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Commonwealth of Massachusetts , ` �_9/ D��
Title 5 Official Inspection Form
0 i t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
195 Crystal Lake Rd `
J Property Address
Dana & Caroline Caffe
Owner Owner's Name/ W
information is Ostefyille V. MA 02655 8-18-20 -
required for every - '
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.
A. Inspector Information 1#_IL fOL f�
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services n h
Company Name
P.O. Box 73
Company Address
East Falmouth a MA 02536
City/Town State Zip Code
508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000);I have personally inspected the.sewage disposal system at theproperty address listed
above;the information reported below is true, accurate and complete as of the time of my inspection; and
the inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.After conducting'this inspection I have determined that
the system:
1. ® Passes
2. ❑ Conditionally Passes. _
.3. ❑ Needs Further Evaluation by the Local,Approving Authority
4. ❑ Fails
8-18-20.
I pector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of
101000 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
w 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
1
Commonwealth of Massachusetts
3 Title 5 Official Inspection Form
I-r
i� wa .
;y�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments'
195 Crystal Lake Rd
Property Address
Dana & Caroline Caffe
Owner Owner's Name
information is ired for every Osterville MA 02655 8-18-20
requ
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System.Passes:'•
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
System is in good working order with no sign of failure.
2) System Conditionally Passes:
❑ One or more system components as described in the "ConditionalPass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Eli
lw,. Title 5 Official Inspection Fora
i,i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
` 195 Crystal Lake Rd
Property Address
Dana &Caroline Caffe ,
Owner Owner's Name
information is required for every Ostefville MA 02655 8-18-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.) -
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired. "
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑N ❑ ND (Explain below):
❑ obstruction is removed ` ❑ Y ❑N- ❑ ND (Explain below):
, S
❑ 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 El ❑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
I
Title. 5 Official Inspection Form
i�► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
195 Crystal Lake Rd
Property Address
Dana & Caroline Caffe
Owner Owner's Name
information is required for every Osterville MA 02655 8-18-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
[--]The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® 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 Fora
r�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
195 Crystal Lake Rd
Property Address
Dana & Caroline Caffe
Owner Owner's Name
information is required for every Osterville MA 02655 8-18-20
page. Cityfrown 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 'h`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
Commonwealth of Massachusetts
-3/ Title 5 Official Inspection Form
� i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a
195 Crystal Lake Rd
Property Address
Dana & Caroline Caffe
Owner Owner's Name
information is required for every Osterville MA 02655 8-18-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
❑ ® 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?
® ❑ Wasthe facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ 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
,w Title 5 Official Inspection Form
h) Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
y </
(+c
r ;
>�''
195 Crystal Lake Rd
Property Address
Dana &Caroline Caffe
Owner Owner's Name
information is required for every Osterville MA 02655 8-18-20
page. City/Town State Zip Code Date of Inspection
D. System Information s ,
1. Residential Flow Conditions: ,
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
Number of current residents: 0
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: 2020
Date
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
1 ws
i,l Subsurface Sewage Disposal System Form Not for Voluntary Assessments
195 Crystal Lake Rd
Property Address
Dana &Caroline Caffe
Owner Owner's Name
information is required for every Osterville MA 02655 8-18-20
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: N/A
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
I
Commonwealth of Massachusetts ;
II
Title 5 Official Inspection Form
i�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
>` 195 Crystal Lake Rd
Property Address
Dana &Caroline Caffe
Owner Owner's Name
information is required for every Osterville MA 02655 8-18-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System: ,
® Septictank, distribution box, soil absorption system.
❑ Single cesspool
❑, Overflow cesspool
„ r
❑ P rivy
❑ 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:
1982
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 24"feet`
Material of construction:
® cast iron ® 40 PVC ❑ other(explain).
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Good condition.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
11At� ?p Title 5 Official Inspection Form-
it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�. 195 Crystal Lake Rd
Property Address
Dana & Caroline Caffe
Owner Owner's Name
information is required for every Osteryille MA 02655 8-18-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 1811
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gal
Sludge depth:
6"
Distance from top of sludge to bottom of outlet tee or baffle
26"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
15"
How were dimensions determined? Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed and no sign of leakage.
t5in.sp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
,. Title 5 Official Inspection Form
r�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 p Y rY
195 Crystal Lake Rd
Property Address
Dana & Caroline Caffe ,
Owner Owner's Name
information is required for every Osterville MA 02655 8-18-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
- Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
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 i nspecti on)(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 & Massachusetts
- Title 5 Official Inspection Form
:,,I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
195 Crystal Lake Rd
Property Address
Dana & Caroline Caffe
Owner Owner's Name
information is required for every Cisterville MA 02655 8-18-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
9. Distribution Boz(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
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.):
Good condition with water at working level and no sign of back-up from pit.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
� Commonwealth of Massachusetts
Title 5 Official Inspection Form
w
i�.'► Subsurface sewage Disposal System Form -Not for Voluntary Assessments
195 Crystal Lake Rd
Property Address
Dana & Caroline Caffe
Owner Owner's Name
information is Osterville MA 02655 8-18-20
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: `• ❑ Yes ❑ 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: ti
Type:
® `` �' leaching pits `number:
1-1000 gal
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
w_
, I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
195 Crystal Lake Rd
Property Address
Dana & Caroline Caffe
Owner Owner's Name
information is Osterville MA 02655 8-18-20
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach pit in good condition and empty at inspection with stain line at 12" off bottom of pit.
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
I
Commonwealth of Massachusetts '
r� Title 5 Official Inspection Form
i-lh Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
195 Crystal Lake Rd
Property Address
Dana &Caroline Caffe
Owner Owner's Name
information is Ostefville MA 02655 8-18-20
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) t
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
Gr
3�2r- r
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
c Commonwealth of Massachusetts
r� Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
- ` 195 Crystal Lake Rd
Property Address
Dana & Caroline Caffe
Owner Owner's Name
information is required for every Ostefville MA 02655 8-18-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
,'. Title 5 Official Inspection Form
p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
195 Crystal Lake Rd
Property Address
Dana &Caroline Caffe
Owner Owner's Name
information is required for every Osterville MA 02655 8-18-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) .
15. Site Exam:
❑ Check Slope
❑ Surface water i
❑ Check cellar y
❑ Shallow wells
Estimated depth to high ground water: 20
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record t
If checked, date of design plan reviewed: Date
® Observed site.(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
® Checked with local excavators, installers- (attach documentation)
Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
USGS and town maps show groundwater at 20'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
195 Crystal Lake Rd
.=r
Property Address
Dana & Caroline Caffe
Owner Owner's Name
information is required for every Osterville MA 02655 8-18-20
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® 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
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key. ,BARNSTABLE
®5 MA
9.Clty 4.State 5.Zip Code
5082800505
B.Telephone Number
INW!"RUCTIONS B. Project Cancelled
1. This form Is
only avatiadln for ;Check here if this project ialwas cancelled,
online Ming of
project date
ravlabns.
decal �be►." C. Project Dates
th Validate that 11/11/2010 11/11/2010
the project .... .... ....
location Is correct 1.orlglnei Start Date(mmldti yyyy) 2.,t)rlpinaf End Date(mrnlddlyyyy)
for the entered
dam'4. Emeryournew I Later Reylsed start Pate(ntr'nlddlyyyyj 4.Laleat .WA&ed End Data(mm/.ddlyyyy)
Qrdlec�dales. ,
5. Car*your
no ncelton. D. Revised Project Dates
Submit date
changes. .11/15/2010 1111612010
1.l2o�risad Sian data(ntmldcl/yyyyj 2.Ravl"d End pate Patn(mmlddlyyyyj
E. other Project Revisions
F. Revision History
ardOWm.doc•rev.215/04
NOV-9-2010 11:08 FROM: TO:15oe7906304 P.•3
Commonwealth of Massachusetks ■
10011!ST67
Asbestos Notification Form ANF-001 DecelNumber
„Impor�,°Re out A. Asbestos Abatement Description
forms p to the f. s_Is this facility fee exempt•city,town,district, municipal housing authority,owner•occu led
computer,raga tY p ty,-, pa 9 p
only the ton key residence of four units or less? .r„-Yes 'No,
to move your
Cursor•do not b. Provide blanket decal number if applicable_
use the return Blanket Decal Number
key. 2. Facility Location:
'HSRMAN SCHAFFER j195 CRYSTAL LAKE RD
a1 Names of FAdlrty—_--.—__._._. rt�..strugl Addrass,
"°' i tBAFiNS fABI.lW 'MA _ 02855 (508)280.05
i
C.Ckyrrown d State e.Zip Code f.Telephone Number'
INSTRUCTIONS 3' worksite Location-
1.All sections of this _.. . .. �..__. ' _......_ ! i...._. ._
form MUM t)e a.Building NarWWkting Location b.Building S (:L d.Floor e.Room
completed In oMer
to comply with 4. Is the facility occupied?. F -Yes 1 No
DER notification
requirements or alo
CMR 7.16 5. Asbestos Contractor
Of
the Division -- -•-----.—_.—_—.._�. ._._...} c._.__._.
Ofoccupaucmel AIR SAFE IN4 I All ENDICOTT STREET
So"(DO$) A.NAm9 b.Address
notitir on _.
NORWOOD - �02062 `7817823390
requlramerttsof4b3 `.---._.__.._—_...._...=..... l__._.__..._.......
�612 r-CllY7gwn _:...._.._._....---...._.__.. d Zip Cade _ ...,_........._.... ._._..
0.7o1®phone Number
IAC000464 ( Contract r _
�_._ _�.___...__.._.__....._.. -.--- ° Verbal
f.C�&STIcensa Number 9 Type:
✓, Written
i Cnntad Pnrs_nn's Tina
6. tJAIME I-AMAYA A^ SOS47 _..._
e.Name of 0-6-Site Su�-rv_isorlForemen„,-. - b.SupendsorfFpremsn DOS t~ertifir�tion Numhor
SAM COHEN AM0607B7
a-Name of Project,Monitor b,Project,Monitor[SOS CertTficat on N r _
$ IENVIROTEST LABS AA0001za '
8-Name ofAsbestas ArtalytlCal LabAhelyilCtil,I.a�„_4S,C@r gjpi orl Number y.
-.11/1112010 - _ $1111112010
�o r.raraJoct StaK QMa_(mmlddlyyyy►-------- - h.F�td Date primlddlpylr}!1__.._..`.:----....
C• ours Work h
a
v 10. a.what type of project is this?
o j—I Demolition 6` Renovation _.....__ ....
LVJ Repair L Other, please spedfy: b.Desadbe .
11, a.Check abatarnent procedures:
®° F l Cleve bag Encapsulation
o `i Enclosure Disposal only
Cleanup _ i Other, specify:
Z Full Containment b.Describe
a 12, Is the job boing conducted: ✓,Indoors? I ?Outdoors?
0 anioolap.doo•ioim Asbestos Notl&ation Form•Page 1 of3
NOV-9-2010 11:08 FROM: T0:15087906304 P.4
Commonwealth of Massachusetts
Asbestos Notification Farm ANF-001
A. Asbestos Abatement Description (cunt.)
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed,enclosed,or
encapsulated: 11000
_
'Nil—pipes yrduds(linear R) b.7otaf-W6 6ui%W (oii a►e-fty
c.Boller,breaching,duct,tank - ____) d.InSuteting Gemeni S- --•-' --- - ^W
surface coatlnge -t_jn.-ft._ Sq.ft: Lim ft-
Q.Corrugated 4r layered paper { ..,....._..--;a f.TrcweUSpmyer Coalinga ...........-. l--...__..
pipe Insulatlon Lin.ft. $q.f1 - On.fl $q.ft
g.Spray-on firopmofins i 104.. ........ . # h,TmNM board,wall beard �-
LEn.ft_.... . Sq.ft. Lln:iC -
,,..-..,. . . {
i-Cloths,woven fabrics i j.Other,please specify. -�
,
........... _�..._— Lin.
Lin.ft. S ft-
k.Thermal,solid com pipe I ERMIC I --
..----'
Int3ulatt4n ?Lin.(t Sq.ft. �..SRa�fil..----••--•..__—...- ---._.. _.....-...
14. Describe the decontamination system(s)to be used:
CHAMBER OECON
15. Describe the containenzation/dispesal methods to comply with 310 CMR 7.15 and 453 CMR
U-14(2)(9): .
�6 MIL POLY BAGS----.......___...... ... .. ......_. _ ___-----•---•----___.:.---------�
1 B. For Emerpency Asbestos Operations,the DEP and DOS officials who evaluated the emergency:
r- -_. ... . ...
L_._.�.._,........a,.,..-------
C.Dete(mmltldlyyyy,afAutharizadon'�-.�".�-- � ----- .',,,.,. -
d�tvP Waiver* .....,.....__�_—•- ---�
�. _.
e.Name of DOS 4ftiCial
IYYYY� t�OS waiver�
0 17. Do prevailing wage rates as per M.G.L-c. 149,§26.27 or 27A—F apply to this project? [l Yea R',No
Q B. Facility Description
-- o 1. Current or prior use of%cility: jR SIQENTIAL2. W
q
s the facility owne'•OOCUpied residential with 4 units or less? F�j Yes 'LI ND
;SAME
3 I
a Fa ilty Owner Name ti.Addreaa-----.. ---
p
NNIUMMCi Ia.Cit !Town $. _...._...._._.._.... w..,...,.. .,.___..................:._..--
Y_ _--�_ d.Zip Code c.Tolcpnons iMumber(area Code end extarxsTon}
6
w 4. a-Noma of Fecil O+uA. nei"s Onit'M __..._.._....
9 Manager b.On She Manager Addme
--- — --
Q C.CitylTown ._... _...._..__....-.--..._....._......_....._.:.. ....
��- d-Zip Code e.Telephone Number(aroa ooda end wdenston) _---- -
■ anfoQiap.doc•10f02 Asbestos NoUfh;atlan Form•Pa e 2 of 3■
I NOV-9-2010 11:09 FROM: TO:15087906304 P.5
Commonwealth of Massachusetts
1.04115767
Asbestos Notification Form ANF-001 Decal Numtrer
B. Facility Description (cone.) 4
a Name pf Oarwral Contractor h.Address
I �
c.CI rrewn d.Zl Code w Talsehone Numhar ■raa coda and e)denslan)
r.Contraaara Workers Gump.Insurer g.Polio�Number _ In.Exp.Date{mmldtllvnh) .
6. What 18 the SIZE 0f this facility? a-Square Feet b Number of floors C. Asbestos Transportation and Disposal
1- Transporter of asbestos-containing material from site to temporary storage site{if necessary}-
AIRSAFE
Note:Transfer a.Name OfTrarmporter. ..... _'_ h.Address_. .._. _. . . . ..: _. .�.._
Stations must
comps vdth the a-atyfrown d.Zip Code e.Telephone Number
Solid Waste
DIVI31 n 2. Transporter of asbestos-containing waste material from removal/temporary ske to final disposal site:
FtnuWom 310
CMR 19.060 i � I
e.Name oiTranaoorter ._.._._ _. .. .. _._.. tr.Address_-
- j
C.Cfty/rown d,Zip Code e.TaleLone Number
3.
a.Refuse Transfer Stetlon and Owner b,Address
i
Tip Code a.TaIeRhone Numbio v
4. 1 NO REMOVAL..DISTURBING ONLY DHCDd f
a.Final Disposal Site Loudon Name W bb,Rnal Bic oral$It@ 4acatlon Owners Name
NO REMOVAL.DISTURBING j BOSTON T
g_Final t Llosal Sit aae Address___..__ •_ d.City/l own
A 02108 -- ;
e.Staff F.Zip Coda g.Telephone umber
Q D. Certification
N
The undersigned hereby states,under the DF WALSH
o penalties of perjury,that he/she has read the a,Name — b.Authofted Stgnotura
�o Comrnonwealth of Massachusetts regulaftns; .Vp i
® for the Removal,Containment or
c.Posltlonlritle..— -- d.Da�mm/ddbM)
Encapsulatlon of Osbsstos,453 CMR 6.00 and ---—�
310 CMR 7.15,and that the information (781)162-3390 ;AS
®a contained in this notification is true and correct a Toleeons Number f.Re rasenlln
to the best of histherknowledge and belief. 61 ENDICOTT
O - g.Addras5-_. -
�u. - ;NGRWbOD j 020632 _ l
h.t:atgrrown I.zip Cane
ancol ap.doe-10= Aabesioa Notlecation form o Pege 3 of 3
l
F
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 195 Crystal Lake Road, Osterville
Property Address
Eileen Mciver
Owner Owner's Name
information is Osterville MA - 02635 Jul d 1, 2010 at 8 AM
required for Y
every page. Cityrrown 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 out A. General Information
,
forms on the l 1
computer,use 1. Inspector:
Y Y
only the tab key
r
.
to move your David B. Mason
cursor-do not Name of Inspector
use the return
key. David B. Mason
Company Name
4 Glacier path
Company Address
East Sandwich MA 02537
City/Town State Zip Code
508-833-2177 S1287
Telephone Number License Number !
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection.The inspection
Was performed based'on my training and experience in the proper function and maintenance of onstte
sewage disposal systems. l am a DEP approved system inspector pursuant to Section 15:340•—of
Title 5(310 CMR 15.000). The system: i W
® Passes ❑ Conditionally.Passes ❑ Fails -
❑ Needs Further Evaluation by the Local-:Approving Authority , .
r
July 2, 2010
Inspec s Signal t Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
ti report to the appropriate regional office of the DER 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.
(Sins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disp sal System-Page 1 of 17.
{
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form 2
Subsurface'Sewage Disposal System Form - Not for Voluntary Assessments
195 Crystal LakeRoad; Osterville
Property Address
Eileen Mciver
Owner Owner's Name
information is Osterville MA 02635 Jul
required for y 1, 2010 at 8 AM
every 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: s ,
® 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`. ,
System passes based on conditions noted specifically-on July 1, 2010 at 8 AM. Increase or change
in use or occupancy may result in the failure of the system
.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):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System form - Not for Voluntary Assessments
195 Crystal Lake Road, Osterville
Property Address -
Eileen Mciver
Owner Owner's Name
information is Osterville MA - 02635 ..Jul 1 2010 at 8 AM
required for Y
every page. City/Town State Zip Code t 'Date of Inspection
B. Certification (cont.)
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, settle_d or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ 'Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ' ❑ ND (Explain below):
,
❑ The system required pumping more than 4 times a'year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced '❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N' ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order,to determine if r
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 s
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
ti
f ,
Commonwealth of Massachusetts x
ro Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 195 Crystal Lake Road, Osterville
Property Address
Eileen Mciver
Owner Owner's Name
information is Osterville MA 02635 Jul 1 2010 at 8 AM
required for y >
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.j'`
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:
El 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 asurface 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 a septic tank and SAS and the SAS is within,50 feet of a private water
supply well.
❑ The system has'a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well;'water analysis,:performed at a DEP certified laboratory, for coliform
bacteria 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. .
P
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes",or"No"to each of the following for all inspections:
Yes No
❑ z Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool;
El ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS of cesspool
El ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1lY2 day flow
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
L Commonwealth of Massachusetts s
w Title 5 :Official Ips''pection Form '
Subsurface Sewage Disposal System Form,-Not for Voluntary Assessments
°M 195 Crystal Lake Road, Osterville.
Property Address
Eileen Mciver
Owner Owner's Name
information is Osteryille MA 02635 Jul 1, 2010 at 8 AM
required for � y
every page. Cityrrown 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
ti obstructed pipe(s), Number of times pumped:
d . ® Any portion of the SAS;'cesspool or privy is below high ground water elevation. .
Any portion of cesspool orprivy is within 100 feet of a surface water supply on
tributary to a surface water supply.
® .
z° An y portion of'a cesspool or,privy is within,a Zone.1 of a public well.
El E Any portion of a cesspool or privy is within 50feet4of 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 othe"r failure criteria are triggered. A copy of the analysis
and chain of custody must be-attached to this form.];
ElThe system is a cesspool'serving a facility with a design flow of 2000gpd
10 000 d. v
9p N s
El 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 Bowd of Health to determine what will be
necessary,to correct the;failure.
-E) Large Systems: To be considered a large system the system muss 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 , k
El El thus stem is Within
n 400 feet of a surface drinking water supply
El Elpig 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
El D
Area.-;IWPA)or,a mapped Zone II of apublic water supply well
If you-have answered"yes to.any question in Section,E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed: The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner'should contact the appropriate
regional office of the Department.
t5ins•09/08 ¢ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,N 195 Crystal Lake Road, Osterville
Property Address
Eileen Mciver
Owner Owner's Name
information is Y required for Osterville MA 02635 ' Jul 1 2010 at 8 AM
every,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
® ❑ 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
® 0- approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 ' Number of bedrooms (actual). 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
� . 195 Crystal Lake Road, Osterville
Property Address
Eileen Mciver
Owner Owner's Name
information is Osterville MA 02635 Jul 1, 2010 at 8 AM
required for Y
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
f System passes based on the information.observed on July 1, 2010'at 8 AM.This does not guarentee
the continued operation of the system. Increase in occupancy may result in hydraulic failure.
Garbage grinder is prohibited and requires removal.
Number of current residents: unoccupied
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] '❑ Yes.® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes '® No
Water meter readings, if available last 2 ears usage d yes
g _ ( Y 9 (gp ))�
Detail: -
2008- 37,000 gallons and 2009 27,000 gallons
Sump pump? ❑ Yes ® No
Last date of occupancy: unknown
bate
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System+Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments,
195 Crystal Lake Road, Osterville
Property Address
Eileen Mciver
Owner Owner's Name
information is Jul
required for Osterville � MA 02635 y 1, 2010 at 8'AM
every page. City/Town 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:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons R
How was quantity pumped determined?.
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil;absorption system
❑ Single cesspool
❑ Overflow/cesspool
❑ Privy
❑ ` Shared system (yes or no) (if yes,attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval. ;
❑ Other(describe): r
l5ins-09/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form,
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 195 Crystal Lake Road, Osterville
Property Address
Eileen Mciver
Owner Owner's Name
information is Osteryille MA 02635 Jul 1 2010 at 8 AM
required for Y
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of.information:
Compliance issued April 14, 2010
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
Building Sewer(locate on site plan):
Depth below grade 3
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other.(explain):
Distance from private water supply well'or suction line: Not'Applicable
feet
Comments (on condition of joints,venting,.evidence of leakage, etc.):
Appears in working order
Septic Tank(locate on site plan):
Depth below grade: 2
feet
Material'of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
1000 gallon tank
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
M 195 Crystal Lake Road, Osterville
Property Address
Eileen Mciver
Owner Owner's Name
information is Osterville MA 02635 Jul 1 2010 at 8 AM
required for _Y
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 32
Scum thickness 2
Distance.from top of scum to top of outlet tee or baffle 3
Distance from bottom of scum to bottom of outlet tee or baffle 12
How were dimensions determined? Scour Stick
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outletinvert, evidence of leakage, etc.):
Tank appears structurally sound. Effluent level with outlet tee. Pumping is recommended:
Grease Trap(locate on site plan):
Depth below grade: T feet
Material of construction:
El concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: r
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-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
^M 195 Crystal Lake Road, Osterville
Property Address
Eileen Mciver
Owner Owner's Name
information is Osterville MA 02635 Jul 1, 2010 at 8 AM
required for Y
every page. City/Town State Zip Code Date of Inspection
D. System Information (cOht j, ,
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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
f
Commonwealth of Massachusetts
W Title 5 Official. Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
}
,M 195 Crystal Lake Road, Osterville
Property Address
Eileen Mciver
Owner Owner's Name
information is Y required for Osterville MA 02635 Jul 1, 2010 at 8 AM
every page. City/Town 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 Level with outlet inverts
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.):
No evidence of solids carryover. slight build up of powdered detergent noted.
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:
Leach pit was not excavated due to location being under a paved driveway. No cover to grade, but
that is not a condition to pass, further evaluate or fail.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
195 Crystal Lake Road, Osterville
Property Address
Eileen Mciver
Owner Owner's Name
information is Osterville MA 02635 Jul 1', 2010 at 8 AM
required for Y
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching P Its number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields. number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No conditions noted that would provide indication of status of system pass+or fail. Except the effluent
in the dbox is level with the outlet pipe.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
.Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form :
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 195 Crystal Lake Road, Osterville
Property Address - b
Eileen Mciver
Owner Owner's Name
information is Osteryille MA 02635 Jul 1, 2010 at 8 AM
required for y
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:'
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.)_
w 4
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .
wM 195 Crystal Lake Road, Osterville
Property Address
Eileen Mciver
Owner Owner's Name
information is Osterville MA 02635 Jul 1 2010 at 8 AM
required for y
every page. City/Town State Zip Code Date of Inspection
D. System Information,(cont.),
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
4
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 195 Crystal Lake Road, Osterville
Property Address
Eileen Mciver
Owner Owner's Name
information is Osterville MA` 02635 Jul 1, 2010 at 8 AM
required for - Y
every page. Cityrrown State Zip Code ` Date of Inspection
D. System Information (cont.)'
Site Exam:
® Check Slope -
® Surface'water
® Check cellar , ;
❑ Shallow wells
20
Estimated depth to:high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within*150 feet of SAS)
®. Checked with local Board of Health —explain:'
Engineered plans on file
❑' Checked with local excavators, installers (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Used engineered plan on file based on test hole data.
-
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 195 Crystal Lake Road, Osterville
Property Address
Eileen Mciver
Owner Owner's Name ,
information is Osteryille MA 02635 Jul 1, 2010 at 8 AM
required for Y
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection,Summary: A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information-Estimated depth to high groundwater.
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
A
0
a 4
r
No. .20®o M 3 FJ 2-
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: J.Z'
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
application for Mi!�Po!gal *p!5tem Con5tructtou Vermtt
Application for a Permit to Construct( ) Repair( ) Upgrade( ) AbandonV
Q ❑ Complete System ❑Individual Components
Location Address or Lot No. ICI - Owner's Name,Address,and Tel.No. 8,1 Px,,, m`CL..c r
Assessor's Map/Parcel f 3 o SS-
�� lL� /►1/lr
Installer's Name,Address,and Tel.No. , 4 Qvj-of t ,'t Designer's Name,Address and Tel.No.
v-A
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alt ratio s(Answer when applicable) c tr /. Oo �, .
v P „ �
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of
Signe ._ Date
Application Approved by Date / 6 r
Application"Disapproved br : Date
for the following reasons
Permit No. ��' �"/ Date Issued 711 Yl#jr-
r ". �' -.•].-,•,.n,r'" �-�.mt;. .vas+:.�.wv>. i'- �3.»:,,,...r......�7 F,:-.c.�+-..:,�,�:..::.a.•--•":.•. .:�
�IS�+ t Fee'" 2
V No.
r THE COMMONWEALTH.OF MASSACHUSETTS Entered in computer: s,,el_"
',PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Zipprication for 33i5po9;al 6p5tem Construction Permit
Application for a Permit to Construct O Repair O Upgrade O Abandor4O ❑Complete System Individual Components
Location Address or Lot No. JQ 5' C !f>raj A i7• Owner's Name,Address,and Tel.No. ��` 2e (N`�", r
Assessor's Map/Parcel 3 q SS p>i✓�ll t �1'1/fi �)
Installer's Name,Address,and Tel.No. `1 Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers(x ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alteratio s(Answer when applicable) ✓(G�q,},�, U, f/ ./oo / ,4 4� r• ,
{
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of �a th.
Sign dXn
, DateApplication Approved byVIN Date
Application Disapproved b Date
for the following reasons
Permit No.,� Do Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
-THIS IS TO ERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( )
Abandoned�( --)`by f
A.� �, � �G, � ��-v"Ar has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. WE 00.7 dated -3//(/6
Installer Designer
#bedrooms 1'V�/�"' Approved design flow /V gpd
The issuance of this pem�it(shall not be construed as a guarantee that the system tl�l'funfcttii`o'n��as deLig.ed. c
Date _ 1 1 L!/�!! Inspector / _)1 t V,= Ye
No. OCl r0q� _ Fee S - d
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS-
lwigoaY *pgtem Construction Vermit
Permission is hereby granted to Construct ( ) Repair ( ) Upgr de ( ) Abandon
System located at /G/5� C f A 6
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions.
Provided: Cons ruction must be completed within three years of the date of this ermit.
Date 1�1�G�'_ Approved by 61-1 .
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dC�ry ��E L IJarec,, ) Q:,, �,��
IAI A C. E PE R MIT
v8LlAGt
I NSTALLER'S NAME & ADDRESS
6 U I L D E R OR OWNER
0 A T E ' ERMIT ISSUED
DATE C0MPLIAMCE ISSUED
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LAI-
LOCQ"T%ON ; _ _ - 5EW-6,C;E. PERMIT UO.
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- D-IJ►TE--PER-N�1T---ISSU-ED.-- ��.� _ �-----. _._.
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD '-",F HEALTH,
.. OF................... ..... ... ....>' .. .: ..-..------------
Applirativit -for Uttipmal Works Tontitrurtion Prrulit
Application is hereby made for a Permit to Construct 0111�) or Repair ( ) an Individual Sewage Disposal
A
System at: `��
u _....------......
Y c ion-Addres or Lot No.
W "`t r A�ie s
� Installer Address ��� �
d Type of Building Size Lot______ __________�/�_____._.Sq. feet
U Dwelling—No. of Bedrooms_____________________ __________________Expansion Attic ( ) Garbage Grinder ( )
per, Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Other fixtures ------------------------------
W Design Flow..............................................,, gallons per person per day. Total daily flow........._..........------------------------gallons.
WSeptic Tank—Liquid capacity/d�//P..gallons Length---------------- Width---------------- Diameter_------------- Depth---_____.---
x Disposal Trench—No.__ _ _ --- Width-------------------- Total Length__--__-____•----_-- Total leaching area--------------------sq. ft.
Seepage Pit No-------_------------ Iameter.................... Depth below inlet.................... Total leaching area-:_.---__-______sq. ft.
Z Other Distribution box (i• Dosing tank ( )
aPercolation Test Results Performed by--------- ----------- ----------------------------------•----------------- Date------------------------------- -------
Test Pit No. 1.........-------minutes per inch Depth of Test Pit-------------------- Depth to ground water--________-____-_-.--
fi Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water_--._.--___--______-.--
----------------------------------------•-----------------------------•-------•-•-•---------•-----•-----•---------------------------
O Description of Soil----------- +�,c;� ----------------
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 Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ' sued by -boar of healt• �
Sign --------- �_.44_s
ate ^��
Application Approved By. �� -------------------- �` .. --1�._---- ----�'s _
Date
Application Disapproved for the following reasons------------------------ ---------------------------------- --------------..........................
-------------------------------------------------------------------------------------•----------------------------- ----------------------------------------------- --------------------------.........
Date
PermitNo.....................-----•-•-•------------------------- Issued...................... .................................
Date
No........ y..... Y FEs. . ..................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEA TH
r .................
ApplirFation -fair Biipu,i al Workii Tons#rurtion Vrrnfit
Application is hereby made for a Permit to Construct (r ) or Repair ( ) an Individual Sewage Disposal
System at
ot--- tVA"=• _did• •-- -- /IS .�,�
c ion-Addres or Lot No.
-------- .................3....................
r Addre
i fr
a ____ ____ _________ __ ______ _ _. .___ __ ________._ .........
Installer Address
UType of Building ! Size Lot______ 4C-e'�.S.-Sq. feet
Dwelling—No. of Bedrooms_____________________`_-__________-________Expansion Attic ( ) Garbage Grinder ( )
p`-, Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Otherfixtures ----- ----------------------------------------------- ---------
W Design Flow_______________________________________ ____gallons per person per day. Total daily flow--------------------------------------------gallons.
Septic "1':Irlk—Liquid caplcity/ Q__gallons Length................ Width-_____-_----_-- Diameter-----........... Depth---______.--..--
' Disposal Trench—No. ... Width-------------------- Total Length----_-------------- Total leaching area--------------------sq. ft.
x
Seepage Pit--hlo_....._............__ iameter......_............. Depth below inlet.................... Total leaching area__-____-_______sq. ft.
Z Other Distribution box ( Dosing tank ( )
a Percolation Test Results Performed by---------------------------------------------------------------- Date---------_________-_-------------------.
Test Pit No. 1-------------___minutes per inch Depth of Test Pit..................... Depth to ground water_--___--______-__-___--.
P�q Test Pit No. 2________________minutes per inch Depth of Test Pit-____________-::____ Depth to ground water........................ .
0 ------ -------•-•--••------•-•-•---•-•------------•-------------------------------•------------------•-------------------------------------
DDescription of Soil--------------- "- ----------------------------------••------------------_______-------_-___-_-------------------------------------------------------------
W
------------------------------------- ------------------------------------------------------------ ............
0 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ' sued by oar of h al
Signd---_- - ---•- •- -- ------ - - ----- -- ---------
Application Approved By._ `."._____ / !�_ �_ r �~�"
Date
Application Disapproved for the following reasons--------------------•---• ----••-------•------------------••-----------------------__.___...___________
------------------------ ---•---.___._...--•----._.....--------•---------._.___.__.__________-•--••--•....__--••--.._.._-'--•..-_.__.._-----•---•---•-----_._._:_.---------------___._____..------•----•-
Date
Permit No. Issued --------------
-------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALT
-1. ..........O F..... ...:, �
..............
Tatif irate of TOmptiararr �;
THI IS T. C-E TI hat the Individual Sewage Disposal System constructed or paired ( )
t e-
at---
--- / Install
" +M l '�d
has been installed in accordance with the provisions Ar XI of The State Sanitary Code as described m the
application for Dispose Works Construction Permit NoL/._�- ._.._,t/..�_ ...___._._.._ dated'..
THE ISSUANCE OF THIS CERTIFICATE SHALL ROT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ;-`--'••-•-•--••-•-•--••-••••••-•----•----_•:••-...•••-•••••••.....- Inspector.........................-•---------••••••••-•---••••._.._..........................
THE COMMONWEALTH OF MASSACHUSETTS
°W BOARD H�tEALTH
� ..!�!.....:. OF . 6 e ..... ...............................
No. l�I
---•-••---- FEE. ..............
Bi.sp ial: Porkli ion Vrrmit
Permission 's eby nted__'"""___._- ____ ,
to Con r ct ( or,�Rep ' ( ) an Individual Se ge Dis a] st
at No. ��%% .+ �'-
S; eta"'
as shown on the application for Disposal Works Construc on t No
l ------
ated_
1 _
.
7,,r M Board of Health
DATE ---------------------------------------------- --------------------
s, FORM 1255 HOBBS & WARREN. INC.: PUBLISHERS- •. "'-.
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