HomeMy WebLinkAbout0131 CRYSTAL LAKE ROAD - Health 131 CRYSTAL LAKE R7 OSTERVILLE
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Crocker, Sharon
From: Crocker, Sharon
Sent: Monday, October 19, 2020 3:27 PM
To: McKean, Thomas
Subject: 131 Crystal Lake Rd Ost - Daily Flow Design
Tom,
We received a call from D. Kenney, Robert Paul Properties, 508-776-2048 EMAIL:
dkennev@robertpaul.com
She said at the time the current owner purchased, there was correspondence going back and forth to
determine daily flow.
Owner is looking to sell and wants to make sure gets credit for 4 bedroom.
I will leave file on your desk. The 1988 permit says 3 bdrm. There is a letter to BOH from Peter Sullivan stating
the design flow is 549 gallons.
I do not see it on the BOH agenda for June 2000(before my time) but it looks like it went to Board. No letter in
file.
Please review.
Thank you
ro
Sharon Crocker
Office Manager
Town of Barnstable—Hea t
508-862-4739
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THE COMMONWEALTH OF MASSACHUSETTS
t� 3
BOARD,, OF HEALTH' , ,,.,,-
........................... .OF..:.. .
Auuliratiun for VrTuti#
Application is hereby made for a Permit to :Construct ( ) or Repair. ( )' an. Individual Sewage.Dtsposal
System at:
�............... ysT,a 4....[_.4!L a ..... .:... �.� �.A.- ------------ -
oca�jtio�n/•Address o' or Lot No
1.2
{�� Owner Address
wnG............4.5. . .
Installer Address
Type of Building Size Lot..R3f r ....Sq. feet
U Dwelling—No. of Bedrooms.... .......Expansion Attic ( ) Garbage Giinder.( '
Other—Type T e of Building No.-`of ersons p yp g p Showers { ) Cafeteria ( <)
a Other fixture
77------------- ---• I...........................
Design Flow.... .....:... .. 5 4r ...::.:...gallons per person per day. Total daily flow....�30.. gallons.
Septic Tank—Liquid capacitylQgallons Length./a'_G' Width. .1 1". )�e»e1er.'>r� ,�"_ Depth
xDisposal Trench—No. ................. Width...................-_Total Length..................... Total leaching .....area _ _.s q.#t.
Seepage Pit No........I......... Diameter...�'.Q-........ Depth below inlet __..� .........Total~leaching area..:Z4 ..sq, ft.,
z. Other Distribution box (✓ Dosing tank ( )
Percolation Test Results Performed by,:__ 4a4 T : ..t,. )1 :. ...: ..... Date:_7 Ir.
Test Pit No. 149.A ..Z.minutes per inch Depth of Test Pit_____C ... Depth to ground water �-.........
Test Pit No. 2.:..............minutes per inch Depth of Test.Pit ................. Depth to groundwater..................
O Description of Soil s Ta= .....::: ....... •...::.. -_..:- ...............
W .................... •: ....... ..... .......................... ....
U Nature of Repairs or Alterations=Answer when applicable......_ ............ ..... ....... .. ..........................................
:..
Agreement
The undersigned agrees to install;the aforedescribed Individual Sewage Disposal System h.accordance with
the provisions of TITLE 5 of the States Sanitary Code-The undersigned further agrees not to place the system in
operat uptil a e e of Compliance has been issued by the board of health.
ed
to
Application Approved y ........... :. ...... ....................................^ s�...
Date
Application Disapproved for the f ollmu ng reasons......::.................. ...... ..._............
...... ............. ..... .......... ......• •.. .Date
Permit No.....`g :..: .......: '' Issued. ----•--- -- ---
^Date
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ngineeri Sullivan Eng Inc
'7 Parker.'Road
'., Box 659`osterville MA 02655 m`
Peter Sullivan P.E . Mass. Registration No. 29733
Phone 508-428-3344 Fax 508-428' 115 -
e-mail: psullpe@aol.com
`June"8, 2000
Town of Barnstable
Board of Health _ r_ 71 �
367 Main Street
.Hyannis, MA 02601
Af
RE: Septic Evalua tion/13 1 Crystal Lake Road, Osterville s 9
toy, ?400 k
Map 139:Parce1005-002 wa° sr,
Dear Board of Health,
Based on a review the{folloWing'information, an evaluation in
of f,Y
accordance with 310CMRf15.301(2} has>been performed:
1. Sketch Plan of Land in Osterville dated 4 19-85 by William H Fardie, PE "
2 Application for Disposal Works Permit 85-446
3. "As built" card/Compliance Card dated,8-15-85 " r`
4. Title V Septic Evaluation Inspection Report dated June`3, 2000,X n
It has been determined that the.existing septic has the,presenVcapacity,
of 549 gallons per day and appears:to be in good wo"r'king order.
I trust this-meets our' resent needs: 1f ou,re uire additional
information, please do not hesitate- to,contact.:me� .. R
Very truly your
d OF
PMR
Peter Sullivan` SULLIVAN
7.9733
t Sullivan Engineering.Ific. CIVIL
, , � j
Wmbers'of
American Society of Civil Engineers, Boston Society,of Civil Engineers' 4
'Lo CAT IONjoal SEWAGE PERMIT NO.
Ln , 239 A- ��cvsr � L,4,t6 i7ary 'R5 -926
VILLAGE
i INSTA LLER'S NAME i ADDRESS
A C "E),Fv&io"e7ry 60P
B U I L D E R 0 8�YwN-E#
I ci 09^ Ern S
�
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
i
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TOWN OF BARNSTABLE
�'QCATION I C SEWAGE #
VILLAGE O ST'erj, ASSESSOR'S MAP & LOT 13 OoS•dDa--
,_r
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY /S0-0
LEACHING FACILITY: (type) IT (size) 7 X(D
NO.OF BEDROOMS
BUILDER OR OWNER K/A US ul Ir��r,nn
PERMIIDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
At
{
Sa- 35
All = aq
3 133- N 0
y Ay- 30
36-r
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C"
SYSTEM INFORMATION. (continued)
Property Address: 131 Oystal Lake Road, OsteMlle,MA
Owner: Klaus Ullaman
Date of Inspection: June Z.2000 r -
Map: 139
` Parcel: 005-002.
SKETCH OF SEWAGE DISPOSAL SYSTEM: ~
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house) 4 .
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AL
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33- 140
;
AH- 10
revised 9/2/98 Page 10ofII T h
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
a SYSTEM INFORMATION (continued)
Property Address: 131 Crystal Lake Road, Osterville,MA
Owner: Klaus Ullaman
Date of Inspection: June 2, 2000
NRCS Report name
Soil Type
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater 20+/- Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property,observation hole,basement sump etc.)
Determined from local conditions
✓ Checked with local Board of Health
Checked FEMA Maps
Checked pumping records
Check local excavators, installers
✓ Used USGS Data
Describe how you established the High Groundwater Elevation. Must be completed)
The bottom of the pit to grade was 14'. .Using the Barnstable topographic map and water contours map, the maps were showing
approximately 20' +/- to groundwater at this site. Using the Cape Cod Commission Technical Bulletin, the high groundwater
adjustment for this site(MI W 29, Zone A, 4100)was 1.S'.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty
or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,
written or implied, relating to the system, the inspection and/or this report.
revised 9/2/98 Page 11of11
n: Fas ...... ._. ............
THE COMMONWEALTH OF MASSACHUSETTS �
B ARD. OF HEALTH
O ."
.............................................. a
,�� lirtt#inn for �iknttttl nrkl (��ans#rur#iun fermi#
Application is hereby made for a Permit to Construct ( ) or Repair ( .) an Disposal
Individual'Sewage.
System at: ..... ��:� _. •-
e
�ji S! - - or Lot No
........ +s
�/ Location•Addre
j��N............ Adaresa .... .
Y/ Owner - ...
... .....
1 I•Tv....... ................
•Installer feet .
.a Size Lot........ Sq.
Type of Building Garbage Grinder .( )
U Dwelling—No. Of Bedrooms....�....
...Expansion'Attic.( ) t
... ..: Showers —• Cafeteria ( )
Pk Other—Type of Building ............................ No. of persons......... ( )
....................................
d Other fixtures ...................................... ........... y
llons er erson per day. Total ilygJlow 3. •O •Igallons.`
Design Flow.....SZ!-- Sa P P /� WtdthS� Diameterf�.Or Depth
..Total leaching area........ ........sq�ft _
W Septic Tank—Liquid capactty��! •gallons Len I' g :� ,
x Disposal Trench—No.....................Width....................Total Len th.. g
Diameter../..p............ Depth below inlet..A ..........Total leaching area.�i�1• sq. ft.
Seepage Pit NO..�............... Dosing tank ( ,)'
z Other Distribution box (1%1 ^l .•..... Date..•-� f� F
Percolation Test Results Performed by. ,IL)eT4-e�••f- ,�! ' .
.i 7`m eiforinutes per inch Depth of Test Pit.13.--•--••---..•Depth to ground wat
.a Test Pit No: I�fSS
w Test Pit No. 2................minutesper inch Depth of Test Pit....................Depth to ground water.::::::.::::::::::::::-•
......................................
Descriptionof Soil..:.'�� re1�D..........1/ A"..JL•A j�N
V .. _....... ........ ..... ..
:...
W .
x Nature of Repairs or Alterations—Answer when applicable
U ,
...................................... ..,
4 Agreement:
agrees to�install the aforedescnbed Individual Sewage Disposal System in accordance with
The undersigned
the provisions of TITLE 5 of the State Sanitary Code-The undersigned further agrees not to place the system in ,
operation until a er' cat Compliance has been issued by the board of health.
/ gned......... .`... ..... ................ �oau
............
i tion Approved By.............. 1 t Date
App CD
Application Disapproved for the following reasons
.................
Date
.......
....Permit No........�55.�.-.. � Issued Dace..
.. �L * • S A
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
t • .....
OF ......... +
THISIS TO CERTIFY-That-the Iridividual Sewage Disposal System constructed ( ) or,Repaired{ )
by............... .�1dre�.c b 'r Ina ally
A �.c3..........��... .. ....... ....
at.......................... . N� t
�„9.......... �.f ,1
has been installed in accordance wv h the�r visions of TITLE x`5 of The State Sanitary Code as described m the
application for Disposal Works Construction.Permit No.....�,�-•"
�LD•- dated...... ? .."7/9 S........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS UED AS GU NT E THAT THE
SYSTEM WILL�FUNCT N SATISFACTORY:,
DATE....... `G?1! • � ........ Inspector
. .
THE COMMONWEALTH OF MASSACHUSETTS r ~
t r ;'.BOARD' OF
';HEALTH
.............................
OF ..`.. Fes . �
No' ���•'T`I
3�ittianttl orko �nr� ion. rrmt#
......../r ..
tl..
Permission is hereby granted ....................................
to Construct ( ) or Repair-.(.. ) an Ind ual Sewage Disposal S tem '
�1 C � ��.................................................
at NO............�"._Yc}:fA ....� Street
e. �5 tea....... ' ......:.
as shown on the a_pplication for Disposal Works Construction Permit N�----� ,
i 1 .Board o •• ...... .. ,
pp Bolth
a f Health
.... �j� l ���'U� g ..
...
DATE..
FORM 126'3 A.M::9t1L IN.INC..BOSTON ..
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FETCH. LA OF LAMD IN03TER ILLS VI
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13dAp9 lots 239,139A t' r.49 Shown on R' ,o/an Prepared .for
Reicl H.M.4n .Tana 7984, by Baxter eAly /nc. O-c/
re e/ed Da natwb/e R-iy/$try of Deea/s, 2�k394 &o c 4/,
i E/G�l�i`iv.�3 basec�orl.....4. 1✓af/a„eleoo/off,..
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P-3s// .. .i
're s r Pi r DATA
{ Made. 7-3/-84 —
i Wit. N/,? Toi/N TACOD/
Pe,L.R61a less Yhe.v 2ncin. t.
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WILLIAM �G
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fARDIE h
09�G16TEP`��
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L.0CATION SEWAGE PERMIT NO.
' Lnr "�t39 A• ��.�srw� L,arIL?..DAD ��-�/�/6
VI L L A G E
J STL�2�iKE 3 i ^ .
INSTA LLER'.S NAME i _ ADDRESS
1 t� efn C � UaP�►t�•T ( �P•
d U I L D E R r `
` \ DATE PERMI.T . ISSUED
DATE. COMPLIANCE "ISSUED'y '
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°� Commonwealth of Massachusetts
(e Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�o � t
131 Crystal Lake Rd
Property Address
r•,
Evans
Owner Owner's Name <
information is y
required for every Osterville MA 02655 10/1/20
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.
A. Inspector Information
Frank Nunes III
Name of Inspector
saa
Company Name
Box 841
Company Address
East Falmouth MA 02536
Citylrown State Zip Code
508.272.6433 13010
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4.. ❑ Fails
10/1/20
Inspector's gnature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
Commonwealth of Massachusetts
(P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
.�� 131 Crystal Lake Rd
Property Address
Evans
Owner Owner's Name
information is
required for every Osterville MA 02655 10/1/20
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
131 Crystal Lake Rd
Property Address
Evans
Owner Owners Name
information is
required for every Osterville MA 02655 10/1/20
page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes(cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
r
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
Commonwealth of Massachusetts
�. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
131 Crystal Lake Rd
Property Address
Evans
Owner Owner's Name
information is
required for every Osterville MA 02655 10/1/20
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
131 Crystal Lake Rd
Property Address
Evans
Owner Owner's Name
information is
required for every Osterville MA 02655 10/1/20
page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6° below invert or available volume is less
than '/2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
f
Commonwealth of Massachusetts
�. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
131 Crystal Lake Rd
Property Address
Evans
Owner Owner's Name
information is
required for every Osterville MA 02655 10/1/20
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ 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)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
005
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
131 Crystal Lake Rd `
Property Address
Evans t
Owner Owner's Name
information is
required for every Osterville ,� MA 02655 10/1/20
page. Cityrrown State Zip Code Date of Inspection <"
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3+ Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 549 gpd
Description:
1985 plan and permit for 3 bedroom on file at BOH, OK for 4 bedroom by Thomas McKean based on
letter from Sullivan Engineering stating a daily flow of 549 gpd provided
C� Number of current residents: 4
Does residence have a garbage grinder? ® Yes ❑ No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: OccupiedDate
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�o
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
131 Crystal Lake Rd
Property Address
Evans
Owner Owner's Name
information is
required for every Osterville MA 02655 10/1/20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings,,if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Pumped summer 2019 per owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
f
Commonwealth of Massachusetts
L-� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�o
131 Crystal Lake Rd
Property Address
Evans
Owner Owner s Name
information is
required for every Osterville MA 02655 10/1/20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
1985 per BOH record
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
5. Building Sewer(locate on site plan):
Depth below grade: 7'6"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >10'feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
f
Commonwealth of Massachusetts
�. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
131 Crystal Lake Rd
Property Address
Evans
Owner Owner's Name
information is
required for every Osterville MA 02655 10/1/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 71
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
H-10 tank appears to be structurally sound, inlet cover raised to 12" of grade, probing gives no
indication of a raised cover at the outlet
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500g
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Unable to take scum and sludge measurements to to the excessive depth of the tank. Pumping
suggested every 3yrs to prolong the life of the system
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
131 Crystal Lake Rd
Property Address
Evans
Owner Owner's Name
information is
required for every Osterville MA 02655 10/1/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
131 Crystal Lake Rd �
Property Address
Evans
Owner Owner's Name
information is
required for every Osterville MA 02655 10/1/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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.):
Probing gives no indication of a raised cover, the box is approximately 7' below grade and due to its
excessive depth it was not inspected
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
(P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
131 Crystal Lake Rd
Property Address
Evans
Owner Owner's Name
information is
required for every Osterville MA 02655 10/1/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® 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:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
1
Commonwealth of Massachusetts
,ip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
v 131 Crystal Lake Rd
Property Address
Evans
Owner Owner's Name
information is
required for every Osterville MA 02655 10/1/20
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach pit is damp at this time, bottom of pit is 13'6" below grade, stain line 2' below the invert, no
indication of past hydraulic failure, cover raised to 12"of grade, pit has 4'of effective leaching per
1985 compliance
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
,io Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
131 Crystal Lake Rd
Property Address
Evans
Owner Owner s Name
information is
required for every Osterville MA 02655 10/1/20
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
6
• R
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
YA ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
a
u 131 Crystal Lake Rd
Property Address
Evans
Owner Owners Name
information is
required for every Osterville MA 02655 10/1/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
1Y
�3 c� GSv
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
131 Crystal Lake Rd
Property Address
Evans
Owner Owner's Name
information is
required for every Osterville MA 02655 10/1/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: >14'
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: 1985
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
4' seperation per 1985 compliance
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
TOPO mapping puts the site at 28'msl and nearby surface water at 4'msl
You must describe how you established the high ground water elevation:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins .doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
P P 9 Y 9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '
131 Crystal Lake Rd
Property Address
Evans
Owner Owner's Name
information is
required for every Osterville MA 02655 10/1/20
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist k
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
-46
i
Commonwealth of Massachusetts
Executive of Environmental Affairs ASS
DEP
Department of o
Environmental Protection 9 �`
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 131 Crystal Lake R oad. O sterville, M a.
Address of Owner: Brian O' Connell
(if different) 1029 Pleasant Street. Worcester, Ma 01602
Date of Inspection: 08/13/96
N ame Hof Inspector: Michael D eD ecko
Company Name, Address and Telephone number: Atlantic Environmental
P.o B ox 2384 - M ashpee M a 02649. Tel : (508) 4771420
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
Passes
---- Conditionally Passes
---- Needs further evaluation by the local Approving Authority
---- Fails
Inspector ' s Signature Uc ate: 08/1 V96
The system Inspector shall submit a copy of this inspection report to the Approving
Authority within thirty (30) days of completing this inspection. If the system
is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the
system owner shall submit the report to the appropriate regional office or the Department
of Environmental Protection.
The original should be sent to the system owner and copy sent to the buyer, if applicable
and the approving authority.
I �
SUBSURFACE SEWAGE DISPOSAL SYSTEM
PART AINSPECTION FORM
CERTIFICATION (continu
ed)
Property Address: 131 Crystal Lake Road. 0sterville, Ma.
rs
Date Inspection:eof . Brian O'Connell
08/13/96
INSPECTION SUMMARY.
Check A, B, C, or D
A)SYSTEM PASSES:
XI have not found an � '
y information which indicates that the system violates any of th
indicated below ena not evaluated area
failure criteria as defined in 310 CMR 1 5.303. Any failure crit
B)SYSTEM CONDITIONALLY PASSES-
---- One or more system components need to b
completion of the replacement or repaire relac, be rep aced or repaired. The system, upon
inspection.
Indicate yes, no, or not determinate
instances. If "not determinated", explain why not. Describe basis of determination in all
---- The septic tank is metal, cracked, structurally unsound, shows
exfiltration, or tank failure is imminent. The system will pass.ins
septic tank is replaced with a conforming se tic substantial infiltration or
Health. R tank as approved-inspection if Board of
g
---- Sewage backup or breakout or high static water level observed
box is due to broken or obstructed pipets)or due to a brat
distribution box. The system will pass ' ecti in the distribution
Health). ----- inspection if(with approval oftthe Board of
tled or n
broken pipets)are replaced
----- obstruction is removed
---- distribution box is levelled or replaced
..._ The system required pumping more khan four times a year d '
Pipets). The system will pass i a to brok inspection if(with approval of en or obstructed
the Board of Health):
----- broken pipets)are replaced
----- obstruction is removed
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR
PART A M
CERTIFICATION (continued)
Property Address: 131 Crystal Lake Road. 0sterville, Ma.
Date of Inspection : 08/13/96onnell
C) FURTHER EVALUATION IS REQUIRED BY THE BOA
RD OF HEALTH:
---- Conditions exist which require further evaluation by the Board of Health i
termine if the system is failing to protect the public health . safety and the -
n order to de-
ment. enviran
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH
SYSTEM IS NOT FUNCTIONING IN A FANNER WHICH WILL PROTECT THE
PUBLIC HEALTH. AND SAFETYAND THE ENVIRONMENT: ECT THE
---- Cesspool or privy is within 50 feet of a surface of water
---- Cesspool or privy is within 50 feet of a.bordering vegetated wetland or r a small
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH A
ND SUPPLIER, IFAPPROPRIATE) DETERMINES THAT THEE SYSTEM I FUNCR
TIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH MIS SAFE
AND THE ENVIRONMENT. AND SAFETY
---- The system has a septic tank and soil absorption system a
surface water supply or tributary to a surface water supply.
d is within 100 feet to a
The system has a septic tank and soil absorption system a d is within of a public water supply well. n a Zone I
The system has a septic tank and soil absorption system and is wit i
of a private water supply well. hm 50 feet
---- The system has a septic tank and soil absorption system and is less
than 100
feet but 50 feet or more from a private water supply well, unless a well analy-
sis for coliform bacteria and volatile organic compounds indicates that water analy-
Free from pollution from that facility and the presence of ammonia nitrogen the well is
nitrate notrogen is equal to or less than 5 ppm, trogen and
D)SYSTEM FAILS:
-- I have determined that the system violates one or more
as defined in 310 CM 15.303. The basis for this determination is ide
acted to de ' 'ed below.
The Board of Health should be conk a of the following failure criteriat
rect the failure. determine whale will be necessary to cor-
--- Backup of sewage into facility or system component d
ar clogged SAS or cesspool. due to an overloaded or
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 131 Crystal Lake R oad. 0 sterville, M a
Owner: Brian O'Connell
Date of Inspection : 08/13/96
D) SYS T E M FAI LS (continued)
-- Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
--- Static liquid level in the distribution box above outlet invert due to an over-
loaded or clogged SAS or cesspool.
--- Liquid depth in cesspool is less than 6" below invert or available volume is
less than 112 day flow.
--- Required pumping more than 4-times in the last year NOT due to clogged
or obstructed pipe(s).
number of times pumped
--- Any portion of the S oil Absorption System, cesspool or privy is below the high
groundwater elevation.
--- Any portion of cesspool or privy is within 100 feet of a surface water supply
ortributary to a surface water supply.
---Any portion of a cesspool or privy is within a Zone I 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 ana-
lysis. 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.
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 131 Crystal Lake R oad. O sterville, M a.
Owner: Brian O'Connell
Date of Inspection : 08/13/96
j
E) LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above
The design flow of system is 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 :
--- 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 I I of a public water supply well
The owner or operator of any such system shall bring the system and faciliity into full compli-
ance 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.
SUBSURFACE SELVAGE DISPOSAL SYSTEM INS
PART B PECTION FORM
CHECKLIST
Property Address: 131 Crystal Lake Road. Ostervill
Owner: Brian O'Connell e. Ma.
Date of Inspection: 08/13/96
Check if the following have been done :
-x Pumping information was requested of the owner.ner, occupant and Board of
--x None of the system components have been Pumped and the system has been receiving normal flow ratesfor duri least two weeks
ng the
volumes of water have not been introduced into the system rec period. Large
of this inspection. ently or as part
--x As built plans have been obtained and examined. Note if they
with NIA. ey are not available
--x The facility or dwelling was inspected for signs of sewage b
--x The system does not receive non-sanitary or industrial
act-up.
strial waste flow.
--x The site was inspected for signs of breakout.
--x All system components, excluding the Soil Absorption System.located on the site. y m, have been
---x The septic tank manholes were uncovered, o
tic tank was inspected for conditions of baff esnor teeed d the ma interior of the sep-
tion, dimensions, depth of liquid, depth of sludge, depth of material of construc-
---x The size and location of the Soil Absorption System scum.
mined based on existing information or approximated by nonce has been deter-
mined
---x The facility owners and occupants if different y intrusive methods
information on the proper maintenance of Subsurface Disposal were provided with
p sal System.
b
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 131 Crystal Lake R oad. 0 sterville, M a.
Owner: Brian O'Connell
Date of Inspection: 08/13/96
RESIDENTIAL:
Design flow : �j q0 gallons
Number of bedrooms : 0 4
Number of current residents: O 3
Garbage grinder (yes or no) : 0v
Laundry connected to system (yes or no):
Seasonal use (yes or no) :NO
Water meter readings, if available: N(s4 .
Last date of occupancy : V;-A"
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow : gallons/day
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 :
Other: (Describe) .............................................................:..............................................
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information
System pumped as part of inspection(yes or no):....N .......
if yes, volume pomped: .................... gallons
Reasonfor pumping:............................................................................ ........................_......
" _ 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 131 Crystal Lake R oad. O sterville, M a.
Owner: Brian O'Connell
Date of inspection: 08/13/96
TYPE OF SYSTEM
-Septic tank/distribution box/soil absorption system
--- Single cesspool
--- Overflow cesspool
--- Privy
--- Shared system(yes or no) (if yes, attach previous inspection records, if any)
--- Other (explain)...........................................................................................
APPROXIMATE AGE of all c mponents, date installed (if known) and source of information
Q,��X.... ..... ..,...........................................................................:...................
................................................................................................................................................
................................
S ewage odors detected when arriving at the site: (yes or no)....1V C�..
SEPTIC TANK : '
ANK : .. 45.....
(locate on site plan
Depth below grade: ..........
Material of construction: .. .. concrete ......... metal ........ FRP ........ other (explain)
................................................................................................................................................
Dimensions: v+
Sludge depth:... .'..'.....
Distance from top of sludge to bottom of outlet tee or baffle:....... .`j.................
Scum thickness:.....;4''..........
.
Distance from top of scum to top of outlet tee or baffle: .......1.0. ..........................
Distance from bottom of scum to bottom of outlet tee or baffle:......un\"..........
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, tc.)...........
..r4K...(Q.4.. d..�'9... ..� .�. [.��x aura..
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 131 Crystal Lake Road. 0sterville, Ma.
Owner: Brian O'Connell
Date of inspection: 08/13/96
GREASE TRAP : .......
..........
(locate on site plan)
Depth below grade: ...............
Material of construction: ........concrete.........metal........FRP........other(explain)....
..........................................................................................................................................
Dimensions:...............................
Scum thickness:........................
Distance from top of scum to top of outlet tee or baffle:.......................................
Distance from bottom scum to bottom of outlet tee or baffle:...............................
Comments:
(Recommendation for pumping condition of inlet and outlet tees or baffles, depth of liquid
level in relation to outlet invert, structural integrity, evidence of leakage, etc.)........................
................................................................................................................................................
................................................................................................................................................
TIGHT OR HOLDING TANKS:.... . .
(locate-on site plan)
.Depth below grade:...............
Material of construction:........concrete........metal.........FR P..........other (explain)..........
...................................................................................................................................
Dimensions:............................
Capacity:....................gallons
Design flow:...............gallons/day
Alarm level:.............................
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
.................................................................................................................................................
................................................................................................................................................
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM' INFORMATION (continued)
Property Address: 131 Crystal Lake R oad. O sterville,M a.
Owner: Brian O'Connell
Date of inspection: 08/13/96
DISTRIBUTION BOX:kf5
(locate on site plan)
Depth of liquid level above outlet invert:..... vc
Comment:
(note if level and distribution equal evidence of olids carryover, evidence of leakage intro
or out of box, etc.). -.Q��n ..... ... . .. ..: ..C�,►. $-t.��!�- 1ctY�..... . .�
-,.. . .►..................................................................................................................
PUMP CHAMBER:....:N-0
(locate on the site)
Pumps in working order: (yes or no)...............
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)....................
................................................................................................................................................
................................................................................................................................................
SOIL ABSORPTION SYSTEM (SAS):.....Ok �
(locate on site plan, if possible; excavation'not required, but may be approximated by non-
intrusive methods)
if not determined to be present, explain:
.................................................................................................................................................
.................................................................................................................................................
Type:
leaching pits, number: ..j... .4." ..V ►-V--
leaching chambers,number.........
leaching galleries, number:...........
leaching trenches,number ,length......................
leaching fields, number, dimensions:...................
overflow, cesspool, number:..........
Comments:
(note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetatio�r
�d
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property address: 131 Crystal Lake Road. O sterville, Ma.
Owner: Brian O'Connell
Date of inspection: 08/13/96
CESSPOOLS:......
(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: .....................
Indicator of ground water: ....................
inflow (cesspool must be pumped as part of inspection)
.................................................................................................
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.)
................................................................................................................................................
.................................................................................................................................................
PRIVY : ....1 �...
(locate on the site)
Material of construction: ....................................
Dimensions: ......................
Depth of solids: ................
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.) .
................................................................................................................................................
................................................................................................................................................
AA
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address : 131 Crystal Lake R oad. O sterville, M a.
Owner: Brian O'Connell
Date of inspection: 08113/96
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks locate at
wells within 100'.
ct
� 3
o LJ z _
R3 do
y
fs
DEPTH TO GROUNDWATER:
Depth to groundwater: t zR.feet
Method of determination or approximative:
.......................................... . .............. . .....................`...............................................
112
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................. ....................OF..........................................................................................
Appliratiou for Disposal Works Tonotrnr#inn Frrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
DI"
..............G•Z,/Stea. -..... .!41=.....l w� =------------. ............................DI" .....----------------------------------------............
Location-Address or Lot No.
Owner Address
w ............ ------..._ n G . ---------------------------------------------- --------------------------------------------- -------------------------------------•----------
F Installer Address
Type of Building Size Lot.Z.3,.�`........Sq. feet
,., Dwelling—No. of Bedrooms............ ...........................Expansion Attic ( ) Garbage Grinder ( )
a
p., Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures --------------------------------
w Design Flow.......................7.. ....._._...._.__gallons per person per day. Total daily flow...... ...........................gallons.
WSeptic Tank—Liquid'capacityJ-"Z o-__gallons Length../A4-6-. Width._ ':_,9.'___ Dia s-j"!n1". Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------- .......... Diameter..../. Depth below inlet......1`.._..... Total leaching area...2Z.7...sq. ft.
Z Other Distribution box (v") Dosing tank ( )
Percolation Test Results Performed by.... .T' .l°4.. ........................... Date.... ..........
a ,4 Test Pit No. I49� U.Zminutes per inch Depth of Test Pit...... -3...... Depth to ground water_-_ _...___..
fT4 Test Pit No. 2................minutes per inch Depth of Test Pit___--_..---____.__._ Depth to ground water........................
P ------------------------------------•---••--------•--------•.---••••.................---....--------.........................................................
0 Description of Soil..... ---•ZMi-.t?.......1Y...... --------------------•--------•-•--------------------------•--•-----•----
x
U
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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operat u it a ert a of Compliance has been issued by the board of health.
.... ned LI---- -;-•--------------------- ----------------•------ D �. __..Q..
Application Approved y--•-----•----__` - --•• =-•---- -•-•---•-----•----•.............•-•-••. -- M------ te•.�
Date
Application Disapproved for the following reasons------------------------•-------------------------------•----------------------•--...........................
....•----•-------•-••---•-----------------•------•------.._..-------•-•••-----•--------............._......•--••--•-••------•-•----••--------•-•--•----•--------••-•---••------------•---•...•-•-------•-
Date
PermitNo......` •..- ?_.._.. ..__. Issued_.......................................................
Date
r
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-•................. ...............:.OF.........---...................._........ .....
Appliration for 14spos al Works Cnayns rur#iun Prrutit
Application is hereby made for a`Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
F 1 �"-
..._.---� f -t J, ,....AA.X—.F..... �1 . f �.3 9` ......... ------------------
_" `� -: Location.Addre or•Lot No.
VOwner Address
a4�.••... .. ^......................................... ..•-•----•-------•...._.............---•--••------•-•-...........•-----...........................
Installer Address
Type of Building Size Lot............................Sq. feet
�-, Dwelling—No. of Bedrooms..... .:.:...............................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building ..._...._ No. of persons............................ Showers
Pk YP g ------------------- P ..............................................— Cafeteria (
d Other fixtures -------•---•---------------------------••------------.....---------------- ..------
Design Flow...._51�..............................gallons per,,person per day. Total'�laily ow---'3.__ ........ gallons.
WSeptic Tank—Liquid capacityj.�._.....gallons Length/_0-.(.--.-.. WidthQi'.'___�'....... Diameterif.--r_..... Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No../................ Diameter.1.Q............ Depth below inlet.-.�..._........... Total leaching area.20,.........sq. ft.
Z Other Distribution box (&/J Dosing tank ( )
Percolation Test Results Performed by._ -A�L7.m.:,r! N-0.0...... Date..' ... �.-. .............
a0 7----•--•------. . . .
Test Pit No: l� s�_.____minutes per inch Depth of Test Pit-_�-�............. Depth to groun wat ............ -
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
............................. ..........•-••-•------••...--••.....................
Description of Soil -------.//-=-:� _
j A 4...$.A hP(-••---------------------------------•--------------------•--•........---.
V
W -
UNature of Repairs or Alterations—Answer when applicable._..............................................................................................
-•-----------------------------------------------------------------------------•---......--------•------•--••---------------------------------------------------------------------------------•-------•
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a ertiicajp,oCompliance has been issued by the board of health.
gned............................. ............................................ ••-•------- -----...........
Date
Applic tion Approved By----------------- •- -- .......................................... -•- ------
Date
Application Disapproved for the following reasons---------------•--•---------------------------------............................................................
..................•---•------..........-•---------.......------•----------------------....... --•-----.._......--•---•--------- -----=-------------------•---•----------------••---•--.
Date
Permit No....._._..�--�--' �' ��3.....--.... Issued-....................................................... .
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
r�
{ ..............................:..........OF............... ......................................................................
Trrtifirn#r ,af Tautph aura
t THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by...• �� ... ..- -- .....
---- ••.
Ins aller
- ------- ri c --.... ----------- .:....." - -.... g `s��
has been"installed in accordance w th the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No----- �__------ dated ' ._" . . ...............:..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS WED AS GU NT E THAT THE
SYSTEM WILL FJINCTUON SATISFACTORY.
� Inspector............
DATE...........-•-- THE COMMONWEALTH OF MASSACHUSETTS
BOARD. OF HEALTH
...OF.......................................... ............
FEE. ... ....
Disposal Works Tu irrn rraui#
Permission is hereby granted............ ------------------ -------------- �._ .............
----•---.............
to Construct ( ) or Repair ( ) an IndfFil.lual Sewage Disposal System
atNo............ • 40 .. l ..............................................
- -
Street
as shownon the application for Disposal Works Construction Permit N4.= ` ated � ......
----------------
.................
' ,q� Board of Health
DATEE;......... '� �....................................
FORM 1255 A.M. SUL IN, INC., BOSTON
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FARDIE
No. 8995�O�e
9. 9 ;
SJpNAL�N
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9 ,
ULLMAN RE5IDENGE
10
0 ADDITION
131 GRY5TAL LAKE RD.
Na y ��►'0 05TERALLE, MA
r— — ——— ———-,_ MATTNEW HYATT, R.A.
I ARCHITECT
(' 36 5T. PAUL STREET #3
BROOKL I NE,MA 02446
A .�
POSITION OF NEW A.G. PANEL I f 611-134-3142
aY _
N
LJF-1
TO STAIRWAY L16HT
TO TRACK LIGHTING to
:3@2
TO HOT WATER 5HUTOFF (.�Ji� I)
ii CT/
-
_
IL II i I" e
POSITION OF NEW TRACK
LIGHTING T.B.D BY OWNER II II
�2 20: 2 I
t TO EXT. LIGHTS 2
OPP
BASEMENT FLOOR
POHER PLAN
56ALE: 1/8° = 1--0"
< J t "• DATE: 116100
f::3A5FMF-NT 9- 00R PONF—P ICI AN
9 \
r
r
ULLMAN RE5I0ENGE
ADDITION
Imo)N N 131 CRYSTAL LAKE RD.
05TERVILLE, MA
MATTHEW HYATT, R.A.
ARCHITECT
- 36 5T. PALL STREET#3
BROOKLINE,MA 02446
cc LIGHT FIXTURE T.B.D. 51 /1 As 617-134-3142
OWNER(TM)
�` _ naeer farm
TO H.W. HEATER SHUTOF I _
TO STAIRWAY LIGHT
°
2 EX15T'6 FIXTURES
TO STAIRWAY LIGHT
2
�.
xc
2
-------
2 """ - 2 -�2:
qp
{
--- t FIRST FLOOR
POWER PLAN
SCALE: 1/8" = 11-011
.7 DATE: I/b/00
PONER P- 1_._.
ULLMAN RE5IDENGE
ADDITION
131 GRY5TAL LAKE RD.
05TER\ALLE, MA
MATTHEW WATT, R.A.
ARGHITEGT
36 5T. PAUL 5TREET#3
BROOKLINE,MA 02446
r - 611-134-3142
01 0
6CD
S�bpr,sf� - -
MOW w
LIGHT FIXTURE T.B.D. BY
OWNER(TYP.)
-
II I, ;,, II 2
P051TION OF NEW TRACK .
LIGHTING T.B.D BY OWNER
2 ; I 2 ,
2,
5EGOND FLOOR
POWER PLAN
5GALE: 1/8" = 1'-0"
DATE: 1/6/00
SEGOND FLOOR PONER PLANrs-