HomeMy WebLinkAbout0008 EAST BAY ROAD - Health (2) 633 Main StR£e-r-
Osterville
A= 141 105
i,
No: p /0_ J Fee Z
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Ye
ZIPtlfltation for aispo8al *pstem Construttion permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(. ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
00i
Prcel , \ k Gib oZ 1Assessor's Mp/ 6
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
�o ► 0,F c" C d�1 CAI ineee
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 Alterations(Answer when applicable)
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 Health.
Sign e Date I
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No.�r 7�' "0 3_ Date Issued
;. . .. _ Y^ ,. •,^_.t.,� _ _. _ .r mot. .� `
No.C �y "'✓ Fee 7
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: /'
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Y
2ppf cation for Bisposal 6pstem Construction jermit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(VC) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address,and Tel.No.
/yf -Ms, -6V/ �03Z �� S--k-' A ?-IZ
Assessor's Map/Parcel [�1 1` N1 ' �at'�G v L u, v� t'1 oZ I 1
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
OL4 co. Ccsl '. 9 rot {
Type of Building: a`
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder
Other Type of Building No.of Persons Showers( ) Cafeteria( ) f
I
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'orAlterations(Answer when applicable)
s4•.
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
i
Compliance has been issued by this Board of Health.
Signed''"^ 1 Date
Application Approve�'dby ."
Application Disapproved by Date
for the following reasons i
{
3
a Permit No. :�20 1R- --O Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS $ ._
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
Abandoned(-,/SbY
at has been constructed-in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No�'./&-0 3 3 dated �•�c� (1K
Installer �o6 k � 0.r, C', Designer
#bedrooms S Approved design flow gpd
The issuance of this permit shall not be construed-as a guarantee that the system will function as;designed
I
`ice' � y i
Date 1 � Inspector ._ ) j
No. °�at^'� —r✓ Fee r--
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Disposal 6pstem Constrnction 3permit
Permission is hereby granted to Construct(. ) Repair( ) Upgrade( ) Abandon(1/)
System located at G?):4 0-\a f- ----s-E-.
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be com
pleted within three years of the date of this permit.
Date c-� i ( Approved by\",
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M
633 Main Street Osterville
Property Address
Greg Nowak
Owner Owner's Name
information is '
Osterville r!
required for every Ma. 02655 11/18/2015 I,...:.
page. City/Town State Zip Code Date of Inspection
1
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information filling out forms # �/
on the computer, 27,S-
use only the tab 1. Inspector:
key to move your
cursor-do not Michael T Bisienere
key the return Name of Inspector
Y
Cape Septic Inspections
VQ Company Name
624 Old Barnstable Road
Company Address
Mashpee Ma. 02649
City/Town State Zip Code
508-280-3356 S13938
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
11/18/2015
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 633 Main Street Osterville
Property Address
Greg Nowak
Owner Owners Name
information is
required for every Osterville Ma. 02655 11/18/2015
page. Cltyfrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D.or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
This home h - _as a H 10 1500 gallon septic tank a H 10 D-Box and a leaching trench with infiltrators
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°M •'" 633 Main Street Osterville
Property Address
Greg Nowak
Owner Owners Name
information is
required for every Osterville Ma. 02655 11/18/2015
page. Cltylrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
broken i❑ pipe(s) are replaced p p ( ) p ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�M '< 633 Main Street Osterville
Property Address
Greg Nowak
Owner Owner's Name
information is
required for every Osterville Ma. 02655 11/18/2015
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
'*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
u - Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
° M ,.•''y 633 Main Street Osterville
Property Address
Gre Nowak
Owner Owners Name
information is Osterville
required for every Ma. 02655 11/18/2015
page. City/Town
9 State Zip Code
Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone
1 of a well.
public w
P i
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
0 ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3113
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
633 Main Street Osterville
Property Address
Greg Nowak
Owner Owners Name
information is
required for every Osterville Ma. 02655 11/18/2015
page. Cltyrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?"
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 1
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): >330
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
1 Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 633 Main Street Osterville
Property Address
Greg Nowak
Owner Owners Name
information is
required for every OSterVllle Ma. 02655 11/18/2015
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.) ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use?
® Yes ❑ No
Water meter readings, if available(last 2 years usage (gpd)):
Detail:
I called the water dept. they believe that the water is supplied by the house on 8 East Bay Road.This
home dose not have an account with the water dept.At the time of the inspection there was not a
clothwasher in the home there is a pipe that would discharge water on the ground if a washer was
hooked up to it.PLEASE NOTE THAT WOULD BE A VIOLATION OF TITLE 5
Sump pump? ❑ Yes ® No
Last date of occupancy: 10/2015
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
633 Main Street Osterville
Property Address
Greg Nowak
Owner Owners Name
information is Osterville
required for every Ma. 02655 11/18/2015
page. Cltyrrown 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
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°ti„ •''� 633 Main Street Osterville
Property Address
Greg Nowak
Owner Owners Name
information is
required for every Osterville Ma. 02655 11/18/2015
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:
03/09/1995
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 28"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade: 18"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: standard 1500 gallon
Sludge depth:
3"
t5ins•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Tit
le 5 Official Inspection Form
s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M •'' 633 Main Street Osterville
Property Address
Greg Nowak
Owner Owners Name
information is
required for every Osterville Ma. 02655 11/18/2015
page. Citylrown 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 apx. 35"
Scum thickness
V.
Distance from top of scum to top of outlet tee or baffle apx. 5"
Distance from bottom of scum to bottom of outlet tee or baffle apx. 12"
How were dimensions determined? sludge Judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
I would recommend the new owner put the tank on a maint. plan with a local septic pumping co.
based on the future use of the home.The Barnstable Health Dept has a list of local pumping co
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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,•'' 633 Main Street Osterville
Property Address
Greg Nowak
Owner Owners Name
information is OSterVille
required for every Ma. 02655 11/18/2015
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
f
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,.•'' 633 Main Street Osterville
Property Address
Greg Nowak
Owner Owners Name
information is
required for every Osterville Ma. 02655 11/18/2015
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
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.):
At the time of the inspection there no signs of solids carryover or evidence of hydraulic failure
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 633 Main Street Osterville
Property Address
Greg Nowak
Owner Owners Name
information is
required for every Osterville Ma. 02655 11/18/2015
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: one apx. 33'with
infiltrators
❑ 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.):
At the time of the inspection the s.a.s was dry and there were no si ns of hydraulic failure
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
•''~ 633 Main Street Osterville
Property Address
Greg Nowak
Owner Owners Name
information is
required for every Osterville Ma. 02655 11/18/2015
City/Town/T
page. y own State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
.•' 633 Main Street Osterville
Property Address
Greg Nowak _
wner Owner's Name
formation is
quired for every Osterville _ __ Ma. 02655 _ 11/18/2015
ige. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
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• Commonwealth of Massachusetts
Tit
le 5 Official Inspection Form
m
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
633 Main Street Osterville
Property Address
Greg Nowak
Owner Owners Name
information is
required for every Osterville Ma. 02655 11/18/2015
page. Cltyrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 15 plus feet
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
I augered a hole at a lower elevation and shot it with a transit
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
• Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,•' 633 Main Street Osterville
Property Address
Greg Nowak
Owner Owner's Name
information is
required for every Osterville Ma. 02655 11/18/2015
page. Cityrrown 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
41
5 Fe
/j u Cr e•A TU
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Y
Y
Y
Commonwealth of Massachusetts An �}
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
633,Main Street Osterville, MA 02655
Property Address
Jonathan Slone 8 East Bay Road
Owner Owner's Name
information is Osterville MA 02655 June 25 2010
required for ,
every page. Citylrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out A. General Information
When
forms the
computer,
r,use 1. Inspector:
only the tab key VL�
to move your Patrick T. Sullivan 1�5��S55LLLL
cursor-do not use the return Name of Inspector
key. Ready Rooter, Inc.
Company Name
P.O. Box 371.
Company Address
Sandwich MA 02563
A/ City/Town State Zip Code
508-888-6055 S1 12843
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local.Approving Authority
June 29, 2010
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
�v
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Dispo al System•Page 1 of 1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M •''� 633 Main Street Osterville, MA 02655
Property Address
Jonathan Slone 8 East Bay Road
Owner Owner's Name
information is required for Osterville MA 02655 June 25, 2010
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below:
Comments:
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/nor
D)for the following statements. If"not
determined,",please explain.
The septic tank is metal and over 20 years old* septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltrat' exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is repla d 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 le than 20 years old is available.
❑ Y ❑ N ❑ ND ( plain below):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 2
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
633 Main Street Osterville, MA 02655
Property Address
Jonathan Slone 8 East Bay Road
Owner Owner's Name
information is Osterville
required for MA 02655 June 25, 2010
every page. City/Town State Zip Code 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, settl d or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced Y ❑ N FIND (Explain below):
❑ obstruction is removed ❑ Y ❑. N ❑ ND (Explain below):
❑ distribution box is leveled or repla d ❑ 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 Requir/he and of Health:
❑ Conditions exist which require uation by the Board of Health in order to determine if
the system is failing to protect h, safety or the environment.
1. System will pass unless alth determines in accordance with 310 CMR
15.303(1)(b)that the system tioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is wiof 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 3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
633 Main Street Osterville, MA 02655
Property Address
Jonathan Slone 8 East Bay Road
Owner Owner's Name
information is Osterville MA 02655 June 25 2010
required for ,
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption ystem (SAS) and the SAS is within
100 feet of a surface water supply or tributary t a surface water supply.
❑ The system has a septic tank and SAS and t SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS a the SAS is within 50 feet of a private water
supply well. '
❑ The system has a septic tank and SAS and t 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 wa/nce
is, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the p ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no o criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable tzof
s:
You must indicate "Yes" or"No"toollowing for all inspections:
Yes No
❑ ® Backup of sewaor system component due to overloaded or
clogged SAS or
❑ ® Discharge or pont to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less Y
than '/day flow
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 4
Commonwealth of Massachusetts'
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
633 Main Street Osterville, MA 02655
Property Address
Jonathan Slone 8 East Bay Road
Owner Owner's Name
information is Osterville MA 02655 June 25, 2010
required for Osteown State Zip Code Date of Inspection
every page.
B. Certification (cont.)
Yes No
El obstructed
pumping more than 4 times in the last year NOT due to clogged or
El obstructed pipe(s). Number of times pumped:
El ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 20009pd-
10,000gpd.
ined that one or more of the above failure
El ® The system fails. I have determ
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
Board of Health to determine what will be
system owner should contact the
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd. ,,
For large systems, you must indicate either"yes" or"n " to each of the following, in addition to the
questions in Section D.
Yes No
the system is within 400 f et of a surface drinking water supply -
the system is within 20 feet of a tributary to a surface drinking water supply
the system is locate in a nitrogen sensitive area (Interim Wellhead Protection
f 0 El Area—IWPA) or a apped Zone II of a public water supply well
If you have answered"yes"to any que ion in Section em has fa led The owner or operator of any large
red a significant threat,
or answered"yes" in Section D above he largey upgrade an the
system considered a with
CM 15 304. Theunder ion E or failed under Section D shall sys system owner should contact the appropriate
system in accordance with 310
regional office of the Department.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5
t5ins•09/08
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
633 Main Street Osterville, MA 02655
Property Address
Jonathan Slone 8 East Bay Road
Owner Owner's Name
information is required for Osteryille MA 02655 June 25, 2010
---
every page. CityrTown 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
El this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
Z ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?'
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual):
1
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
330 GPD
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6of6 i
t5ins•09/08
Commonwealth of Massachusetts
a v Title 5 Official Inspection. Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
GSM 633 Main Street Osterville, MA 02655
Property Address
Jonathan Slone 8 East Bay Road
Owner Owner's Name
information is Osterville MA 02655 June 25, 2010
required for State Zip Code Date of Inspection
every page. City/Town
D. System Information
Description:
2
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
1s laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes CK No
Laundry system inspected? ❑ Yes ❑ No.
Seasonal uses ® Yes ❑ No
N/A
Water meter readings, if available(last 2 years usage (gpd)):
Detail:
Shares meter with main house. 8 East Bay Road
Sump pump?
Yes ® No
Current
Last date of occupancy: Date
Commercial/Industrial Flow Conditions: .-
Type of Establishment:
Design flow(based on 310 CMR. 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
❑ ,Yes ❑ No
Grease trap present?
Industrial waste holding tank present?
❑ Yes ❑ No.
Non-sanitary waste discharged to the Titl 5 system? ID Yes ❑ No
Water meter readings, if available:
Title 5 official Inspection form:Subsurface Sewage Disposal System-Page 7 of 7
t5ins-09/08
L
f
Commonwealth of Massachusetts
i
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
633 Main Street Osterville, MA 02655
Property Address
Jonathan Slone 8 East Bay Road
Owner Owner's Name
information is Osterville MA 02655 June 25, 201.0
required for
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Readt Rooter records: Pumped 2005
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval
❑ Other(describe):
t5ins-09/08 Title 5 Official Inspection Form:.Subsurface Sewage Disposal System-Page 8 of 8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
633 Main Street Osterville, MA 02655
Property Address
Jonathan Slone 8 East Bay Road
Owner Owners Name
information is Osterville
required for MA 02655 June 25, 2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information.
System.installed Nov. 1998. As-built and Certificate of Compliance on file at Board of Health
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 32-1feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: N/A
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site Ian):
Depth below grade: 2
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: 11'X 5'X 4.5' 1500 gallons
Sludge depth:
1"
t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 9
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
633 Main Street Osterville, MA 02655
Property Address
Jonathan Slone 8 East Bay Road
Owner Owner's Name
information is required for Osterville MA 02655 June 25, 2010
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
37"
Scum thickness
1
Distance from top of scum to top of outlet tee or baffle 61-
Distance from bottom of scum to bottom of outlet tee or baffle
13"
How were dimensions determined?
Tape measure and dip tube.
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels
q e s as related to outlet Invert, evidence of leakage, etc.):
Inlet and outlet PVC tees in place. Liquid level at outlet invert. Risers bring covers within 6"of grade.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fibergl ss ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outle teeafle -
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M ,•''� 633 Main Street Osterville, MA 02655
Property Address
Jonathan Slone 8 East Bay Road
Owner Owner's Name
information is required for Osterville MA 02655 June 25, 2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time-,of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
633 Main Street Osterville, MA 02655
Property Address
Jonathan Slone 8 East Bay Road
Owner Owners Name
information is Osterville
required for MA 02655 June 25, 2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 011
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.):
One inlet, one outlet. Liquid level at outlet invert. No.solids carryover. No high water staining over
outlet invert. Riser brings cover within 6"of grade.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of p mp chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 633 Main Street Osterville, MA 02655
Property Address
Jonathan Slone 8 East Bay Road
Owner Owners Name
information is Osterville
re uired for MA 02655 June 25, 2010
every page. CityfFown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 4-Maxis w/4' ofstone.
t
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
I
❑ overflow cesspool number:
Q 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.):
Camera used to locate and inspect SAS. 1"of liquid at base of chambers. No sign of past hydraulic
failure.
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 1
Indication of groundwater inflow ❑ Yes ❑ No
l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 13
l
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
633 Main Street Osterville, MA 02655
Property Address
Jonathan Slone 8 East Bay Road
Owner Owner's Name
information is Osterville MA 02655 June 25 2010
required for ,
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,.sig of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 14
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
633 Main Street Osterville, MA 02655
Property Address
Jonathan Slone 8 East Bay Road
Owner Owners Name
information is required for Osterville MA 02655 June 25,2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
�. 'PAA;
`cs J
0
-"7Sj ` d1
I
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15
Commonwealth of Massachusetts
. Title 5 Official Inspection Form ,
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 633 Main Street Osterville, MA 02655
Property Address
Jonathan Slone 8 East Bay Road
Owner Owner's Name
information is required for Osterville MA 02655. June 25, 2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: '5
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: 1995
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:
ma.water.usgs.gov terraserver-usa.com
You must describe how you established the high ground water elevation:
Test hole to 10'found no ground water(1995). Base of SAS 3.5' below grade. Accessed local ground
water contours and topo mapping.
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 16
f ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
633 Main Street Osterville, MA 02655
Property Address
Jonathan Slone 8 East Bay Road
Owner Owner's Name
information is required for Osteryille MA 02655 June 25, 2010
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
f
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17,
I
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
633.Main Street Osterville, MA 02655
Property Address
Jonathan Slone 8 East Bay Road
Owner Owner's Name
information is Osterville MA 02.655 June 25 2010
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.
Important:When filling out A. General Information
forms on the
computer,use 1. Inspector:
only the tab key
to move your Patrick T. Sullivan
cursor-do not Name of Inspector
use the return
key. Ready Rooter, Inc.
Company Name
P.O. Box 371
Company Address
Sandwich MA 02563
BRD° City/Town State Zip Code
508-888-6055 SI 12843
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
June 29, 2010
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
15ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 1
i
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
n
1 �
w
t
7 5��
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 633 Main Street
Osterville
Owner's Name: Jonathan Sloane
Owner's Address: P.O.Box 351
Weston,MA
Date of Inspection: 8%15/2007
Name of Inspector: (please print) ° Patrick T. Sullivan
Company Name: Ready Rooter
Mailing Address: P.O.Box 371
Sandwich,MA 02563
Telephone Number: (508)888-6055
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The System:
asses
Conditionally Passes
Needs Further Evaluation by the Local Authority
Fails
Inspector's Signature: ��^ Date: P o
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow,of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the' .
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable and therapproving
authority. (.-)
Notes and Comments C11
C), _
0
l r
(
""This report only describes conditions at the time of inspection and under the conditions f 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.
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 633 Main Street
Osterville
Owner: Jonathan Sloane
Date of Inspection: 8/15/2007
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the" nditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined (Y,N,/thefor the following statements. If"not determined"please
explain.
The septic tank is metal and over 2or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration o or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complyinas approved by the Board of Health.
*A metal septic tank will pass inspection rally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 ygars old is available.
ND explain: l
Observation of sewage bac p or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a br ken, settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):7
f broken pipe(s)are replaced
obstruction is removed
f, distribution box is leveled or replaced
ND explain: f
r`
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if ith approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain;
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 633 Main Street
Osterville
Owner: Jonathan Sloane
Date of Inspection: 1/11/2007
C. Further Evaluation is Required /bordering
ard of Health:
Conditions exist which require fluation by t e Board of Health in order to determine if the system
is failing to protect public health, safetyvironmen.
1. System will pass unless Board dete mines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a hic will protect public health,safety and the environment:
_Cesspool or privy is within surface water
_Cesspool or privy is within a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Suu Iplier,if any)determines that the
system is functioning in a manner that protects the public health,say and environment:
_The system has a septic tank and soil absorption system(S/AS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.%y
The system has a septic tank and SAS and the SAS iswithin a Zone 1 of a public water supply.
i
r
The system has a septic tank and SAS and the SA.' is within 50 feet of a private water supply well.
_The system has a septic tank and SAS and the yS AS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to de;
me distance
This system passes if the well water analysis performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicate that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate ni ogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the an ysis must be attached to this form.
3. Other:
4
r
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 633 Main Street
Osterville
Owner: Jonathan Sloane
Date of Inspection: 8/15/2007
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Z Static liquid level in the distribution box above outlet invert due to and 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
-Z 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.
-Z Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
(Yes/No)The system fails. I have determined that one or more of the above criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facil' with a design flow of 10,060 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the folio mg:
(The following criteria apply to large systems in additio to the criteria above)
yes no
_the system is within 400 feet of a surf a drinking water supply
the system is within 200 feet of a ibutary to a surface drinking water supply
_the system is located in a ni gen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water s pply well
If you have answered"yes"to y question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the arge system has failed.The owner or operator of any large system considered a
significant threat under Se on E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 633 Main Street
Osterville
Owner: Jonathan Sloane
Date of Inspection: 8/15/2007
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
-Z 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?
_ _Z 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 than owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
_/ _ 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(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 633 Main Street
Osterville
Owner: Jonathan Sloane
Date of Inspection: 8/15/2007
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 33t� Q.f'. ice:
Number of current residents: 3 —
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system(yes or no):2��if yes separate inspection required]
Laundry system inspected(yes or no): —
Seasonal use: (yes or no):'�,<e S
Water meter readings, if available(last 2 years usage(gpd)): �C,,,,.a.�:. b•„�,�,��.� �S=�
Sump Pump(yes or no): k-�
Last date of occupancy: C,
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203):_ gpd
Basis of design flow(seats/persons/sq. ft. eta:'
Grease trap present(yes or no):_ /Sor
Industrial waste holding tank present( no):
Non-sanitary waste discharged to th itle 5 system(yes or no):_
Water meter readings,if available•
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no): A)J
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
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)
Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:`
Were sewage odors detected when arriving at the site(yes or no):
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued) .
Property Address: 633 Main Street
Osterville
Owner: Jonathan Sloane
Date of Inspection: 8/15/2007
BUILDING SEWER(locate on site plan)
Depth below grade: ;:p y"
Materials of construction:_cast iron_40 PVC other(explain):
Distance from private water supply well or suction line: ltzel�
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: (locate on site plan)
Depth below grade:��'
Material of construction:�ncrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of
certificate)
Dimensions:
Sludge depth:
Distance from the top of sludge to bottom of outlet tee or baffle: 3'7"
Scum thickness: k "
Distance from top of scum to top of outlet tee or baffle: •c
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: 4\'\e a-fc,.r-e
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
GREASE TRAP:_(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_fib rglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of ou/age,
fle:
Distance from bottom of scum to bottoe or baffle:
Date of last pumping:
Comments(on pumping recommendati outlet tee.or baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of l
II_
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 633 Main Street
Osterville
Owner: Jonathan Sloane
Date of Inspection: 8/15/2007
TIGHT or HOLDING TANK: (tank must be p ped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal fiberglass_polyethylene_other(explain):
Dimensions:
Capacity: gallon
Design Flow: gall s/day
Alarm present(yes or no):
Alarm level: Alarm in w rking order(yes or no):
Date of last pumping:
Comments(condition of alarm nd float switches,etc.):
DISTRIBUTION BOX:—Z(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(not if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
1..4 ��V C?S— .?�'V'!`c.).,:.J. c\t�?.3-� C'k�.]` "C'�� ��i�JZ'i w zo S_'
PUMP CHAMBER: (locat/site Pumps in working order(yes or noAlarms in working order(yes or noComments(note condition of pumpndition of pumps and appurtenances,etc.):
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 633 Main Street
Osterville
Owner: Jonathan Sloane
Date of Inspection: 8/15/2007
SOIL ABSORPTION SYSTEM(SAS): locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
leaching chambers,number:
leaching galleries,number:-ij_ o.c r w( Y' 5�2.
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.):
Ssd\�..
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or o):
Comments(note condition of soil,sig 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 hydra c failure,level of ponding,condition of vegetation,etc.):
I
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 633 Main Street
Osterville
Owner: Jonathan Sloane
Date of Inspection: 8/15/2007
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
� T
j
O CAS �
� LA
3
. � II
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 633 Main Street
Osterville
Owner: Jonathan Sloane
Date of Inspection: 8/15/2007
SITE EXAM
Slope
Surface water
Check cellar Qo -,c
Shallow wells
Estimated depth to ground water 3 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record—If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with the local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
:-Accessed USGS database-explain: YvNg,, �-s. 54 5- �n
T-Hr p":s - usw cc�w�
You must describe how you established the high ground
(�water
(�elevation:
_' (.� c l.� y�r.-� �.� f Zr.eX cal t�r.Jac 'e'✓�G,�y..�A J=�`tit_ �����
Town of Barnstable P# �°I��
Department of Health,Safety,and Environmental Services
Public Health Division bate -az-01
o� 367 Main Street,Hyannis MA 02601
HARNB7CAHLE, +
y nrA33.
�AT i6j9. A,� Date Scheduled 4 Time z;'3 o Fee Pd. VD 0 x 0
fD tM't
Soil Suitability Assessment for Sewage-Disposal
Performed By: -- —72 S—01 Witnessed By:
LOCATION & GENERAL INFORIVIATION
<
L//ooc�cation Address Owner's Na
111
Address
STEPHEN J. VOXLA
Assessor's Map/Parcel: 1A\ O Engineer's Name 42 Canterbury Lana '
East Falmouth,
NEW CONSTRUCTION V00
REPAIR Telephone# TelePhone: �n .
Land Use Slopes(%) 2 1 O 1` Surface Stones h
Distances from: Open Water Body �t l50 ft Possible Wet Area ►o D R Drinking Water Well tt l
Drainage Way ,�J ft Property Line , l0 ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
>a
s
4 t
1
N
!v
1
Parent material(geologic) Depth to Bedrock
Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face
Estimated Seasonal High Groundwater T=L 0
D ` ER1I NATIOI�i d1Y S ASON'A Gus:
VATE t t' l3LE
Method Used Ur&i6mtLxw'r to1.y .
Depth Observed standing in obs.hole: in. Depth to soil mottles: in.
Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft.
Index Well# __..._._. .Reading Date:__ _._ Index Well level. Adj.factor Adj.Groundwater Level
PER+CQL�;TON TEST Dafr~ ... Time
Observation
Hole# Z Time at 9"
:Depth of Pere _Z�b� 30 Time at 6"
Start Pre-soak Time @ Z:AS: 3, j Ti 6")
'.End Pre-soak 3:00 �`.Z0 yNe•TStC_ �o SplVILA
«1 Z4 I�AWVUS
:Efate Min./Inch —
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YIN)
Original: Public Health Division Observation Hole Data To Be Completed on Back j
Copy: Applicant
DEED OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency,%Gra el
V,3lZ No Loose C-Lu'r-%c3.
Y\
(I- L3 - t_5 1—i fL 4t 1.
a Scow\p \S 0\LT
0
DEEP OBSERVATION HOLE LOG
ole#
..
Depth from Soil Horizon Soil Two SOII Color ..Soil they
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency,° Gravel)
p
G- Z3U 1rS 1oyR 14 1.
z�-��o � t-\���►O Z.�� 1.
N b A, .ko,� �.
DEEP OBSERVATION HOLE.LOB .
.::....
Ho'Ie
Sup a from Soil Hori n Soil Texture Soil Color IS r Other
Depth �y°
Surface(m.) f; (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency,° Gravel
1
BS; RVA.TI - HOLE LO;G XXX
rgle# :>
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency.° ra el
Flood Insurance Rate Map:
Above 500 year flood boundary No Yes
Y rY
Within 500 year boundary No— Yes
Within 100 year flood boundary No_V/ Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system? lyz Tc s
If not,what is the depth of naturally occurring pervious material?_i4
Certification
I certify that on `-`31,�� (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with
the required training,expertise and experience described in 310 CMR 15.017.
Signature Date a -Z`i bl
TOWN OF BARNSTABLE
LOCATION 3a;,l� rr.� SEWAGE# S-30(o
VILLAGE O �r�,3\i,-�� ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO. /
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type}-1.,����TaaTd3- '�$ (size) (4 gy,*,`,�s c_,v/
NO.OF BEDROOMS L/
OWNER �o•,, ,o-� ����,�-�
PERMIT DATE: 3 I aS COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ? Je— 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
Y
40 O O
D
TOWN OF BARNSTABLE
J OCATION Q-3 ` Z3 SEWAGE#
� ILLAGE ASSESSOR'S MAP A PARCEL
INSTALLERS NAME&PHONE NO. Lctrc-s—) Z(O3
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) n } �-•4�c�.1"�5 (size) y 5 �/ �Y�•�
NO.OF BEDROOMS
OWNER
PERMIT DATE: 3 �� COMPLIANCE DATE: f 1-24 �t Q
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 Bit