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HomeMy WebLinkAbout0079 EAST OSTERVILLE ROAD - Health 79 East ®sterville Road - - Ostervilie P A = 122 099 t i I I t Commonwealth of Massachusetts Title 5 Official Inspection Form 171 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r? 79 East Osterville Road 1 •Ll Pn.'.. Property Address IM Joan Micka ,r. Owner owner's Name � informations required for every Osteryille ✓ MA 02655 2-8-18 • page Cityfrown State Zip Code Date of Inspection ' Inspection results must be submitted on this form. Inspection forams may not be altered in any way.Please see completeness checklist at the end of the form. important:When A. General Information SI# �a?S3� filling out forms o`��``�(%'iiOFr�l4Sni,�i� on the computer, ..••••••. use only the tab 1. Inspector: key to move your N cursor-do not = JAMES James D.Sears use the return Name of Inspector key. Capewide Enterprises IC�f Company Name ��,4�7`,�•5 ..... 153 Commercial Street /Rn11111i mAa�``�� Company Address Mashpee MA 02649 Cityrrown State Zip Code 508-477-8877 S1623 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 2-9-18 spector'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 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.doc•rev.6116 Tille 50ffcial Inspection Form.Subsurface Sewage Disposal System•Page 1 of 17 1111147d VS 2l, abed xed dH 9NE 860Z 66 qad Commonwealth of Massachusetts Title 5 Official Inspection Form (1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 East Osterville Road Property Address Joan Micka Owner Owner's Name information Is required for every Ostervi Ile MA 02655 2-8-18 page. Cityfrown State Zip GDde Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E 1 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"(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): Oins.doc•rev.6116 Title 5 Official Inspect-on Form:subsurface Sewage Disposal System-Page 2 of 17 6I• a5ed xed dH 9£2Z 81.0Z 66 gad Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments J 79 East Osterville Road Property Address Joan Micka Owner Owner's Name information is required for every Osterville MA 02655 2-8-18 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumpslalarms not operational.System will pass with Board of Health approval if pumpslalarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below). ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a 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 t5in6.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 0Z abed Y2J dH 9EZZ 960Z 66 Gad Commonwealth of Massachusetts Title 5 Official Inspection Form h Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 East Osterville Road Property Address Joan Micka Owner Owner's Name Information is required for every Osterville. MA 02655 2-8-18 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fall 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 OEM1111111111 is less than 6" below invert or available volume is less than '/z day flow P rY t5iru.doc•rev.6116 Tills 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 6Z a5ed xed dH LUZ 91.0Z 66 qad Commonwealth of Massachusetts Title 5 Official Inspection Form is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 East Osterville Road Property Address Joan Micka Owner Owner's Name information is required for every Osteryille MA 02655 2-8-18 page, City/Town State Zip Code Date of Inspection B, Certification (cant.) 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 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 6 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 ❑ 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.doc-rev.&16 Title 5Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 ZZ a5ed xeJ dH LUZ 860Z 66 9ad Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 East Osterville Road Property Address Joan Micka Owner Owner's Name Information is required for every Osterville MA 02655 2-6-18 page. Cityrrown 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 NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ Were all system components, excluding the SAS, located on site? ® ❑ 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. El ® 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): Z DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms). 330 t5ins.doc-rev.61'6 Title 5 Official Inspection Form:Suosurface Sewage Disposal System•Page 6 of 17 £Z a5ed xeJ dH KZZ 81.02 66 9ad Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 East Osterville Road Property Address Joan Micka Owner Owner's Name information is required for every Osterville MA 02655 2-8-18 page City,"Town State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal. Tank D Box and pit. Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection (� Yes ® No information in this report) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage NA 9 ( Y 9 (gPd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present 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.doc•rev.GAG Title 5 Official Inspeellon Form:subsurface Sewage Disposal System•Page 7 of 17 t7Z a5ed xed dH SUE 81,02 6 6 CI�d Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ' 79 East Osterville Road Property Address Joan Micka Owner Owner's Name information is required for every Osterville MA 02655 2-8-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA 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 UA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5im.doc-rev.6/16 Title 5Ofricial Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 5Z a5ed xed dH 6EZZ 860Z 6L 9ad Commonwealth of Massachusetts Title 5 Official Inspection Form I' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 East Osterville Road Property Address Joan Micka Owner Owners Name information is Osterville MA 02655 2-8-18 required for every page. Cityllrown State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components, date installed (if known)and source of information: NA 2013 New D Box. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1' Depth below grade: teat 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.): Pipeing is 4" PVC SCH -40. Septic Tank (locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ® Yes ❑ No Dimensions: 1000 Gal. Precast H-10 Sludge depth: 211 t5ins.cloc ray.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 9Z a5ed Y2J dH 6£:2Z 8602 66 4ad c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 East Osterville Road Property Address Joan Micka Owner Owner's Name information is required for every Osterville MA 02655 2-8-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-Tape 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,): Tank and cover's at 4" below grade. Inlet tee outlet baffle.Tank at working level. No sign of leakage or over loading. 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 15ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 LZ abed xed dH 6£ZZ 2 60Z 6 6 qad Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 East Osterville Road Property Address Joan Micka Owner Owner's Name information is required for every Osterville MA 02655 2-8-18 page, Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee o!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.doe-rev.6/16 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 8Z a5ed xej dH Ot7:22 8602 66 9ad Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Fong -Not for Voluntary Assessments 79 East Osterville Road Pro pe rty Address Joan Micka Owner Owner's Name Information is required for every Osterville MA 02655 2-8-18 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.): D Box is 16"x16"x14" below grade w/one line out. Box is clean and solid w/cover at 6". No sign of over loading or solid carry over. 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.doo•rev.6/•G Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 6Z abed xed dH Ot7:ZZ 860Z 66 9aJ Commonwealth of Massachusetts Title 5 Official Inspection Form C Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 East Osterville Road Property Address Joan Micka Owner Owner's Name information Is required for every Osterville MA 02655 2-8-18 page, City/Town State tip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number; 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.); Leaching is one 1000 Gal. Precast Pit. Pit and cover at 20" below grade 8"water in pit. Wl stain line at 2'. 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 l5ins.doc•rev.6118 Title 5 Official Inspection form.Subsurface Sewage Disposal System-Page 13of V 0£ a5ed xed dH OV:22 860Z 1.6 qa.J Commonwealth of Massachusetts : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 East Osterville Road Property Address Joan Micka Owner Owner's Name information is Osterville MA 02655 2-6-18 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, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 15ins.doc-rev.&16 Title 5 Orftial Inspection Form:Subsurface Sewap Disposal System-Page 14 of 17 6£ a5ed xed dH 0b?E 9 0Z 1,6 9ad c Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 79 East Osterville Road Property Address Joan Micka Owner Owner's Name information is required for every Osterville MA 02655 2-8-18 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 E R I q 17 d C 1 � + 13-,1L 3 r a -1 r. o, t 13-3 I i i I � (Sins.doc-rev.6116 Title 5 Offidal hepectlo)Forth:Subsurface SewaSe Disposal System•Pape 15 of 17 ZE abed xeJ dH 6bZZ 860Z 6L gad Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 East Osterville Road Property Address Joan Micka Owner Owner's Name information is required for every Osterville MA 02655 2-8-18 page. City/Town 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: 46+ 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 propertylobservation 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 Well SDW-252 AT 46' Zone B 2' ADJ. Before filing this Inspection Report, please sea Report Completeness Checklist on next page. t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 ££ a5ed xed dH 6bZZ 860Z 66 qad Commonwealth of Massachusetts t Title 5 Official Inspection Form IQ Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 79 East Osterville Road Property Address Joan Micka Owner Owner's Name information is required for every Osterville MA 02655 2-8-18 page C41Town 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 i f5ins.doc•rev.6116 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 17 of 17 b£ a5ed xed dH 6ti:2Z 860Z 66 qad ✓ TOWN OF BARNSTARL LOCA71ON 1l SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. ;SEPTIC TANK CAPACITY 0 LEACHING FACILITY: (type) Pi T (size) VO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between-the: Maximum Adjusted.Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching,facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �' P�,ss� TOWN OF BARNS ASEWAGE LOCATION # VII:LAGE ASSESSOR'S MAP &LO " 0 q INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY &® .--'LEACHJN.G FACILITY: (type) �� (size) � ® NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by a N4 ,. . Q AA 9 �L 3-0 . i No. � Fee �(} THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftpfiratiou for Misposal *pstrm Coustrurtiou 3permit Application for a Permit to Construct( ) Repair(V�Upgrade( ) Abandon( ) ❑Complete System 2Individual Components Location Address or Lot No. Owner's ISame,Address,and�gTel.No. S a dt 0 Assessor's Map/Parcel —19 L, 6y1 t-di\(2 Installer's Name,Adiir s at Te.No. �¢ `�7� � �T Designer's Name,Address,and Tel.No. C�v�,s�w��� V�'14y� Type of Building: _ Dwelling No.of Bedrooms Lot Size sQ-•ff. 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) Q_" 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. Signed Date '4 —1 q' -A0(j 2 Application Approved by Date/ Application Disapproved by Date for the following reasons Permit No. 4-4— Date Issued —' �/No.� Fee , THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS a Application for Disposal *pstem Construction 3permit Application for a Permit to Construct( ) Repair Upgrade('') Abandon( ) ❑Complete System individual Components Location Address or Lot No.79 o S Y`V 1 Owner's Aflame Add ;and'Tel.No. O J gr JOd�vti ,a Tel p � Assessor's Map/Parcel °Z /®Qq (_ InstalleT.1am,k' Adddr�s�a Tel.No. (S� Designer's Name,Address,and Tel.No. 0 ,5V c MA Type of Building: Dwelling No.of Bedrooms VA Lot Size ' S 9Q—R. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) i Other Fixtures Design Flow(min.required) IV fl 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 •Y O Nature of Repairs or Alterations(Answer when applicable) �Q- 0.c�' x i Date last inspected: I >`•` 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 He Signed Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. G Date Issued —� - - ------------ = = = _- - _ THE COMMONWEALTH OF MASSACHUSETTS fir BARNSTABLE,MASSACHUSETTS Certifitate of-ComphA ite ` THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed Repaired V Upgraded g g P Y ( ) P ( ) Pg ( ) C dvJ LL ¢ 2S ne b �O� 1n� 1S Abando d,� ) y, �c-� at Cc6T oce V i + S s has been constructed in acc dance L/ with the provisions of Title 5 an he for Disposal System Construction Permit No a U' - dated ` /� /� Installer C LUC Designer #bedrooms N Approved design flow and The issuance of this permit tall ttp"onj r ed- a guarantee that the system will nction aU�ied_ �j Date l � � Inspector - - - = - _- =--=--------------=---- No. e Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS j Vsposal *Pste Construction 3permit Permission is hereby granted to Cou&uQt( ) e air(V U gra e( ) ,` Abandon( ) System located at 7/ �0.5 Osv-err% '��. ?4k (�S Y 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. I , Provided:Cpns(tructio must b/e completed within three years of the date of this permit. Date �l ! Approved by [ i IHE Town of Barnstable Barnstable Regulatory Services Department , AFAmefiaCKY BARNEMABLE, Public Health Division sb39 ♦� fDt""`A 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL #7012 1010 0000 2850 9095 May 16, 2013 Joan M. Micka 79 East Osterville Road, Osterville, MA 02655 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 79 East Osterville Road, Osterville, MA was last inspected on 4/16/2013 by James E. Sears, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: • The distribution box needs to be replaced. You are ordered to repair or replace the septic system within sixty (60)-days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period-will result in future enforcement'action. PER ORDER OF T E BOARD OF .HEALTH Thomas McKean, R.S. CHO Agent of the Board of Health Q:\SEPTIC\conditionally passed\79 E.Osterville Rd.Ost May2013.doc i Parcel Detail http://issgl2/intranet/propdata/ParceiDetail.aspx?ID=7727 t r 7 ezi �. Sit°Cttf1iRA e Logged In As: Wednesday, May 15 2013 Parcel Detail Parcel Lookup Parcel Info Parcel ID 122-099I _ Developer LOT 2 Location 17 EAST OSTERVILLE ROAD �.< Pri FrontageSec j 100 Sec Road F7__--_-_m -�' Frontage village OSTERVILLE Fire District __ I Town sewer exists at this address INI. Road Index 0470 Asbuilt Se tic Scan: P Interactive 122099_1 Map ` ( Owner Info Owner IMiCKA,JOAN M Co-Owner Streetl 79 EAST OSTERVILLE RD I Street2 City OSTERVILLE 'S zip tate MA i0 5 _ Country ( � _.. __. J Land Info - Acres 0.35 use Single Tam MDL-01 I zoning RC J Nghbd 0105 Topography'!Above Street Roadaved Utilities;Public Water,Gas,Septic Location I Construction Info Building'! of 1 Year 1977 Roof Gable/Hip Ext Vin ISidin^�g Built Struct ( Wall y Living 1—._ "_'-._'"_" Roof•A h GIs/Cm� AC I ne g; " Area 11390 Cover f p p TypeBed - Style Ranch' wauDrywall L Rooms IInt 2 Bedrooms ( -wc $k.t 1�Q Model Residential Int. Cafpet - Bath 2 Full �m Floor. Rooms .- �`. Grade jAverage Type Hot Water I Rooms 15 ROOMS Ll Stories 1 St0 Heat,---­ Found Poured COnC. I � � _W ry Fuel- ation I Aft"; Gross r'258 mm Area! Permit History r _ .......... http://issgl2/intranet/propdata/PatcelDetail.aspx?ID=7727 5/15/2013 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 79 East Osterville Rd. Property Address Joan Micka Owner Owner's Name information is required for every Ostertyille MA 02655 4-16-13 ire page. Clty/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 and of the form. Important When A. General Information filling out forms �gtunrlrrrn on the use only he tab 1. Inspector: ;`� �SN OF/agssq�%� keyto move our O - y 4 � � z• ti cursor-do not James D.Sears _�.. JA M E S N key the return. Name of Inspector o; SEARS y Capewide Enterprises,LLC �11 Company Name --- — -----y��l a•RT1F� .• gyp\;, 153 Commercial Street Company Address lunu� Mashpee MA 02649 Cityrrown State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this addMss and tH-V the information reported below is true, accurate and complete as of the time of thenspection. fMe inspection was performed based on my training and experience in the proper function arlCm,' intenand-f of o5tite sewage disposal systems. 1 am a DEP approved system inspector pursuant-to Section'15.346.;�f Title 5(310 CMR 15.000)--The system: t ❑ Passes ® Conditionally Passes ❑ Fa'r s ❑ Needs Further Evaluation by the Local Approving Authority r•p r . 4-16-13 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 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.3113 Title 5 0 .' eclion Form:Subsurface Sewage Disposal System-Pagel or 17 Apr 17,13 09:15p p.2 Commonwealth of Massachusetts i - - - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 East Osterville Rd. Property Address Joan Micka Owner Owner's Name information is Osterryille MA 02655 4-16-13 required for 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: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for`yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years olds' 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•3113 Title 5 Official Inspection Form:Subsutdoe Sewage Disposal System•Page 2 of 17 Apr 1713 09:16p p.3 Commonwealth of Massachusetts ---W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 East Osterville Rd. Property Address Joan Micka Owner Owner's Name information is required for every Osterrville MA 02655 4-96-13 page.. City/Town State rip 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 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): Need to replace D Box ❑ 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 15ins•W13 Title 5 Official Inspection Form:Srbsurlaoe Sewage Disposal Sys;ern-Page 3 of 17 Apr 1713 09:16p p.4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 4 4 79 East Osterville Rd. Property Address Joan Micka Owner Owner's Name information is Osterrville MA 02655 4-16-13 required for every _ page. Cityrrown 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 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 13mMmI is less than 6"below invert or available volume is less than Y day flow t5ins-3113 Title 5 Official h5pection Fam:Subsurtme Sewage Dlsposat System-Page 4 0117 I Apr 1713 09:16p p.5 Commonwealth of Massachusetts Title 5 official Inspection Form T; - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 East Osterville Rd. Property Address Joan Micka Owner owner's Name information is required for every Ostenville MA 02655 4-16-13 page. City/Town state Zip Code Date of Inspection B. Certification (cont.) Yes No ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s), Number.of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® 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 El ❑ the system is located in a nitrogen sensitive area (interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 15ins•31113 Tnfle 5 Official Inspeclion Form:Subsurface Sewage Disposal System•Page 5 of 17 Apr 1713 09:17p p,6 Commonwealth of Massachusetts -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary ryAssessments 79 East Osterville Rd. Property Address Joan Micka Owner Owners Name information is required for every Osterrville MA 02655 4-16-13 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate dyes"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) CK ❑ 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)j31O CMR 15.302(5)j D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15,203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3113 - Title 5 OfTieial Inspection Fond'Subsurlace Sewage Disposal System-Page 6 of 17 Apr 1713 09:17p p•7 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form- Not for Voluntary Assessments a 79 East Osterville Rd. Property Address. Joan Micka Owner Ownet's Name regUiT dfors Osterrvllle MA 02655 4-16-13 required for every page_ Citylrown State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gat.Tank D Box and Pit. Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2011-40,000Gals g y g (gP �� 2012-29,000Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date Commercial/lndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day igpdt 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 ct 17 Apr 1713 09:17p p.g Commonwealth of Massachusetts uigg-- Title 5 Official Inspection Form lgi". Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 East Osterville Rd. Property Address Joan Micka Owner Owner's Name information is required for every Osterrville MA 02655 4-16-13 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: NA 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: 0 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): 15ins-31`13 Title 5 Waal Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Apr 1713 09:18p p,9 Commonwealth of Massachusetts - 172 Title 5 Official Inspection Form '+ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 East Ostefville Rd. Property Address Joan Micka Owner Owner's Name information fo is Osterrville MA 02655 4-16-13 required for every page_ Cityrrowrn State Zip Code Date of Inspection D. System Information (cons.) Approximate age of all components, date installed (if known)and source of information: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1` Depth below grade: feet Material of construction: ❑cast iron ❑ 40 PVC ®other(explain): Distance from private water supply well or suction line: feet Comments (an condition of joints,venting, evidence of leakage, etc.): Pipeing tank to box, box to it 4" PVC SCH 20 Septic Tank(locate on site plan): Depth below grade: 4"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) 0 Yes ❑ No Dimensions: 1000 Gal. Precast Sludge depth: 4" Uns•3113 Title 5 Official Irspecticn Form:Subsurfaos Seeage Disposal System-Page 9 of 17 Apr 1713 09:18p p.10 Commonwealth of Massachusetts Title 5 official Inspection Form t o. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 East Osterville Rd. Property Address Joan Micka Owner Owner's Name information is Osterrville MA 02655 4-16-13 required for every page- Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness " - -- - Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 16 How were dimensions determined? Asbuilt-Tape 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.): Tank and cover's at 4" below grade, inlet Gee outlet baffle. Tank at working level. Tank should be pumped. No sign of leakage or over loading. 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 Inspecticn Form:Subsurface Se.vage Disposal System-Page 10 of 17 Apr 1713 09:18p p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 East Osterville Rd. Property Address Joan Nlicka Owner Owner's Name requiredfo is Osterrville MA 02655 4-16-13 required for 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Apr 1713 09:19p p.12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 East Osterville Rd. Property Address Joan Micka Owner Owner's Name information is required for every Osterrville MA 02655 4-16-13 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.): D Box is 16"x21"-'14"below grade w/one line out. Wall's are gone, need to replace D Box. 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): Jf SAS not located, explain why: 15ins-3113 TPoe 5 Official Inspection Form Subsurface Sewage Disposal System.-Page 12 of 17 Apr 1713 09:19p p.13 Commonwealth of Massachusetts Title 5 official Inspection Form kvlw - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 East Osterville Rd. Property Address Joan Micka Owner Owner's Name information is required for every Osterrville MA 02655 4-16-13 page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovativefalternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is one 1000 Gal. Precast Pit. Pit and cover at 20"below grade. 20"water in pit, wlstain line 4"above level. 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 l5ins•3113 Tide 5 Official Insoec6on Form Suosurtace Sewage Disposal System-Page 13 cf'7' Apr 1713 09:19p p.14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 East Osterville Rd. Property Address Joan Micka Owner Owner's Name information is required for every Osterrville MA 02655 4-16-13 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-): (Sins.WS - Title 6 Official Inspection Form.Subsurface Sewage Disposa:System-Page 14 of 17 _ Apr 1713 09:20p p.15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 East Osterville Rd. Property Address Joan Micka Owner Owner's Name information is required for every Osterrville MA 02655 4-16-13 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 i __ fc FAR �c /3 +� f - I -� Z17 /37a- 31 J I I X -3 � � � 03 /Y- 3 3 7- [Sins.3113 Title 5 Official It'spectlon Forth:Subsurface Sewage Disposal System.Page 15 of 17 Apr 17.13 09:20p p.16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 East Osterville Rd. Property Address Joan Micka Owner Owner's Name information is required for every Osterrville MA G2655 4-16-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth torn��igh ground water: 4 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: U.SGS Well SDW 252 You must describe how you established the high ground water elevation: USGS Well SDW-252 at 46' Zone B 2' ADJ Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5im-3113 - - Tille 5 Official Inspection Form:Subsurface Sewage Disposal system-page 16 of 17 Apr 171 3 09:20p p.17 r Commonwealth of Massachusetts Title 5 Official Inspection Form -� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 East Osterville Rd. Property Address Joan Micka Owner Owner's Name information is required for every Osterrville MA 02656 4-16-13 page. CityTrown 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 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syslem-Page 17 of 17 & COMMONWEALTH OF MASSA.CHUS,L:TTS EXECUTIVE OFFICE OF ENVIlRONMENITAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION u w V n h A V•Iy yJev TITLE; 5 OFFICIAL INSPECTION FORM--NOT FOIE VOL UNTARY ASSESS iNIENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A MAP CERTIFICAT ION PARCEL ! Property Address: 79 EAST OSTERVILLE RD OSTERVILLE'02655 Owner's Name: COBY VINCENT Owner's Address: 79 EAST OSTERVILLE RD OSTERVILLE 02655 Date of Inspection: 2/7/03 ' �vt® —. - Name of Inspector:-(please print) JOHN GRACI, INC. 02003Company Name: SEPTIC INSPECTIONS [t4:0? Mailing Address: P.O. BOX 2l19 TEATICKET, MA.02536 ��NST,q0 CEP Telephone Number: 508-564-6813 FAX 508-564-7270 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 pei formed based on my training and experience in the proper function and maintenance of on site sewage disposal systeans. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CNIIR 15.000). The system- X Passes _ Conditionall asses _ Needs Furt Evaluation by the Local Approving Authority Fails Inspector's Signature: �� Date: 2/7/03 The system inspector shall submit a opy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspectio I. 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 authori(y. Notes and Comments THE SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY `fWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. RECOMMEND REPLACING COVER TO LEACH PIT. ****This report only describes conditions at the time of inspection and under :.he conditions of use at that time. This inspection does not address how the system will perform in the future wider the same or different conditions of use. Titlr S IncnFrtinn Form A/I S/')O()f1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 79 EAST OSTERVILLE RD OSTERVILLE 02655 Owner: COBY VINCENT Date of Inspection: 2/7/03 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. RECOMMEND REPLACING COVER TO LEACH PIT. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 79 EAST OSTERVILLE RD OSTERVILLE 02655 Owner: COBY VINCENT Date of Inspection: 2/7/03 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. I 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance n/a "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: n/a z Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 79 EAST OSTERVILLE RD OSTERVILLE 02655 Owner: COBY VINCENT Date of Inspection: 2/7/03 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped NOT IN THE LAST YEAR INFO FROM OWNER. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X 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 failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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. a Page`of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 79 EAST OSTERVILLE RD OSTERVILLE 02655 Owner: COBY VINCENT ` Date of Inspection: 2/7/03 Check if the following have been done.You must indicate "yes" or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? _ X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components, excluding the SAS, located on site? X _ 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 ? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information.For example,a plan at the Board of Health. X _ 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)] 5 Page 6 of-11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 79 EAST OSTERVILLE RD OSTERVILLE 02655 Owner: COBY VINCENT Date of Inspection: 2/7/03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)):40 Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203):n/agpd Basis of design flow(seats/persons/sqft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: NOT IN THE LAST YEAR INFO FROM OWNER Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X 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): n/a Approximate age of all components,date installed(if known)and source of information: 25 YRS OLD IN FROM OWNER Were sewage odors detected when arriving at the site(yes or no): NO F Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 79 EAST OSTERVILLE RD OSTERVILLE 02655 Owner: COBY VINCENT Date of Inspection: 2/7/03 BUILDING SEWER(locate on site plan) Depth below grade: 9,1 Materials of construction:_cast iron =40 PVC Xother(explain): 20 PVC Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting, evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 3" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: L 8' 6" H 5' 7" W 4' 10" Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle:32" 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: 0 How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL SEPTIC TANK COMPONENTS ARE STRCTURALLY SOUND AND FUNCTIONING PROPERLY.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP: _(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a Page E of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 79 EAST OSTERVILLE RD OSTERVILLE 02655 Owner: COBY VINCENT Date of Inspection: 2/7/03 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box,etc.): D-BOX IS STRUCTURALLY SOUND. PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R Page 9 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 79 EAST OSTERVILLE RD OSTERVILLE 02655 Owner: COBY VINCENT Date of Inspection: 2/7/03 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PIT IS STRUCTURALLY SOUND.RECOMMEND REPLACING COVER.THE LEACH PIT HAD 2' IN AT THE TIME OF THE INSPECTION.THE STAIN LINES INDICATE THE PIT HAS NOT BEEN MORE THAN 1/2 FULL.BOTTOM IS AT 8' CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a 4 Page*10 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 79 EAST OSTERVILLE RD OSTERVILLE 02655 Owner: COBY VINCENT Date of Inspection: 2/7/03 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. I _ - o a p � OC 31 AC 3� in Page I 1 of 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM..INFORMATION (continued) Property Address: 79 EAST OSTERVILLE RD OSTERVILLE 02655 Owner: COBY VINCENT Date of Inspection: 2/7/03 SITE EXAM ---'`-` _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+ feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 12+ FT. I NoS��... y Fps.. 65................. THE COMMONWEALTH OF MASSACHUSETTS 0� BOARD O HEAL H " ------.. e..OF............ ...................... ............................ Appiiration for Diipnsai Works Toust.rurtion ramit Application is hereby made'for a Permit to Construct or Repair ( ) an Individual Sewage Disposal W-__............... .. ......-. . ... - .................................... , .ocation-A s or Lot No J .. � ...--•-� ............................ ....................... - ..._............ ......._...-- ._.........••......_... Own � s �W a Installer Address U Typ of PBuilding Size Lot..../_5/_ .Sq. feet Dwelling—No, of Bedrooms.........An..............................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures _______ _ _ __________ _................................................ ---------- w Design Flow......... .........................gallons per person per day. Total daily flow..............A0.. ...............gallons. WSeptic Tank—Liquid capacity aWgallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... W th_.......... . - Total Length......... _......_ tal leaching area....................sq. ft.h.;:Seepage Pit No... D' el otal leachin area..39 .sq. ft. z Other Distribution box ( ) Dosing tank ( ) �� — _ -7 Percolation Test Results Performed by.. �F.. Date.._. !� a Test Pit No. 1................minutes per inch Depth of Test Pit..........._..____.. Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P ....................... . ................... . 0 Description of Soil-• .-`3 � x w UNature of Repairs or Alterations—Answer when applicable.......................:....................................................................._.. ---------------------------•--------------------------------------------------------•---•------••-••------••-••--------•--•-------•--------•-------•-•-•--•-••-••---••-•--•......--•-••---•---•--•-•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of ealth. gne ...----- . ... � ---- - f ....7 . Date Application Approved By............ •--- ....... ------------ --•-- Date Application Disapproved for the following reasons---------------------•--•----•-••----•------------------------------------------•----------------•----•.......... Date PermitNo......................................................... Issued....................................................... Date No........ ............................. THE COMMONWEALTH OF MASSACHUSETTS 0 TH HEA BOARD 0 . .......................... ........... *.....OF....... ........................ Appliration for Disposal Works Tonstrurtion Prrutit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal Sys .24 /0 %, I ' .0' 6flll�_ A/ .............................11 .................. 0, .................................. Aocation- ss or Lot Np. ...................Z. .............. ....... ......................... Ownar sass .... ................. .... 7�--------------­----------- .... .......... .......................... .. ........ .. .................................................... ......... . .......... ............. Installer Address Type of Building Size Lot--- feet Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder ( ) Other—Type of Building ............................. No. of persons............................ Showers Cafeteria ( ) Otherfixtures ..... .............................................................................................................................I................. Design Flow.......... 9.........................gallons per person per day. Total daily flow------------_-Ali.q.- '_...............gallons. Septic Tank—Liquid capacit)/f0!??!jallons Length................ Width.......__._..._. Diameter__._____--_-_-_- Depth................ Disposal Trench—No..................... V,&dth.......... Total Length.... /......Xotal leaching area..__. sq. f t. Seepage Pit No D ........-_%Z-.02riATtpt1f-be1, .................... otal I hm uea..�.kefr....sq. f t. Z Other Distribution box Dosing tank wo _7 0-4 a'00' - -Percolation Test Results Performed by. �.2�................. .......... Test Pit No. I................minutes per inch Depth of Test Pit- ____-__-_-• Depth to ground water.._..................... Test Pit No. 2................minutes per inch Depth of Test Pit................_... Depth to ground water.___........_........... ---- --------------------- .................................... ---------------- 0 Description of Soil..7 .J­ --;L ;i X X ..... ........... /--------- ......... ....................................... .......................................................................................................'­---------------------------------------------------- --------------------------------------------- ------------------------------------------------------................................................................................................ U Nature of Repairs or Alterations—Answer when applicable.-___________________________________________•---_- ............................................ ............................... ........... ................7.................................................................................... .................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T I T!L- 5 of the State Sanitary Code—The uridersign6d further agrees not to place the system in operation until a Certificate of Compliance has been issued b the b d�par o eat �e'Agne .. .... ......4 ----- .......... .... ................. ....;4gn Date Application Approved By........... ­ .... . .. . . . . . . . 0�............. ...... 7 7 17 ................. Date Application Disapproved for the following reasons:.............................................................................................................. ........................................................................................................................................................................................................ Date Permit No.......................................................... Issued......................*............: .................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL 7........ OF..... `-......:: ......................... TwWrtifiratr of Tompliam THIS IS TO CERTIFY, T the 06i'vidual Se ge Disposal System constructed 04" or Repaired by................................... ............ ..... ................ .. ......... ....................... ;;Z_1 V affer 1 014 at..........�c.......... ..........oz.. ...... .... ......... ........... .... .......... ..................... ........ .. .. ----- has been installed in accordance with the provisions of TI T", 5 of The State Sanitary Code as descr*b d in the application for Disposal Works Construction Permit No.--.&7__-70/0.0�........ dated__../!;�__.Z......;P.�...... ----- ---- --- .......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM Wl� FUNCTION SATISFACTORY. DATE...... ...... ..... 29......................... Inspector--- .................................... THE COMMONWEALTH OF MASSACHUSETTS BOAR�DaQF HEA ..... ............ ....... ...OF... -------- ................................. FEE ............ Elitspos I Works Cron u0w famit Permission is y granted..... ........--------................... ..... . ... .. .. a Ovi ua��(to ;n it an ividual S)e�5pge DisposO Sfstep,� ........ . ......at Construe as s own on the application for Disposal Works Construction P N Dated... 1 40 .......................... fpd&—dO- 2r .................................... 4 Board of DATE....... ......................................... FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS - �tc., r�a1 L�4 FLow to 3 SSC) G.P.V. --- - - - T l o0 00 P.D. ijSN'e}-�A� PIT - uSE. loco Gam, p 0 ,L"QGL(/AL- AV-EA = (SD S.F. Q ' D• c.A S►�. � l .o _ Sd G.RD. xot p TOTAL Z'>E.Swla = 425 TOTA L t::),dt L.-( rLr�W = 33c 6.PD. raNA:� px G�i�GtULQTlC71..1 C11�T� � +1.1 2�4tIIJ OfL L£.SS. � j , \�`a l � . -resT ToP 1-Nc =ioo.o Coa.�1 +uv. `D.riSCJ�� 4' IMv. ,o TAhlK 3 - G,AL. %S.3Z 9S,So /�'�rCi•- FIT CELZTtFICD cGAL I ii_ bl�.TC— II/Z1 17 nb Gv'AT�.t 1 c t,►<'t'1 F ( T�-(A T Q. Pt-!a,►,1 . TZ C_F E V-a►4 c:.C, t-1i.t;L•i�tJ CC M\PL�(S illI"i'1-Z T+-�` �'jID� l_r►-1� L,9T "L. n.a,a °:c•rt~>/�cl% S:'cr,�cc:Cn�c:�T� o� �'r,-+cam jUk!►J G�' r�f�.t� �.At�r �o� IZEGIS [-C_.i�i�D 'tJ�l�tJ iU2u'�=.Yvl� f ( t �l`� 17 t_/a►-i 1!� �-1 UT U:A i C-7 U1.1 AaJ OSTC--V-VtLLG_ c� I�rC AS i 1 1:.!`,t �'�%:i\(r_1.1 i '1�1i:�/1.=ti' �- �.+�{_: i✓�t=ji=1-i �7l 1GE11tSJ -- - r li 1 Gh.ti�.l 1•. .r L'at li ;C.i`� ��i tel:- 1 �::C�N�� t�l=_ LC7'G 1_IFJ <� _ ,{l�' W�I7 ✓�