow r ......Address. ... ....................... ................................. ...................................... ...................................................... Installer Address Type of Building Size Lot.j�._,9.32...Sq. feet Dwelling—No. of Bedrooms................3..............-------Expansion .... Garbage Grinder Other—Type of Building ............................ No. of persons.......... ..... Showers —'Cafeteria Otherfixtures ............................................................................................................ Design Flow............................................gallons per person per day. Total daily flow.......... b.......__..........._....._gallons. 9 Septic Tank—Liquid capacity............gallons Length................ Width._......_._..__. Diameter_________....... Depth....___.._...._. Disposal Trench—No. .................... Width......./----------- Total Length........_...____..._ Total leaching area....................sq. ft. Seepage Pit No---------/--------- Diameter................... Depth below inlet.................... Total leaching area__ ..............sq. f t. Z Other Distribution box Dosing(,PL-,nk Percolation Test Resu;ts Performed by.....j----- ....... ..... ... Date._ ........... �4 Test Pit No. 1... minutes per inch Depth of Test Pit.................... Depth to ground water.......____._........__. 44 Test Pit No. 2--- finutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 0 ............6......... ........I ------1------1-1---------------1*1-i------------------------------ 5 ............ ..../-�cat.......... '. �5 0 Description.of Soil.......... �5Af_ , ............................... U ....................................................................................................... ............................................I............................................................................................................................................................ U 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 T IT LE 5 of the State Sanitary Code— he undersigned further agrees not to place t/hhes stem.in t operation until a Certificate of Compliance has be i su y he bo; f 9111th. Signed---. .......... .................................. . . ........ Date ��112 116 Application Approved By- . ..... ....... ... ............................. ........I..................... Date Application Disapproved for the following reasons:................................................................................................................ .............................................................................................................................................................................7.......................... Date PermitNo.................................................------- Issued............................................... ...... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA -A- .....OF.... ..JP.r4 t&....................... MwWrtffiratr of Tompliana THIS IS, TO C IF YJ That the Individual Sewage Disposal System constructed (>�_or Repaired - %__10 Z P -------------------------- ..... by... ----------A - .-i-- ................................................ I I..,, n:tall s :...... ............at.... . ................ ... . ....................................................................................................... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as describ d in the T-1.J9.. ........... application for Disposal Works Construction Permit .......... dated-.... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........... .......C�./..................................... Inspector---------.....------_.... -<........................................... THE COMMONWEALTH OF MASSACHUSETTS BOAROOF Ho E=.... ............................. ........OF...........i��......... .. ..... .................. 0 3 N 0... Fim Permissionis hereby granted... ... .......................... ..... ... ........................................................................ to Cons, r Repair at).,Individual Sewage Dispp�oQlystern Ito, ,;e at No..... Street as shown on the application for Disposal Works Construction_Rwmit No....................i Dated...-_...____......_._........_......._.... ............................................ DATE_.... 050 1-1(.ard of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ... - t �y�S - (t! - - �.,�,,.✓ a ', Alf 17 so I le Z/ / RGBERT ), j _ hey\1 �., y,y✓" - �I: P. - 7 .'` BUNIKIS f No.'L_162 NA''L ,.r D�,-..� EXISTING SPOT ELEVATION Ox0 ° EXISTING CONTOUR ——— 0 - - - z- 7 -7 g 00,;f tA M_ DO e FINISHED SPOT ELEVATION, 0.0 FINISHED CONTOUR IN APPROVED = BOARD OF HEALTH � �A A,�l S f A 9 ' d, U ASS � , DATE AGENT SCALE: 3Q ' DATES 110ELDREDGE ENGINEERING CO. IN CLIENT I CERTIFY THAT."THE PROPOSED EGiSTERE REGISTERED JOB N0. ��UJ04- BUILDING SHOWN ON THIS PLAN ' CIVIL LAND CONFORMS TO THE ZONING LAWS : ' ENGINEER SURVEYOR. OF BARNS BLE , M S 712 . MAIN ST. CH. BY: 5.P. r3 HYANNIS MASS. SHEET r OF.` ~ ' DATE REG. LAND SURVEYOR .<r /1�0TE /F E/TNER THE.SEPT/G TANK OR L.EAC/•//o/G ?/T ARE MORE TNA/V /2"EELOW /�/ 24"O/AMETER G'GNG'RIFTE COVER ! ` SHALL ®IF BQ®U/sNT TO G/rAOE.�i4N .EXTRA ,' GONCRGTE g"P'VC P/Pt l e,4 V4Y CA S 7- /RON C C�/�R SA/.4 I-t. 8--.lJ S E0 P/TCAl- - G'O'YER�S �/B p PER FT /F/N ,DR/✓EN/A Y ° CD/VC.RFTE — 2 MiN. A _ GAOE Co VEft CLEAN .SAND ' ®AC/CF/LL L149glD LEVEL , 4"CAST J 1 _ _ •' 2"LAYER OF /B" IRON P/PE d 0, GAL. M/N.P/TC// ' I• • • • . • • • ' v o4 WASH- S7t7NE v "PER -r. SEPTIC 7A' AW BOX " ° " ii 8 • •. • � • • o .314 e ° ° r • DEPTH/' � ' • •v •WASHED STDiYE �,a:_. - � o r • • • • • • • oi boo , ,.R-'••'•'� � e •Q�' • • • . e • • s • • p D o PRECAST SEEPAGE o v`e' r • • • . • • • • ' e••o P/T DR 450 V. 1 ANNeR'r LrZ EVAT/DNS CL �- p • `� /NYERT AT QU/LD/NG INLET'-SEPTIC TANK �'-(s F ,T 1° F7 O/A!"!• C(SEE TABUL.4T10N� OUTLET SEPTIC TANK INLET O/SMA50T/ON BOX _� SECT/O/V OF ' GROUND / TER TABLE_ O//TLETD/STR/BUT'/ON Mw—L�9 FT. S�yyAOR 015ROSA L SYS71MM INLET LEACH/NCr PIT ors FT.' 7-i4B41LATION LEACH//V6 PIT plMENS/ON A 3 . FT. 'DES/GN CRITERIA -SCALE : %4" / -v p/rfENs/aN 8rt FT. NUMQER OF BEDROOMS 3 ' GARC3AGE o/SPOSA4 uN/r a� SOIL LOG SD/L TE3T TOTAL EST/MA'TEO FLON/ 2 'e G.4L./DAY cS0/4 TEST /0f/ SOIL 7ES741*2 , lllUMBER OF LE°ACNlNG PITS' /— f`EtGrY. y EL4FV ", DATE aF SOIL TEST c1 j y f r f S/OELEACH/KG PER.O/T % .SY� PT.. O _ RESULTS AVITNESSED 8Y BOTTOM LEs4GN/NG PE1�P/T SQ. A7^ L G�.� '•1. `�` PERCOLA�T/ON RATE#/ < 5 s M//V•I/NCN TOTAL LEACH/NG AREA b SO. AFT. j�` �, %�- FVoftCOLAT/DN RATE Lk2 T M 2V M/N.1/NCH r RESL-'R{�E LE.4G'Nl N6 AREA �•-��SQ. .FT. ' f `- � 0 )•1 y V.`r M r rJ!}'N',' JS T ' 'BUNIKIS N .p No 2216z�4 ; ELORED /NF.�1P /1/ls GO,lNG. F -P 6E ENG / r c , 712 MAIN Sr , S�10NA1 NO O YYATCR N O MYitNN/s MASS. r -� L (� - OR (JNO !F COCJNT1�lCE , ( - Q GRO LINO WA7—ER AT ,64,ff ; �._ � .1 CB NO. O � SHEET Z OF '�-- s y .yam