HomeMy WebLinkAbout0034 CROSSWAY PLACE - Health 34 Crc55way Place
Osterville
_ A= 165-058
7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
34 Crossway Place, '
Property Address
Wendy Stein
Owner Owner's Name p
information is Ostervilie Ma '02656 1018/12 required for every .
page. Citylrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.'
Important:When a ��� ►nil
filling out forms A. General Information tH OF tiggs9i����
on the computer,
use only the tab `off. • ........,• y�,yG
trey to move your 1. Inspector: ? JA M E S
cursor-do not James D Sears ' __0. SEARS :co
use the return
Name of Inspector .
key. Jim The Inspector Man '%%'r'cFRT1F�`��
"�• Company Name s, 5 INS?
' ?�
P.O. Box 784
Company Address
West Yarmouth Ma 02673
Citytrown State Zip Cade
-508-3644398 S 1623
Telephone Number License Number
B. Certification S ,errs
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 16.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
10/8/12
Inspector's Signature pate
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 offilre of the DER The original should be sent to the system owner
and copies sent to the buyer, if applicable,and,the approving authority. F
" "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.
�� �v ►
tsins-11110 Title 5 Forth:S ge Sewa Disposal System,Bags 1 of 17
. y
Commonwealth of Massachusetts
Title 5 Official Inspection Form'
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
34 Crossway Place
Property Address ,
Wendy Stein
Owner Owner's Flame .4
information is sterville Ma 02655 10/8/12
required for every O ,
page. City/Town 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: T
® 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:
®) 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. ,
• . P
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 0 ND(Explain below)-. '
•
t5ins•i 1n0 Tits6 MOW hismc ion Form:&&=face.&WMP Dish:$ystem•Page 2 cf 17
Commonwealth'of Massachusetts
Witte 5 official Insp'ection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
34 Crossway Place
Property Address
Wendy Stein
Owner Owner's Name
information is required for every Osterville Ma 02655 1018/12
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cunt.)
B) System Conditionally Passes(coat.):
❑ 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:
El 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.
I.,System will pass unless Board of Health determines In accordance with 310 CMR
15.3Q3(1 j(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
k
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•i ino T&.5 MOW Inspeebon Fwm Substa DispoW.systm•Pap 3 of 17
Commonwealth of Massachusetts
Title 5 Official lnspection` Farr
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments `
34 Crossway Place
Property Address f
Wendy Stein
Owner Owner's Name
Woffnatio is
fired to°every Osterville Ma 02655 1018/12
page, Cityfrown a State Zip Code :Date of Inspection
B. Certification (cont.) p'
2. System will fail unless the Board of Health(arid,Public'Water Supplier,`if!,any)
determines that the system is functioning in a manner that protects the public health,
safety and environment; s,
❑ 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.
b❑,; The system has a septic tank and SAS and the SAS.is within a Zone l of a public water
supP1Y
G The system has a septic tank and SAS and the;SAS is within 50`fee#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 weir.
j'.
'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 acid 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.°
I Other
1. m � ,•. ,,K ." ` '. ,•
g > D),'System Failure f Criteirla'Applicable to All Systems'
You must indicate"Yeses or."No"to each of the following for all inspections:
Yes .$ No
® } . a 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
41 due'to an overloaded or clogged SAS or cesspool
❑ ❑
Static liquid level in the distribution box above outlet invert dr,e to an overloaded
or clogged SAS or cesspool
Liquid depth in cesspool is less than 6"below invert.or available volume is less'
than f day floe, t
t5ins•1111A e
Tete&offiaaf ins coon Fount:&bwfam Sewage Disposal System'Page 4 of 17
Commonwealth of Massachusetts .
Title 5 official Inspection form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '
34 Crossway Place F
A.
Property Address
Wendy Stein
Owner Owner's Name
information is psterville � t - -
required for every Ma 02655 10/8f12
PW Cityfrown State Zip Code • Date of fnspeWon
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. _
0 Any portion 6f 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, r
❑ ® Any portion of a cesspool or , s within 50 feet of a
.privy i 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 colifonn 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
f and chain of custody must be attached to this form.)
0 r ® The system_is a cesspool serving a facility with a design flow of2000gpd-
_ ' 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
El ❑ z.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 €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•111.0 . T&5 OffGal lnspecbon Form:SOMakm Sewage Disposal system Pam 5 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
34 Crossway Place
Property Address x
Wendy Stein
Owner Owner's Name
e..
ngainred for every 4stervilie '
re , •'Ma 02655 10/8112
page. CitylTown 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 informati6r was provided by the owner, occupant, or Board of Health
i, ❑ " ® 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 NIA)
® ❑ 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? t
❑ Were the m W N 0 manholes uncovered, opened, and the interior 410mam•
inspected for the condition of the NOW 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?
Theo 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 held(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): Y A Number of bedrooms(actual):,,: 3
_ - 330 "
DESIGN flow based on 310 CMR 15.203(fof example: 110 gpd x#of bedrooms): ;
tsms i iH o litre 5 Offidai hsspection Form:Subsurface Sewage Disposal System,Page 6 of 17 {
Commonwealth of Massachusetts
Title 5 Official Inspection' Forrn
Subsurface Sewage Disposal System form Not for Voluntary Assessments
' b
.' 34 Crossway Place
Property Address
Wendy Stein
Owner Owner's Name
M uin3d for every Osterville Ma, 02655 1018/12
page, Citytrown State Zip Code Date of Inspection .
D. System information
Description: 4 ,
Note::Rear system-is two block c pools one main and one overflow ..
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes 0 No
'
Is laundry on a separate.sewage system?[if yes separate inspection required] Q Yes ® No
Laundry system inspected? Q Yes ® No
Seasonal use? ❑ Yes No'
Water meter readings, if available last 2. ears usage na
9 ( Y � (gpd});
Detail:
Sump pump? . r ❑ Yes No
Last date of occupancy: .na
Date
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?; z❑ Yes 0 No
r
Non-sanitary waste discharged to the Title S system? Yes ❑ No
Water meter readings, if available:
tsins•c yr o rf s OffiCUO Inspection Forth:SWm8fam SiWW Djq=W system•Pap 7 of 17 4
t
Commonwealth of Massachusetts `
Title 5 official Inspection Form
Subsurface Sewage Disposal System Foam-Not for Voluntary Assessments
34 Crossway Place ,
Property Address
Wendy Stein
Owner Owner's Name .
infDrmatian is Osterville Ma` 02655 10/8/12`
required for every
page. Cityrrown State Zip Code . Date of Ins on
D. System Information (cunt.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: na
Was system pumped as part of the inspection? ❑ Yes 0 No
If yes,volume pumped: x gallons
How was quantity pumped determined?
Reason for pumping:
Type of System: ;
J
❑ Septic tank,distribution box,soil absorption system
r
• ® cesspool `• • ,s _ _ •' - . .
® Overflow cesspool
❑ Privy k.
. Shared system(yes or no)(if yes,attach previous inspection records, }f 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 11Ho Ti68.5 Official irmpecdonfomr SO-face.S-We Disposal Sidem Pap 8 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
34 Crossway Place
Property Address
Wendy Stein
Owner owners name
information
required for every Osterville Ma 02655 1018112
pap. Cityrrow n State Zip Code Date of inspedon
D. System Information (cons.)
s
Approximate age of all components,date installed(if known)and source of information:
na
Were sewage odors detected when arriving at the site? 0 Yes No
Building Sewer(locate on site plan):
Depth below grade:
3 .
feet
Material of construction:
Q cast iron ❑40 PVC ', ®other(explain):
Distance from private water supply well or suction line: fees
Comments(on condition of joints, venting,evidence of leakage, etc.):
cast iron/omage burgs
Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
❑'concrete . 0 metal ❑fiberglass ❑polyethylene. ❑other(explain).
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliarice?(attach a copy of certificate) Q Yes 0 No
Dimensions:
Sludge depth:
Mns•1111.0 Tift 5 OtfaW ftPWbW F.WW SuEsiefxe Sewage DigmsW System Page 9 017
Commonwealth of Massachusetts
Title 5 Official- inspection~ Fornn
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments,* '
34 Crossway Place
Property Address 4 c
Wendy Stein
Owner Owner's Nameinfomation is
t'
required for every Csterville Ma 02655 10/8/12`
page. Cityrrown State . Zip code .. Date of inspection
D. System Information,(cont.)
Septic Tank(cont)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle'
Distance from bottom of scum to bottom of outlet tee or baffle
HoW were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition_,sbix tural j9tegrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):,
E .
Grease Trap(kscate on site plan):. "
Depth"below grade; feetQ
Material of constiuchon:
-
x,
r ^
+
+ M
El concrete ;:►.Q metal
- fiberglass ,s " O'poiyethylerte' Q other{explain}:'
Dirnensi6ns
;. Scum thickness'
j- j Distance,from top of scurn to top of outlet tee or baffle +
Distance from bottom of scum to bottom of outlet tee or baffle "z ;
Date_ ^of last pumping r °I
Date »
ors; ino r&O.s mspecaonra,n:s r�ce.s �n; sy n foof17
Commonwealth of Massachuietti ,
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
34 Crossway Place
Property Address
Wendy Stein R
Owner Owner's Name
information is Osterville r , Ma - 02655 10/8/12
t>age. for every Citylrown state Zip Cade Date of Inspection,
D. System information (coat.)
Comments(on pumping recommendations, inlet and outlet tee or baffie'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 ❑frberglass, ❑polyethylene ❑other(explain):
Dimensions:
Capacity:
gallons'.
Design Flow: gallons per day
Alarm present: Q Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping,'. Date
1
Comments(condition of alarm and float switches,etc.):
'
*Attach copy of current pumping contract(required). Is copy attached? [] .Yes ❑ No
t5ft•1111.0 TW5 olfiaal>sssps Wn Fwm::Subwftrs.3ew qp Dispcsai System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,
34 Crossway Place
lug Property Address
Wendy Stein
Owner Owner's Name
information is Osterville Wa 02655 10/8112
required for every `
page. Cityrrown State Zip Code Date of InspeWon
Q. System information (coat:)
Distribution Box(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.):
F
` 7 F .
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.):
Soil Absorption System(SAS)(locate on site plan, excavation not required): .
If SAS not located, explain why: ;
i5gi•1111.0 T&5OffidWlnspe jonfarm:3.Wssjf8W.SWapDiSPOSWSystem PW 120171
Commonwealth of Massachusetts ~
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r 34 Crossway Place
Property Address
Wendy Stein «
Owner Owner's Name
Womia
regwre Lon is
required for every Ma a 02655 10/8/12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont«}
Type: y
❑ leaching pits number:
❑ leaching chambers number. ,
® leaching galleries number
❑ leaching trenches number, length:
leaching fields- number,dimensions:
overflow'cesspool "`` number: 1
❑ innovativelaltemative system
Typelname of technology:
Comments•(note condition_ of soil,:signs of hydraulic failure,level of ponding,damp soil, condition of
vegetation, etc.):
leaching is one block c pool T deep w/cover at 32"below grade dry walls clean no sign of
overloading or solid carry over"
y 1
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
F Number and configuration 1 ,
4,6"
Depth,—top of liquid to inlet invert
27
a, Depth of solids layer "
0"
Depth of scum layer
7,
-Dimensions of cesspool
Materials of construction' °
Indication of groundwater inflow ❑ Yes ® 'No
t5ins•t f/1.0 Tithe 5 offidal>nspectm Foam:SubsAace SawW Disposal.System•Page 13 or 17
Commonwealth of Massachuset
Title 5 Official inspection form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
34 Crossway Place
Property Address
Wendy Stein
owner Owner's Nam®
information is
required for every Osterville Mai 02655 2. 10/8112
page. Cityrrown State Zip Code Date of tnspedon
D. System information (coat.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
main pool block 46"below grade w/cover at 6"one line out to over flow pool
Privy(locate on site plan):
Materials of construction:
Dimensions r
4
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•17/10 M6.5 Otf.W Ins F.SWsuAace• - pentinn Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form 1
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
34 Crossway Place
Property Address
Wendy Stein
Owner Owner's Name
information is Osterville r Ma 02655 10/8/12
required for every -
pap. cityrrow n State Zip Code Date of inspection
D. System information (cunt),,
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
016 ,
<r
t5i •11/1U � Form: - ,ns Tits 5 Off el hrpec ion .St bawtace sewage 040sw •Page 1.5 of 17
Commonwealth of Massachusetts - y
Title 5 Official Inspection Fora-`
Subsurface Sewage Disposal System Form-Not for voluntary Assessments
34 Crossway Place
Property Address
Wendy Stein
Owner Owner's Name x.
information is Osteryille '':Ma -�'02655 10/8/12
required for every -
page. Cityrrown State Zip Code Date of Inspection
D. System information (coat.) t,
Site Exam:
® Check Slope =
❑ Surface wafer
® Check cellar
❑ Shallow wells
Estimated depth to high ground water
feet
4
Please indicate all methods used to determine the high ground water elevation:
❑- Obtained from system design plans on i ecord� '
If checked,date of design plan reviewed: .,Date
® Observed site abutting pro a bservation hole within 150 feet of SAS}
Checked with local Board of Health-explain: ,
❑ Checked with local excavators, installers-(attach documentation)' ,
❑ Accessed USGS database_s explain:
You must describe how'you established the high ground water elevation:
rear slope,area drop off
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
151M•1111.0 T&5 MOW Ilssps AM Form:SUbSWfaW$Map Disposal.System•Pam 18 of U
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
34 Crossway Place ,
Property Address '
Wendy Stein
Owner Owner's Name
information is ,
required for every Osterville Ma 02655 10/8/12
page. Cityrrown state Zip Code• Date of Inspection.
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D,�or S 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
4
tsars•'11110 Tills 5 OJfidW bWPB(*Dn Form:&Jbw am Sewage Disposal SYSWn Pap 17 of 17
Commonweaithvf Massachusetts'
Title 5 Official Inspection form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
34 Crossway Place
Property Address
Wendy Stein
Owner Owner's Name
information is
required for every Osterville Ma 02655 10/8/12
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form.Inspection forms_ may not be altered in any
way.Please see completeness checklist at the end of the form.
Important:When filling A. General information U ,����1101pj�ru
on `ASH OF M'fSs
the computer,
use only the tab 1. Inspector: #� 9°y
key to move your = °;' • J A M E S
cursor-do not James D Sears 0, QEARS
use the return Name of Inspector y
key Jim The Inspector Man *�• t?� �o:
Company Name ' �S I N'SP��\\N�`�
P.O. Box 784 IM00
Company Address
West Yarmouth - Ma 02673 y
City/Town State Zip Code
508-364-4398 S1623
Telephone Number- License Number
B. 4 Certification f'�o� S y
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails F
❑ Needs Further Evaluation by the Local.Approving Authority
. A'10l8l12
Cfdspectors Signature Date
d
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.
r V'I
:sins•1 Vtt) rifle 5 €arm:&b=fa" Dish system•Page t of 17
Commonwealth!of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
34 Crossway Place ..M
Property Address
Wendy Stein
Owner owner's Name
info �'is
required for every' Osterville Ma 02655 10/8/12
City/Town page. State Zip Code Date of Inspection
B. Certification (cunt.)
Inspection Summary: Check 'A,B,C,D or E/altivays complete all of Section D
,
A) 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: ro
Comments: f
B) System Conditionally Passes;
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no".or"not determined"(Y,,N, ND)for the following statements, If"not
determined,"please explain.
The septic tank is metal and over 20 years'oid*or the septic tank(whether metal or not)'is structurally
4 unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass
t_ 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):
• ti e ,
t5ins•11110 Titis 5 Olfis�el InWedM Foam:Sulmdo a Smap Disposal System•Pap 2 o117
Commonwealth of Massachusetl
Title 5 Official Inspection Form
Subsurface Sewage Disposal system Form-Not for Voluntary Assessments
34 Crossway Place.
Property Address
Wendy Stein
Owner Owner's Name
infomtation is
required for every Osterville Ma 02655 , 1018112
page. City/Town State Zip Code Date of inspection
B. Certification (cunt)
B) System Conditionally Passes(coat.):' .
❑ 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(Expla in 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 pipes)are replaced ❑ Y ❑ N ❑.ND(Explain below):
Ej obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.,
1..System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water R
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5imt•11/10 Tft 5 Off el Irmpectim Form:$r&=Iece Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts` L ; .
Title 5 Official Inspectio-n1fdrm '
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
34 Crossway Place
Property Address
Wendy Stein
Owner Owner's Name
required fo edery Osteryille i rMa 02655 108/12._
City/Tom w`*g State
'.• �'• � ^:- Zip Code` •
page. p ;.;�,Data of Inspection
B. Certifiea 1 „
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, ,
_ P
safety and environment: y -
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)s'within a Zone 1 of;if public water=.
supply. i.
The system has a septic tank and`SAS and the SAS is within 50 feet of a private water,
supply well
4 ❑ The system has'a septic4tarik•and SAS and'the SAS is less than.100 feet but 50 feet or or '
more from a private water supply well** '
Method used to determine distance:
Ai
**This system passes if the well water:analys srperformed at a DEP'cerified 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 analysismust ,.
be attached to this form. `"'
3..Other
A.
i . e.�
®)'"Systerh Failure Criteria Applicable to At!Systems: s
You�must indicate"Yes"or;`No"to each of the following for all inspections...
_. —
Zr .., . _
Yes No
BackupF.
of sewage into facility or system.component due to overloaded or
''® clogged SASarcesspool.
Discharge or,ponding'of effluent to the'surface„of the ground or surface waters
wAde to an overloaded orclogged SAS or cesspool `
,.. Static lucid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool ' _ ,
ry. Liquid depth in cesspool is less than 6a'below invert or available`volume'is less`
than Y2 day flow `
t5ms•-1111t) x
Tits 5 OftW Inspection Form Sulmoftw Svmgs Disposal system•Page 4 of 17
f +
Commonwealth of Massachusetts
v. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary°Assessments
34 Crossway Place' r
Property Address .
Wendy Stein t r
Owner Owner's Name
inforntaf}on is
required for every Osterville Ma 02655 1018/12
page. Cityrrown State Zip Code Date of inspection
B. Certification (cone.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or'
obstructed pipe(s). Number of tirries 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. '
Mgt
❑ ® 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- is.
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.N
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
1 ❑ ❑ _ •the system is within 200 feet of a tributary to a surface drinking water supply
❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area lWPA}or a mapped Zone If of a public,water supply well
-
•" If you have answered"yes"to any question in Section €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•11/10 Title 5 Ofnaw Inspection Forth:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts , 41
Title 5 Official Inspection''Torm i.
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
34 Crossway Place
Property Address _
Wendy Stein ..'
Owner Owners Name
information is required for every psterville Ma02655 IW8/12 .
per. Cityrrown F State Zip Code ' Date of inspection
C. Checklist
Check if the following have been'done.,You'must indicate"yes"or."no"as to,eabh`of the following:
Yes No: ,.
❑ "Pumping information•was provided by the owner,occupant,,or Board of Health
Ej e any of the system components pumped out in the previous two weeks?
0 Wire
`0- Has the system received normal flows in the previous two week'penod?
,0 ® Have large,volumes of water been introduced to the system recently or as part of
" this inspection? •k;:.
® ❑ Were as built plans of the system obtained and examined?(if they were not
available note as N/A)
❑. Was the facility pr dwelling inspected for signs of sewage backup?
Was the site xinspected for signs of break out?
® ❑ ' Were all system components-excluding the SAS,'located on site?
'® EY Were the manholes uncovered,opened;;and<the interior i
inspected for the condition of the, tees, material of construction,
dimensions depth of liquid, depth of sludge and depth of scum? a
Was the facility owner(and occupants i€'different from owner}provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorp#ion_System(SAS)on the site has
been determined based on:_
❑ Existing information. For example,a plan at the Board of Health#
Determined in thebfield(if any,of the failure criteria related to Part C is at issue
approximation of distance is unacceptai e)[310'CMR 15.302(5j]
D. System information }
r
.Residential Flow Conditions:
IvA
Number of bedrooms(design) -- - .Number of bedrooms(actual): 3
DESIGN flow based on 310 CHAR 15.203(for example: 110 gpd x#of bedrooms}:
r
tslns:11110 t* M&5 MW kUP8CbWFOW SWM9ftM Sewage D+sposaf System a Page 6 of 17,
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System.Form-Not for Voluntary Assessments'
34 Crossway Place .
Property Address'
Wendy Stein
Owner Owrner's Name
information is teNille °
required for every OS Ma 02655 1018/12
page. CitYRown State Zip Code Date of inspection
D. System Information 7.
Description:
Note: front system-is two block c pools one main and one overflow
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes 0 No
Is laundry on a separate sewage system? if yes separate inspection required) ❑ Yes No
t
Laundry system inspected? ❑ Yes ® No
Seasonal use? - ❑ Yes ED No
Water meter readings, if available last 2 ears usage d na
g ( Y 9 (gP )}�
Detail: t
Sump pump? ❑ Yes ® .No
Last date of occupancy;- • na
Date
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? r ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? _ ❑ Yes ❑ No
Water meter.readings, if available:
t5ins•11/10 Title 5 Official Inspection Form:Subswface Sewage Disposal System•Page 7 of 17
• l e
Commonwealth of Massachusetts
Title 5 Official Inspection Forme .
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
34 Crossway Place
Property Address '
Wendy Stein "
Owner Owner's Name
requir required
Osterviile .'Ma > 02655 1018112
required for every 4
page. City/Town State Zip Code Date of Inspection
D. System Information (corn.)
Last date of occupancy/use'. Date
Other(describe below):
General information '
Pumping Records:
Source of information: na
Was system pumped as part of the inspection? . ❑• Yes ® No
If yes,volume pumped: gauons
How was quantity pumped`determined? I
Reason for pumping:
Type of System; + '
El Septic tank, distribution box, soil absorption'system-
® MW cesspool
® Overflow cesspool ,
❑ Privy a .
❑ Shared system es or no If es, attach` revious ins ection records, if an
y (y ) Y P p y), .
❑ - in novativelAltemative 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):
t5hs•.,11110 rifle 5 Q(rrCiei hVectm Fomr.Subsurface Swags Disposal System•Page of V
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
34 Crossway Place
Property Address
Wendy Stein'
Owner Owner's Name
iMo. on Is Osteryille Ma 02655 4AI8/12°
required for every CityTCowrn
page. State Zip Code Date of Inspection
D. System Information (cunt.)
Approximate age of all components, date installed(if known)and source of information:
na
Were sewage odors detected when arriving at the site?, ❑ Yes ® No
Building Sewer(locate on site plan):
31
Depth below grade: feet
i n - -
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.):
.'cast iron/oma-ge burge
Septic Tank(locate on site plan):
Depth below grade: , feet r
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 ❑ Na
Dimensions:
Sludge depth;
r
t5fns 11/10, Title 5 WOW hWeaWn Fortin.SOWfaw Smage DiVosel System-Poe 8 of 17
{
Commonwealth of Massachusetts
Title 5 Official Ins p.ection' Farm
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "
34 Crossway Place
Property Address
Wendy Stein
owner Owner's Name
information is
required for every Osterville Ma 02655 , - 10/8/12
page. City/Town State Zip Code Date of inspection
D. System information (cunt.)
Septic Tank(cunt.)
Distance from top of sludge to bottom of outlet tee or baffle
• Scum thickness
Distance from top of:scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle.
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
f
Grease Trap(locate on site plan): t.
Depth below grade:
feet
Material of construction: . .. ,•
❑concrete' .❑ metal Fl fiberglass ❑polyethylene ❑other(explain): .
Dimensions:
Scum thickness
'bistance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle ,
r Date of last pumping: Date
t5ins•_11M.0 Tft.s Ord bspeciim Form&bPAace&MEige Disposal System•Page 10 of 17
t Commonwealth of Massachusetts '
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
34 Crossway Place
Property Address
Wendy Stein
Owner Owner's Flame
inibmiafion is
required for every Osterville + Ma`.u` `02655. 10/8/12
page. Cityrrown
` State Zip Code Date of Inspection
D. System Information (coat.) k
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: t} " 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•1111..0 Title 5 Official
r
Inspection Form:Subsurface Sewage Disposal System•Page4.11 of 17
Commonwealth'of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
34 Crossway Place
Property Address ,
Wendy Stein
Owner Owner's Name
"'forrivitt1°°is
required for every Osterville Ma 02655 m .1018/12 page. GitylTown State Zip Code Date of Inspection
D. System Information (cone.)
Distribution Box(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.): -
.
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.):
Soil Absorption System(SAS)(locate on site plan, excavation not required).
1
If SAS not located, explain why:
t5ins-11/10 Title 5 Orfiew Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
t
Commonwealth of Massachusetts
Title 5 official Inspection Form- ,
Subsurface Sewage Disposal System Form--Not for Voluntary Assessments
34 Crossway Place
Property Address -
Wendy Stein
Owner Owner's Name
info °'s
required for every Csterville Ma 02655 1018/12
CitytTown
page. State Zip Code Date of Inspection
D. System Information (cont.)'
Type:
❑ leaching pits number:
1-1 leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches ' number, length:
❑ leaching fields number,dimensions:
® overflow,cesspool number 1
❑ 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.):
leaching is one block c pool 7'4"deep w/steel cover at grade in drive way dry walls clean no sign of
overloading or solid carry over"'
Cessl is(cesspool must be pumped as part of inspection)(locate on site plan)*
Number and configuration 1
a
Depth—top of liquid to inlet invert
Depth of solids layer
0"
Depth of.scum layer
6'6m
Dimensions of cesspool
Materials of construction block
•indication of groundwater inflow ❑ Yes No
t5ins•11t10 a Title 5 Official Aispection Form:Subsurface Sewage Disposal System•Page,13 of 17
1
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
34 Crossway Place
Property Address
Wendy stein
Owner Owner's Name
information is required for every Osteryille . - Ma 02655. 10/8/12
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.):
main pool block 29"below grade w/cover at 11 N one line out to overflow pool
,
Privy(locate on site plan).
Materials of construction:
,
Dimensions
i
Depth of solids =
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition,of vegetation,
etc.): ,
Of
Lf
W
b '
t5ins•11H0 Title 5 Official hispechon Fomr..Subsixraee Sewage Disposal.System•Page 14 of 17 '
f
Commonwealth of Massachusetts ,
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
34 Crossway Place
Property Address
Wendy Stein
Owner Owner's Name
inibmiafion is
required for every Osterville _ 'Ma', 02655 10/8112
page, Cityrrown State Zip Code Data of Inspection
D. System Information (cons.)
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 budding.Check one of the boxes below:
® hand-sketch in the area below,
❑ drawing attached separately
; fir 0 �/-r
_
r
t5ins-11H.o Ttte 5 OfficM hryspedon Form.Subsurface.Sege Disposal System-Page 15 of V
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form;-Not for Voluntary Assessments
34 Crossway Place
Property Address
Wendy Stein
Owner owner's Name
inforn'r3tion is '
required for every Ostervitte 4 • Ma 02655 1018/12
page. Citylrown State Zip Code Date of tnspedion
D. System Information (cont.) -
Site Exam: E
® Check Slope �, K
❑ Surface water �
.,.. . -
® 'Check cellar
y ❑ .Shallow wells'
Estimated'depth to high ground water 60'+
- feet i
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:. Hate
® - Observed site abutting proper 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: _.
rear slope,area drop off
F Before filing this Inspection Report,please see Report Completeness Checklist on next page.
15ttss•1111.0 TtHe.5 Oftel hspwfim Form:Stbs wleoe.Sewage Disposal System•Page 16 or 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form`
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
34 Crossway Place
Property Address
Wendy Stein
Owner Owner's Name -
information is Osterville Ma 02655 10/8/12
required for every City(Town
page. State Zip Code Date of tnspedion
E. Report Completeness Checklist.
. " F
® Inspection Summary:A, 8, C,FD, or E checked y
S
® Inspection Summary D(System Failure Criteria Applicable to All,Systems)completed
® System Information—Estimated depth to high groundwater ,
1Z Sketch of.Sewage Disposal System either drawn on page 15 or attached in separate file
1
,• a r. .. f - i. P
t51rts•11/10 TiNe 5 Official ftpedon form:Subsurface Sewage Disposal System-Page 17 of 17
Commonwealth of Massachusetts c
Title 5 Official Inspection Form
.,I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
' 34 CROSSWAY PLACE
Property Address
ARTHUR STEIN
Owner Owner's Name
information is required for every OSTERVILLE MA 02655 7/14/2010
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted-on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
***NOTE: 2 SYSTEMS ONSITE. BOTH ARE OLD CESSPOOLS WITH ORANGE BURGE&CAST
IRON PIPE. RECOMMEND REMOVAL OF DISPOSAL TO ADD TO LIFE OF SYSTEM***
Important:When A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your �.
cursor-do not JAMES D SEARS
use the return
key. Name of Inspector
BLUEWATER HLD CORP
rab Company Name
350 MAIN ST-ROUTE 28
Company Address
W YARMOUTH MA
02673
City/Town State Zip Code
800-593-6449 S-1623
Telephone Number License Number
B. Certification
I certify that I have personally in 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:
X❑ _ Passes ' ❑' Conditionally Passes ❑ pFgsOq���
❑ Needs Further Evaluation by the Local Approving Authority .�' �'^ '•;yN%
JAMES :_m=
SEARS
7/15/2010 %�i••�'F '��•`'�c:
�S T.•. RTI�� ��?
I ector's Signature Date I N SPA: ```7
i F
. �
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System• ge 1 0 77
Commonwealth of Massachusetts
-- ,g Title 5 Official Inspection Form
_
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
. ..........
v. 34 CROSSWAY PLACE
Property Address
ARTHUR STEIN
Owner Owner's Name
information is required for every OSTERVILLE MA 02655 7/14/2010
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: X
❑ 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:
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):
c F
t5ins•09108 Title 5 Official Inspecdon Form:Subsurface Sewage Disposal System•Page 2 of 17
l
\ Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
34 CROSSWAY PLACE
Property Address
ARTHUR STEIN
Owner Owner's Name
information is OSTERVILLE MA 02655 7/14/2010
required for every
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cant.)
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 ❑e.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 ElY ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
F ❑ 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
ev� Commonwealth of Massachusetts
- ,. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M a 34 CROSSWAY PLACE .
Property Address
ARTHUR STEIN
Owner Owner's Name
information is required for every OSTERVILLE MA 02655 7/14/2010
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
El 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.
El 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 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
❑ 0 Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ 0 Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
Ei ❑NA Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El 0 Liquid depth in cesspool is less than 6'` below invert or available volume is less
than Y day flow
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
........... ..
Commonwealth of Massachusetts _
A711
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
34 CROSSWAY PLACE
Property Address
ARTHUR STEIN
Owner Owners Name
information is OSTERVILLE MA 02655 Y/14/2010
required for every
page. City/Town 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:
❑ x❑ Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ X❑.� _Any portion of cesspool or,privy is within.100 feet of a surface water supply or
tributary to a surface water supply.
❑ 0 Any portion of a cesspool or,privy is within a Zone 1 of a public well..
❑ x❑ ^ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ 0 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.
❑ 0 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
El El 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
El.
El Area
system is located in a nitrogen sensitive area(Interim.Wellhead Protection .
l 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
r Section D shall upgrade the
system considered a significant threat under Section E or failed under, pg
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 Title 5 Official Inspection,Fonn:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Q. ... Title 5 Official Inspection Form
y Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
tz
M 34 CROSSWAY PLACE
Property Address
ARTHUR STEIN
Owner Owner's Name
information is required for every OSTERVILLE MA 02655 , 7/14/2010.
page. City/Town 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
❑x ❑ Pumping information was provided by the owner, occupant, or Board.of Health
❑ x❑ Were any of the system components pumped'out in the previous two weeks?
x❑ ❑ Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system' recently or as part of
this inspection?
El RNA Were as built plans of.the system obtained and examined? (If they were not
available note as N/A)
0 - ❑ Was the facility or dwelling inspected for signs of sewage back up?
❑x ❑ Was the site inspected for signs of breakout?
❑x ❑ Were all system components, including the SAS, located on site?
Z ❑ Were the manholes uncovered, opened, and the interior inspected for the
condition of the tees, material of construction, dimensions, depth of liquid, depth
of sludge and depth of scum?
0 ❑. , Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of:subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
Existing information. For example, a plan at the Board of Health.
ElDetermined 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): NA Number of bedrooms(actual): 3
DESIGN flow based on`310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
r
Commonwealth of Massachusetts
-- � Title 5 Official Inspection . Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
34 CROSSWAY PLACE
Property Address
ARTHUR STEIN
Owner Owner's Name
information is required for every OSTERVILLE MA 02655 7/14/2010
page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? AS ❑ No
Is laundry on a separate sewage system?(if yes separate inspection required] ❑Yes N No
Laundry system inspected? f. ❑Yes Z No
Seasonal use? []Yes X❑ No
Water meter readings, if available(last 2 years usage:. 09-63000 GAL
08-113000 GAL
Detail:
Sump pump? ❑Yes No.
Last date of occupancy: CURRENT
Date
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,•09108 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
- - - , Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
- 34 CROSSWAY PLACE
Property Address
ARTHUR STEIN
Owner Owner's Name
information is required for every OSTERVILLE MA 02655 7/14/2010
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: " 2010 PER OWNER.
Was system pumped as part of the inspection? ❑Yes x❑ No
If yes, volume pumped:
gallons '-
How was quantity pumped determined?
Reason for pumping:
Type of System: BOTH FRONT& REAR SYSTEMS
❑ Septic tank, distribution box, soil absorption system
x❑ Cesspool
x❑ 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-09/08 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
2
34 CROSSWAY PLACE
Property Address
ARTHUR STEIN
Owner Owner's Name
information is OSTERVILLE MA 02655 7/.14/2010
required for every
C' !Town State Zip Code Date of Inspection
t
page. �Y p P
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
NA
Were sewage odors detected when arriving at the site? Dyes ❑ pNo
Building Sewer(locate on site plan): FRONT REAR.
3011 3'
Depth below grade: feet
Material of construction:
❑x cast iron 1140 PVC 0 other(explain): CAST IRON/OB CAST IRON/OB
Distance from private water supply well or suction line: feet '
Comments (on condition of joints, venting, evidence of leakage, etc.):
CAMERA LINE AND THERE ARE NO BRAKES OR ROOTS.
Septic Tank(locate on site plan):
Depth below grade: 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:
Sludge depth:
t5ins•09/08 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
�~
34 CROSSWAY PLACE
Property Address
ARTHUR STEIN
Owner Owner's Name
information is required for every OSTERVILLE MA 02655 7/14/2010
page. Cityfrown 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
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.): `
i -
Grease Trap(locate on site plan):
Depth below grade:
feet
Material of construction:
❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
.Distance from to of scum to to of outlet tee or baff
le
P P ,
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: date
t5ins-09/08 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
34 CROSSWAY PLACE
Property Address
ARTHUR STEIN
Owner Owner's Name
information is required for every OSTERVILLE MA 02655 7/14/2010
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•ogm Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 1t of 17
Commonwealth of Massachusetts
Title Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
34 CROSSWAY PLACE
Property Address
ARTHUR STEIN
Owner Owner's Name
information is requ OSTERVILLE MA 02655 7/14/2010
ir ed for 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
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(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.):
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
- -; Title 5 Official Inspection Form
. _..... Subsurface Sewage Disp osal System Form -Not for Voluntary Assessments
34 CROSSWAY PLACE
Property Address
ARTHUR STEIN
Owner Owner's Name
information is OSTERVILLE . MA 02655 7/14/2010
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) `
Type. FR. REAR
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑, leaching trenches number, length:
❑ leaching fields number, dimensions:
❑x overflow cesspool number: 1
❑ 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.):
FRONT-T DEEP BLOCK 18"WATER. NO HIGH STAIN LINE AND WALLS ARE CLEAN. STEEL
COVER AT GRADE IN DRIVEWAY. NO SIGN OF OVERLOADING OR SOLID CARRY OVER.
REAR-T DEEP WITH COVER AT 2'. 2'WATER BUT NO HIGH STAINLINE. NO SIGN OF
OVERLOADING OR SOLID CARRY OVER.
MAIN Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration 1 1
Depth—top of liquid to inlet invert
i 211 211
Depth of solids layer
Depth of scum layer
8, 7,
Dimensions of cesspool
Materials of construction BLOCK BLOCK
Indication of groundwater inflow ❑Yes 0 No
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts ,
Title 5 Official Inspection, Form
Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments,
/r 34 CROSSWAY PLACE
Property Address .
{
ARTHUR STEIN
Owner Owner's Name
information is OSTERVILLE MA ' 02655 . 7/14/2010
required for every
page. Cltyfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition.of soil, signs of hydraulic failure,level"of pond ing,'condition of vegetation,
etc.):
FRONT POOL AT LEVEL. NO IN TEE, OUTLET,TEE WITH COVER AT 8":
REAR POOL AT LEVEL.- NO IN TEE, OUTLET TEE WITH COVER AT-8".
N Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids r .
Comments (note condition of soil,,,signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): r
0
. -
t
t5ins•09/08 x Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
-- - � Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M � 34 CROSSWAY PLACE '
Property Address '
ARTHUR STEIN
Owner Owner's Name
information is required for every OSTERVILLE MA 02655 7/14/2010
.,
page. Cityrrown 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 <
0 drawing attached separately
R?&4 A D !�
!A 01
as
A
�2 7'-3
t5ins•09108 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
34 CROSSWAY PLACE
Property Address
ARTHUR STEIN
Owner Owners Name
information is required for every OSTERVILLE MA - 02655 7/14/2010
page. Cityfrown State .Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
x❑ Check Slope REAR SOME
Z Surface water
NONE
0 Check cellar FINISHED WALK OUT
x❑ Shallow wells NONE
60'+
Estimated depth to high groundwater: 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)
x❑ Accessed USGS database-explain:
You must describe how you established the high groundwater elevation:
REAR SLOPE. AREA DROP`OFF. 60'+. USGS WELL MIW 29 ZONE A 7-2
g7o, �r
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
E. Report Completeness Checklist
P
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
34 CROSSWAY PLACE
Property Address
ARTHUR STEIN
Owner Owner's Name
information is required for every OSTERVILLE MA 02655 7/14/2010
page. Citylrown State Zip Code Date of Inspection
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
E. Report Completeness Checklist
Inspection Summary: A, B, C, D, or E checked
Inspection Summary D (System Failure.Criteria Applicable to All Systems)completed
0 System Information—Estimated depth,to high groundwater u
x❑ Sketch of Sewage Disposal System either-drawn on page 15 or attached in separate file
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
ASSESSOR'S MAP NO. PARCEL
LOCATION SEWAGE PERMIT NO.
34 Lzmos 12
VILLAGE
OAS
INSTA LLER'S NAME ADDRESS
OWNER
e
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUEDmis ? '`
y Rol404j-r2 .
GCE
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