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HomeMy WebLinkAbout0089 EAST OSTERVILLE ROAD - Health a 89 East Osterville.Road Osterville P A = 122 100 2 " E , a o „ n 1 w a I 3 J _ � r � Town of Barnstable Inspectional Services Department R" �MAS& ' Public Health Division MASS. '°fin►9. 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4987 8241 December 15, 2020 WILSON, JOHN T TR 389-G WEST CENTER STREET WEST BRIDGEWATER, MA 02379 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 89 East Osterville Road, Osterville, MA was inspected on 11/02/2020 by Shawn Mcelroy, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Static liquid level in the distribution box is above the outlet invert due to an overloaded or clogged SAS or cesspool. You are ordered to repair or replace the septic system within one (1)year 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 THE BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\89 East Osterville Road Osterville.doc Town of Barnstable BARNSI'ABM Inspectional Services Department �prfD MA'S a Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 4/26/19 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An "x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ❑ Structurally unsound septic tank or SAS O E 1 YEAR DEADLINE CRITERIA Static liquid level in the distribution box is above the outlet invert due to an overloaded or clogged SAS or cesspool ❑ A portion of the SAS, cesspool, or privy is below the high groundwater elevation ❑ A portion of the cesspool is located within a Zone 1 to a public well ❑ A portion of the cesspool is located within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc t L Commonwealth of Massachusetts ,+@ Title 5 Official Inspection Forte '1 Wi Subsurface Sewage Disposal System Form -Not for+Voluntary Assessments r . :.J, >r` 89 East Osterville Rd Property Address John Wilson { ;.: •..�,+ Owner Owner's Name • . " information is t required for every OSterVllle MA 02655 11-2-2020 ' page. City/Town ,�3; y, State yZip 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. . .'r. ! . .rf 1'.,�.L ' .. ,1 .�. `'�rr '.:� - ,s r ,r. 'ta l•t� ,+. A. Inspector Information Shawn Mcelroy Name of Inspector•'t1 Upper Cape Septic Services " � i'y r• - ;1' `'` Company Name rJ J+- ++ P.O. Box 73 Company Address East Falmouth MA 02536 City/Town State Zip Code 508-495-0905 S13971 Telephone Number License Number B. Certification I certify that:) am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000);l have personally inspected the sewage`disposal'systeri at thepropeity address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training andlexperience iii the proper function and maintenance of'on=site sewage`disposal'systems.Aftbr conducting this inspection'I have determined that the system: i • , c' ' „f,. .) r.i'1. •R'iPasses"! Li AII!, m ; ,,2. ❑ Conditionally Passes ,, , i Y`.•' I +r ru r ,t. :.+ t (w`ttir) [ +.arf _ r' i s_ill ,4lr! �'"T `:. r ., ,. + ' r to - t ! r!t(} ,� ,r. :t, r :J !� .:� 4 t t t . +, .• ter.i . Mat i,ifw,•; I Y' 'L t. ,! 3. ❑.. Needs FurtherEvaluation.by the.Local Approving Authority ,r Y 4. ® Fails r'' tpj'. ;`re.1`? r}i'11 'Oi ;f„�,"t; �� : .,tid 3i �.; 1..:ti+ +N A.`41 i A.f!r,J;4(,. 11Id ;-1 I :�ufc 11-2-2020 Inspecto Signature "w ' Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18.,. 4 , < Commonwealth of Massachusetts • ' 1 r , - ,. Title 5 Official Inspection form �i Subsurface Sewage-Disposal System Form -Not for Voluntary Assessments 89 East Osterville Rd Property Address John Wilson ' Owner Owner's Name information is required for every Osterville MA 02655 11=2-2020" - page. City/Town State Zip Code Date of Inspection C. Inspection Summary . Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System-Passes: - ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. r Comments: r t. 2) System Conditionally Passes: One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the fol lowing!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): y• L _ *' i i:` r .rt 1•� 'F °,. r .l ,. r '1 . ;`f • i r _ ° s!. r"f r.7 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 cam'° Commonwealth of Massachusetts ;�: ,�•�.° ,w `.•, -; �x ; , �, ,., x f Title 5 Official, Inspection dorm Y , 4 Subsurface Sewage Disposal S stem.Form,-Not fon.Voluntary,Assessments r 89 East Osterville Rd Property Address John Wilson ,r;,; i Owner Owner's Name information is Osteryille _.t i MA 02655 11-2-2020,. required for every • page. City/Town L or, ,; State Zip Code Date of Inspection CAnspection-Sutimary (cont.) �a, 2) System Conditionally Passes„(con!.), , ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if r r - �"piJm9 ps/alarms'ar2'repaired: 'may)": =c rtsri ii.•r i 'i st, -' --:r. P, „ii • i Y..-iquo,it,i,>�}� `,,J 1w.','1 1 )° ' •••i'wg.>:�i_ri` �+�'.' .. 7 r`?:•`��..t.. ;t^ i1 .r •ffs., ' f1a L) '�'.*.� '. .s+ _ 1. -.rY��:�•Jt'ri+�j!".�y '�c' 1i.�rt�� .. .� '•..rr•}<..:•., a� 'i ... i..,��.qY 3 ..•t,1��j' 53 ''f•7!�i3�; ❑ 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): ' 1,1 -,r rra T '-. i..❑—I)N broken pipes) are_replaced' ❑'Y '°❑N-'' 4O. ND•(Explain below): •�' �` .•r; 7{ `" ❑U1,1"obstruetiori is removed ° + u "'It Y -`❑N ❑,IND'(Explain below): ❑0' 'distributi6 ,box is leveled or r`epia6ed: ❑Y s p ❑l"N'`*=❑ `ND'(Explain below): • f•,.ft•, Li� }F•�R r - 7.r i'. f' • �r :itt ii °..r'0 f� art `• k.tJ3a i '1;,r1 ,ii `�; 7*i.f.J tr.r*. . `,, 3W: ,t 1141Y ' 'i -. �..i j.' r • 1'1 ear, . � ne dn - rTf +f. f '.w.•ri-. 'r.c, c.i k: • t'9 .3 C: j7r' t r.i�" pi* e1,'tie -te-ka _.7 , °. :�s .'' ",itfJ a. lr f{ Cj ❑ The system required pumping more than 4 times a year due to broken:or„obstructed pipe(s). The system will pass inspection.if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑Y ❑N ❑ ND (Explain below): ❑ - obstruction is removed ❑Y ❑N ❑ ND (Explain below): 3) Further Evaluation is Required by.the=Board of Health:.,. 'f �, - , ❑ rConditions exist which require further evaluation by Board of Health in order to determine if i• the'system'is failingto protect'public°Health, safety orthe environment.'-' "4 r a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, • safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 - � ,N Commonwealth of Massachusetts ' ° = 3 Title Official , Bnspection for III Subsurface Sewage Disposal System Form Not for Voluntary Assessments 89 East Osterville Rd Property Address ' John Wilson I Owner Owner's Name information is Osterville ' MA 02655 11-2-2020`. required for every ' page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) _ ❑ Cesspool or privy is within 50 feet of a�Surfacei water = rv- ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to'a surface water supply. ❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. • ❑The system__has a septic tank and SAS and the SAS is within 50 feet-of a private water supply well. ❑The system has a septic tank and SAS and.the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other i+ d _ ' y 4) System Failure Criteria'Applicable'to All Systems:' You must indicate"Yes",or,"No"to each of the following for all inspections: -Yes! -"No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts a f� Title 5 Official Inspection . Fo.ft- .- Subsurface Sewage Disposal System.form-Notfor;VoluntaryAssessments, 89 East Osterville Rd t► F;,. .; ar. Property Address John Wilson , Owner Owner's Name , information is Osterville.- - MA 02655 11-2-2020,;�-J required for every • ' `� page, City/Town . ,,. r State Zip Code Date of Inspection C. Inspection Summary (cont.) 4),,.System Failure Criteria Applicable to All Systems: (cont.), - C i` Q .r j .eyes •J,T_.LNo. �.,1. I i• r. - -. l., r- - i'its "1 -.,f,.. .' .! ,, Static Iiquid'level in the distnbution box above outlet invert due to an overloaded xyr+ gg . .p 1. ."n�. .{-.n `s C'.. r or clo ed SAS or cess ool Liquid depth in cesspool is less than 6" below invert or available 1.volume is less 1.thaiN day 6W" • " ,: ''. r*; . t,r . 1.0", ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ` • # - ❑ ;.�! ®ri .;� ,,;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 ,'#f`tributary to,a surface-water supply:`"' ` Any portion of a cesspool or privy is within a Zone 1 of a.public water supply -_,.C!;'r ,` '!' ❑. }R. t'•�rT =C'v'•T 4�' "tit.. 4, �'.,:r��.J` .. . :. .• .rfe �� `+ ® Any portion'of a`cesspool:or privy is within 50 fee_t of a private water supply well. ❑ ® Any portion'of a'cesspbol or privy is less than 1 Ob feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if,thewell.water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence iof ammonia nitrogen_and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and.chain of custody must be attached to this form.], The system is a cesspool serving a facility with a,design flow of 2000 gpd- . • . , ,r .1,ii.1 4}r.:E] 10'4" ,r l O0 000 gpd: n,"If , ,t .f,' F. � 0-4 ;.l�. , a. ter.... t TM system fails. I have determined that one or more of the above failure {' "- ®etJ+`� 1❑'' '`�` criteria exist as described in 310 CMR15.303,therefore the system fails. The ,•l , ,, # . n, � w , f.�, ��i system owner,shouI contact the,,,Board of Health to determine what will be . . !; ,•;;4 f,,,_� � .. ; necessary qo porrect the failure:,.- '.x•' .t' f %'� � t�`Cs:�`s�a d�� , 1L-'LAP: ��,.d? r�=!i .. /'t^���•'tf �''f:s.. s�i?' �3t 5) ,Large Systems:To be considered a large system the system must serve.a facility with a design flow of`10 000'9pd to 15,000 g, d. r--AFor large.systems, you_must indicate,either,`yes"ior,,no",to each of the following, in addition to the f,_ questions in;Section{CA. ;.�,,�,. . -. , ;� :•, ��, , ,,, ,/ ' Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well t5insp.doc-rev.7/26/2018,, r Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 , Commonwealth of Massachusetts Tide 5 Official inspection Fora .� MI Subsurface Sewage Disposal System Form =Not for Voluntary Assessmentsr'- 89 East Osterville Rd Property Address -- John Wilson Owner Owner's Name n r information is Osterville - MA 02655 11-2-2020" r',-. required for every ' page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the systei-n is considered`a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat`under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. - u 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No r -, ❑ [9 " , 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? ❑ ® µ Has the system received normal flows in the previous two week period? + ❑ v . ; } 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 dwell ing'inspected for signs of sewage back up? r '® `= ❑ 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 f inspected for the condition of the baffles or tees, material of construction, .dimensions, depth of liquid, depth"of•sludge and depth of scum? Wasthe facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health.: '® Determined in the field (if any of the failure criteria.related to Part C is at issue approximation of distance is unacceptable) [310'CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 ' r Commonwealth of Massachusetts , ;_•�- �,;; ;, - _� I , . Y Title 5 Offi al Inspection- Form- <,r1.i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 89 East Osterville Rd Property Address t John Wilson Owner Owner's Name information is required for every Osterville • , =- ..r, Al MA 02655 11-2-2020 , page. City/Town State Zip Code Date of Inspection D. System Information ,fit 1. Residential Flow Conditions: ;,.,# Number of bedrooms (design): 3 Number of bedrooms,(actual): 3 DESIGN flowbased on 310 CMR 15.203 (for.example.: 110 gpd x.#of bedrooms): 330 Description: IrO, -,r Number of current residents: , ,•r s 0 . 0 Does residence have a garbage:grinder?,-, fi< „ ,;,f,,;-ti.,r ya ❑ Yes ® No Does residence have a water treatment unit? •r ►Fr; .� ; ,,�, .•; - F,1�, t�•f�. ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) f 1� f+ V`+�'t ,i:t{, ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? '❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: , Sump pump? '�e�: .,{� _� . ,�v .:� ❑ Yes ® No Last date of occupancy: Unknown j ♦ Date t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page'7 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection FOriw hi Subsurface Sewage Disposal System Form Not for Voluntary Assessments- - 89 East Ostervi►le Rd 1 Property Address John Wilson Owner Owner's Name information isOsterville MA 02655 11-2-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type.of Establishment: Design flow(based on 310 CMR 15:203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? "' ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ' i ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): " fr • i i 3. Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No rY If yes, volume pumped: gallons F YP P How was quantity pumped determined? Reason for um in : P P 9 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts ;• -,w� -,;; ;, .;,r„ „�� ,>;, _ _. a f Title 5 Official- Inspectiom-'FdrM s=t ! e�1 Subsurface Sewage Disposal System Form -Not for-Voluntary Assessments ,.. 89 East Osterville Rd Property Address John Wilson Owner Owner's Name information is Osterville .`4s 4; MA 02655 11-2-2020 required for every page. City/Town• r 4A State Zip Code Date of Inspection D. System Information-(corn.) £ -. J ; , ,; ; ; _ - 4. Type of System: ® `Septic tank,distribution box, soil absorption system q 1 f,• a; ❑ Single cesspool ,it ,-,, .,-; tit, ,, c,; _ ❑, .. •,,i; c 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{ rt r ❑; , _ Tight tank.-Attach.a,copy,ofthe DEP approval,. ❑ �: Other(describe): Approximate`age of all components;,date installed,(if.known) and,source of.information: 1977 oc Were sewage'odors detected when,arriving at thesite?:,1. , t, ,t„,.;, ., rtiw10 Yes ® No 5. Building Sewer(locate on site,plan):,t; �,, ,, , , •,, r.,,cf,, , �; Depth below grade: i, ., - , i, �'' t 1811 feet ` „ ,�,.. ,• : - Mat 1 ,it, 4� erial of construction: r :f .:.E• ,(If M- ,rt :, _;, ^ , ® cast iron "."A"t' 0'407pVC � �`-�``❑"other(explain):'"`'' 11'• Distance from private water supply well or suction line:- feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 ., Commonwealth of Massachusetts 61111 Title 5 Official Ins ectioln, Form Subsurface Sewage Disposal System Form -Noffor Voluntary Assessments 89 East Osterville Rd Property Address John Wilson Owner Owner's Name a information is required for every Osterville MA 02655 11-2-2020 , page. City/Town State Zip Code Date of inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 12" - feet Material of construction: ® concrete ❑ metal ❑ fiberglass' l'polyethylene ] ❑ other(explain) If tank is metal, list age: ' `' years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: , 1000 gal _. Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle` 20 ,. Scum thickness 211 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 14 How were dimensions determined? ,.Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.j: Tank is in good condition with baffles installed and no sign of leakage.. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts •� .�a;E ,r,�c ,_ _ rt �+,� --• , a, Title 5 Official Inspection Fornn M Subsurface Sewage.Dis osal S stem Form;Not for Volunta Assessments, 9 . p y !Y 89 East Osterville Rd , Property Address 1 John Wilson Owner Owner's Name information is required for every Ostefville . ^,, . t MA 02655 11-2-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): ;„�„ ?�,._; r W-,_t Depth below grade: feet 1 J� 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:,,,, ., ;;,� ,,, tl`rt.r ,., tr t.r+ft 'Date y Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of le'akage,'etC'):*"` '�4 �. ,.3"tt- f'.t') it .,.- `t f'.•r i,• ni �r •r� + •.r - 8. Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below,grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 'Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 , , Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18,. Commonwealth of Massachusetts Title S Official Inspection Form i I Subsurface Sewage Disposal System Form -Not for Voliantary'Assessments 89 East Osterville Rd i ' - Property Address John Wilson Owner Owner's Name information is Osterville MA 02655 11-2-2020 required for every ' page. City/Town State Zip Code Date of Inspection .D. System Information (cont.) - t.• t� 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No '� '.0 Alarm level: Alarm in wo�king'order. ❑ Yes ❑ No Date of last pumping: ' r' Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locate,on site plan): s 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 was in bad shape and crumbling. • sR f 7 t5insp.doc-rev.7/26/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts A ,.; Title 5 Official Inspectionf.oft r.I Subsurface Sewage Disposal System.Form--Not for;Voluntary Assessments-,, ,,j ; 89 East Osterville Rd Property Address John Wilson v Owner Owner's Name information is OSterVllle <* .,' required for every MA 02655 11-2-2020° _• page. City/Town t. s., State Zip Code Date of Inspection D. System Information (Copt.) _ - 1 y e; ,;�; �:;; �� r .� 4 10. Pump Chamber(locate on site plan): tz / 0., 1 , , ,C4 'Pumps in working onJer:�;Re",-�If e.t,E' :-I 'it,- ,❑,Yes'1 ❑ No* Alaims in working order: '-.J `t '•: r't ;:`' I ' .t.,t, 2 •i;,arl 'Yes J ElNo* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): :.r+i.1� + f^•. � •-r: `#'.r:•f; .. .•. .ro � ,.., L. j `..-.�.\+ L; .-::sa ...v.°.,�.«^. ,., ,ua€,wr; ... *If pumps or alarms are not in working order, system is a.conditional pass.- 11. Soil Absorption System (SAS) (locate on site plan„excavationlnot�required):, ,_, If SAS not located, explain why: T,, , . , • :_ IT Type; r , ; tw �4 . �r t� r t.- r� leaching pitsr F'cl'"� i :� :! .tt�as. +t number o' ��,..: P, z 1-1000 gal 1, ❑ leaching chambers number: ❑ = leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts f = :% ._•' I R = ti 31 Title 5 Official , ifispecteon'• Forums ' HI Subsurface Sewage Disposal System"Form -Not for Voluntary Assessments 89 East Osterville Rd • i Property Address John Wilson Owner Owner's Name information is Osterville { =' MA 02655 11-2-2020` " required for every page. CitylTown ' State Zip Code Date of_inspection D. System Information (cont.) = { I 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit was holding 6" of water at inspection with clear stain lines above inlet invert. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert. = ' Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note_ condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.c'oc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 c Commonwealth of Massachusetts Pit, Title 5 Official t Inspection.. Form Subsurface Sewage Disposal System Form,-Not for V.olunta Assessments..i / 89 East Osterville Rd h '.`e>r+�„«r -•t Property Address t.i John Wilson ., .N, •,.; , Owner Owner's Name information is required for every Osterville, r MA 02655 11-2-2020,,-- page. City/Town _ •, ,; State Zip Code Date of Inspection D. System Information (cont.) a _ ' '~ 13. Privy (locate on site plan): >C,,irj rr'MAJ8.;C =x • • t' I I ': ,,., �,_,, rY . a ,t r , �..,:tiiiirl. 't! I,!' '1 `lk: i`tt7 �,�b,a.,,•�i' rrl� .i9 �t. . ".1���Rr , Materials'of con`struction:101 Dimensions Depth of solids , :,:�,�,3 aix dfev;,;:kx-,11 '~ Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): f C ' i �.rax f i 1t�, , r t t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18. Commonwealth of Massachusetts - w Title 5 Official Ifspec$ion Ford { k ..�"1 Subsurface Sewage Disposal System Forme-Not for,Voluntary-Assessments 89 East Osterville Rd 4 Property Address v John Wilson Owner Owner's Name information is Osterville - ° ' I MA 02655 11-2-2020 required for every - ' page. City/Town State Zip Code Date of Inspection D. System Information (cont.) • _ F • y 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below - ❑ drawing attached separately .6 _ . 6. � 1'* `i .A 0 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Ifspectionoft `� ,~ f� HI Subsurface Sewage Disposal System Form;Not,forVoluntary:Assessments;-TA,..,, 89 East Osterville Rd Property Address John Wilson fir 41A 1 ", Owner Owner's Name information is required for every Osterville MA 02655 11-2-2020, -1 page. City/Town ,,. t._ State Zip Code Date of Inspection D. System Information (cont;)f,; Ttr .,ti.a 15. Site Exam: :�t. at jA: ; •rts rx}*r? sfl t� 4 t X::,-.�t� :t� ."� :'� �. ,' �.} ❑ Check Slope i t • , „ ,,, ,, ❑ Surface water ❑ Check cellar ❑ Shallow wells r: .,an : .:,c:u �r�, " r Estimated depth to high groundwater-.,..? ;,;;; .:; .!t , ,f,s�}e Please indicate all methods used to determine the high groundwater elevation: i ❑ Obtained from system;design plans on record;_ ,171f_checked; date of design plan reviewed-j,.,�,-- Date""' ® Observed site,(abutting property/observation,hole within_150,feet;of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: . You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/2 612 01 8 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts t r ' Title 5 Official,lnspecti ' n-For - ` = C�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments' 89 East Osterville Rd �t Property Address , John Wilson > ' Owner Owner's Name information is required for every Osteryille -` MA 02655 11-2-2620 ' page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist-, Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked �- ® C. Inspection Summary: +'� "► 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed' ' " ' Alf ! ' ® D: System Information: For 8: Tight/Holding-Tank—Pumping contract attached a For 14: Sketch of Sewage°Disposal System drawn on pg. 16,6r attached -For 15-Explanation'of estimated depth to high groundwater included .. i ♦t 't 1,.. r .1 .r� L r_ .. rt'. .. .-. :e 1 q ;•7 V t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 f -\ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . aDEPARTMENT.OF ENVIRONMENTAL PROTECTION RECEIVED APR 2 7 2004 TOWN OF BARNSTABLE TITLE S HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION MAP Property Address: 89 E_ O s t e rb i 1 l e R nad PARCEL (7GtPrvi 1 �TvuA. e 3 . Owner's Name: Fr LOTancis nrake - Owner's Address: Date of Inspection: Name of Inspector.(please print) W i I I i am E_ . Robinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA Telephone Number. (5081 775—,8776 CERTIFICATION STATEMENT I certify that 1 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 15340 of Title 5(310 CZAR 15.000). The system: /Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: �'lJ, �- Date: G/— - 0�—/ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Neatth* 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 seat to the system owner and copies sent to the buyer,if applicable,and the appro.ving authority. Notes and Comments 4 ****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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:89E. Osterville Road Osterville, MA Owner. Franri G DrakP Date of Inspection: Li — ns L,l Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Syst 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 rep fired.The system,upon completion of the replacement or repair,as approved by the Board of Health,'will pass: Ans er yes,no or not determined.(Y,N,ND).in the for expla the following statements.If')mot determined"please . e septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally nso u d,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existin tank is replaced with a complying septic tank as approved by the Board of Health. •A me al septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicat ng that the tank is less than 20 years old is available. ND ex lain: Observation of sewage backup or break out or high static water level in the distribution box due to'broken or obstru ed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with appro al of Board of Health): broken pipes)are`replaced obstruction is removed distribution box is leveled or replaced ND xplain: The system required pumping more than 4 times a year due to broken or obstwed pipe(s).The system will pass in ection if(with approval of the Board of Health): broken pipe(s),are replaced 5 obstruction-is maotrod -a ND explain: f Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 89 E. Osterville Road Osterville, MA • Owner: Francis .Drake Date of inspection:: /—�--C �1 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 fail' g 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. s stem is not functioning in a manner which will protect public health,-safety.and the environment:.,.: �'Y or Cesspool privy is within 50 feetof a surface water P P Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. S jslem 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- su face 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 aseptic tank and SAS and the SAS is within 50 feet of a private water supply well. LThe system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more frodl -a private water supply well•• Method used to determine distance "This system passes if the welt water analysis,performed at a DEP certified laboratory,for colifornl 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: - 3 Page 4 of I 1 > OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM . ' PART A CERTIFICATION(continued) Property Address: 89 E. Ostervi l le Road Osterville, MA Owner: Francis Drake Date of Inspection: `'— D. System Failure Criteria applicable to all systems: You st indicate'�es"or"no"to each of the following for all inspections: Yes N d or.clogged SAS or cesspool. - - g p.g g Y Y P ground _. . Backup of sewage into facility or stem component due to overloaded — Discharge or ondin of effluent to'the surface`of the nand or surface waters due to an overloaded'or e logged'SAS or cesspool Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or. — cesspool iquid depth in cesspool is less than 6"below invert or available volume ts'less than'/,day flow — — equired pumping more than 4 limes in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped y portion of the SAS,cesspool or privy is below high ground water elevation. ikny portion of cesspool or privy is within I00.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.publk well. y 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 Kato supply well with no acceptable water quality analysis.(This system passes if the Kell 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.! es/No)The system fails.I have determined that one or more of.the above failure criteria exist as described in 340 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: arge Systems: To b considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You ust indicate either"yes"or"no"to each of the following: (The f llowing criteria apply to large systems in addition to the criteria above) yes n 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 11 of a public water supply well If you h e answered"yes"to any question is Section E the system is considered a significant threat,or answered "yes"i Section D above the large system has failed.The awner 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 ov.-ner should contact the appropriate.regional office of the Department. 4 Page 5 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST r Property Address:89 E. Osterville Road Osterville, MA Owner: Franri c Drake Date of Inspection: Check if the following have been done.You must indicate des"or"no"as to each of the following: Yes Now _. _ __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?. ZHas 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: . 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)) 5 Page 6 of I I OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION Property Address: 89 E. Osterville Road Osterville, MA Owner: Francis Drake Date of Inspection: FLOW CONDITIONS RESIDENTIAL. Number of bedrooms(design):. Number of bedrooms(actual): DESIGN flow based on 310 CMR 15103(for example: 110 gpd x#of bedrooms):3(V Number of current residents: d Does residence have a garbage grinder'(yes or no): Is laundry on a separate sewage.system(yes or no):,t© [if yes separate inspection required] Laundry system inspected(yes or no):A10 Seasonal use:(yes or no);,�A Water meter readings,if a atlailable(last 2 years usage"(gpd)): 2 0 0 3 -" 2 3•, 0 0 0 Sump pump(yes or no):. 200.2 — 3.8,0 0 0 Last date of occupancy: A ` COMME IAIANDUSTRIAL Type of esta lishment: Design flow Oased on 310 CMR 15.203): gpd Basis of desi flow(seats/persons/sgR,etc.): Grease trap pre ent(yes or no):_ Industrial waste olding tank present(yes or no):_ Non-sanitary wa to discharged to the Title 5 system(yes or no): Water meter rea, ings,.if available: Last date of oce pancyluse: OTHER(des 'be): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):_ If yes,volume pumped:__gallons-=How was quantity pumped determined?" Reason for pumping: TYP 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)vf-0 6 f c ]'age 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART_C SYSTEM INFORMATION(continued).'. Property Address: 89 E. Osterville Road Osterville, M Owner: Francis Drake Date of Inspection: G —. —6 zi BUILDING EWER(locate on site plan) Depth below dc: - Materials of co truction:_cast iron _40 PVC_other(explain): Distance from p ivate water supply we]']or suction line: Comments(on ondition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: '(locate on site plan) Depth below grade:/b _ Material of construction: 1/concrete 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: / 6*+ (g 4 r7i Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: ;?-I Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: 0 IO ,-- C a v A/i S Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.):. 040 .Ile 2 GREASV P: (locate on site plan) Depth bede:_Materialtruction:_concrete_metal fiberglass_polyethylene_other(explain) —DimensiScum thi :Distance of scum.to top of outlet tee or baffle: Distanceot m of scum to bottom.of outlet tee or baffle: Date of Ipi g:Cotttmenun ing recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as relatelet' vert,evidence of leakage,etc.): 7 Page 8 of I OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.0 SYSTEM INFORMATION(continued) Property Address: 89 E. . Osterville Road Osterville, MA Owner: Franc i c Dra.k_p Date of Inspection: TIGHT o OLDING TANK: (tank must be pumped at time of inspection)(locate on site.plan) Depth below ade: Material of c 'struction: concrete metal fiberglass_polyethylene other(explain): Dimensions Capacity. I gallons Design Flow: allonslday Alarm present(y or no): Alarm level: Alarm in working order(yes or no): Date of last pump' g: Comments(condit on of-alarm and Moat switches,etc.): DISTRIBUTION BOX: (J present must be opened)(locate on site plan) Depth of liquid level above outlet invert: V 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.): PU11IP C IMBER: (locate on site plan) Pumps in w rking order(yes or no): Alarms in w rking order(yes or no): - Comments otc condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 t OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 89 E. Osterville Road. Osterville, MA Owner: Francis Drake Date of Inspection:y-A—O LI / SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) y If SAS not located explain why: Type a. leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow.cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): CE SPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Num rand configuration Depth top of liquid to inlet invert: Depth solids layer: Depth o scum layer: Dimensi ns of cesspool: T Materials f construction: Indication of groundwater inflow(yes or no): Commen (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials f construction: Dimensio s: Depth of s lids: Commen (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 1 I a OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C, SYSTEM INFORMATION(continued) Property Address: 89 E. Osterville Road Osterville, MA Owner: Francis Drake Date of Inspection: 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. J Vo o 11 r 1 10 Page I I of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 89 E. Osterville Road Osterville, MA Owner.Francis Drake Date.of Inspection: G � SUE EXAM Slope Surface water Check cellar Shallow wells - Estimated depth to ground water ter Lfeet 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 local Board of Health-explain: 9fecked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: 11 " !` NST TO' Q BA3tIA M SHPTfG T} tI�C�FAdit Vpa �t7I�.��SR O�fl�it�R lit Y ' � i 4 •1�� 7 tt $t�pai�ton tii$t8t1�C$e�rtce�n ELo umAdj4tW. 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"14t.1�1 1/d •��`� �' ��.s � � 3 map' vyo, ,� i '�d•� Sty : s•z � �s �i 0 _ "nr� avo 1 �sc-i 1+d- -rasod •--►�r9 coo� -�Sn \. �nd'9 SI�V = °� off) roc = �►r+'d._►_ �►�a� .---- �at�►tZ� ��daZd� o� b J-*V<a N 5)1 st---XiC] I No..........`7 Fss...::I 5................ THE COMMONWEALTH OF MASSACHUSETTS BOAR® �HET�....... .....OF... .. ---------------............... I100 I� Appliration for Uhipop al orki C�uattitrttrtion Prrutit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal Sys, a f 4,21 -------------- - . . --------------------...........-----• ' Loca ,Address or Lots. ----------------------------------------- OW Address r, (� ( �a ...................... -• .................................... Installer Address Type f Building Size Lot____./. _Sq. feet Dwelling—No. of Bedrooms..................................................................Expansion Attic ( ) Garbage Grinder ( - ) p, Other—Type of Building ............................ No. of persons............................ Showers { ) — Cafeteria ( ) a Design Flow.............._.U_...._..._-_.__-...._--gal per person per day. Total daily flow Other fixtures _.-. W �� P P P Y Y w................... --9-•®------•-----gallons. WSeptic Tank—Liquid capacity/~gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... th.................... Tt2tal Length........... ...... otal leaching area....................sq. ft. Seepage Pit No..../ Total leac 'ng area.._ _ ... ft. --------- -------------- �} Z Other Distribution box ( Dosing t ( d — /Z 7 7 �G'/1/L Percolation Test Results Performed by. ^__ __ . --__---•----. Date__ ._.$_.---- -------------. Test Pit No. 1... .....minutes per inch Dept of Test Pit__________________ Depth to ground water_.___..___...__.__...__. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ .......... ----------- --- -----.. -----......-•r -----------I-------�.._' Description of Soil.. 0- .;-- X. f . ---- - 2 l -- W UNature of Repairs or Alterations-"Answer when applicable................................................................................................ --------•--------------------------••-----•-------•--------•-----=-----•----•-•------------------------------------------------------------•--•-------................................................ Agreement: 1 '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 th board of health. �ig/ne ------------- -� Date Application Approved B .......... Date Application Disapproved for the following reasons---- ----------------------------------------------------------------------------------------------------------- •-------------------•-----------------.....---------------•.....--------------------.........---------------------------------------------•------••----------------------------------------•------------ Date Permit No.......................................................- Issued-- �� 1�C .................... Date 7Y Fps.... ............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE T ------------ ...............OF... ........... --------------------------------- A#Vftration for Dhiposal Works Tonstrurtion Permit (RepairApplication is hereby made for a Permit to Construct an Individual Sewage Disposal Syste%aV Loc -Address or Lot ]Ao. 7 4 ....... .. . ............................................. ........... .................... .. ....................................... owgri oe r011 Address co ........... ................................ ............................................ ...eknjonew............5; M Installer Y A d ss Type4oi Building SiZe ot... ig"' �...Sq. feet U Dwelling—No. of .Bedrooms............................................Expansion Attic Garbage Grinder Other—Type of Building ............................ No. of persons.__.____________._.__.__.___ Showers Cafeteria Otherfixt0fes .... ....... ............................................................................................................................. Design Flow.............. ....................gallons per person per day. Total daily flow________________" ............gallons. P4 Septic Tank—Liquid capacity.-M"04"'g-allons Length________________ Width__.________.__._ Diameter:__:____________ Depth___________.._.. Disposal Trench—No....................... dth.................... Total Length ......Aotal leaching area_.__. sq.j'ft. gt .......... vbdz ... ......... _. Total leacWng area... ft. Seepage Pit No.___ZAIZO-6., ................... Dow, Other Distribution box Dosing t� - 77 /-1-C 404;t z jk l&, Performed by. ,6t ------------- .............. Percolation Test Resu ..... 0�4 Test Pit No. 1... .........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___.____._______.._____. ------------A--------------_-_-- ..... t. ...........1-------I------------- ------- •---------------------------------------- ........................................ 0 Description of Soil.y!�.... U ......................... ..... .................................................. .........................................................­-------..................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable_________________, ............................................ ......... .............. ............ ...................t................................................................... --------­----------------- Agreement- The undersigned 'agrees A install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T 1'111 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Cqmpligii6 has been issued by t4 board of health. .................... ......... Sign A /-Z Sign ............�F.- ?q� ��C. .7 41 10 �ate Application Approved By........X_ jW....................... ....... Date Application Disapproved for the following reasons:................................................................................................................... ......................................................................................................................................................................................................... Date 7 PermitNo...........................................K........... IssuedL...............................................:.......... Date THE COMMONWEALTH OF MASSACHUSETTS T 4=4 BOARD OF HEALTH............... 4.......OF..... G ......... ............................ Zrrtffiratr of Tompliaurr THj.Y IS TO CERTIFY hat Ind�;,vidual e,, age Disposal System constructed44:::_,, or Repaired ew by ............. ....... ....................................................... ............. ------------------------- n tal eel .. ...... ............... 0__ at....... ........ ...... ......... ....4 ............... ----------------------_--- -------------------------- has been instilled in accordance with the provisions of TIOTOE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit _ay- ................7.....1F.... ........ dated-.. ............. THE ISSUANCE OF THIS:CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......... ....... � .............................................. Inspector-.L.............................. ............................... THE COMMONWEALTH OF MASSACHUSETTS vy BOARD OF HEA .....OF..... . ............ .................. ................................................. No._._.. 7 -1 F�' /3 .................. FEE........................ Maps Works Tit ion Permit OF HEA T ............. ............ -Perm'issio �iseby granted----.—. .................................... ............................... .............................. to Construct or Re *r n 111diZidd'all S,-,eA,. Dis System ... ........... ............. ................. ................. ... ..... ....0. ....................... ............ .. ..... ....................... at No.";__;I_ Street as shown on the application for Disposal Works Construction Pe it Np.. ........ Dated../->_!�-146r"77---_------ ........ .... .... _5/wqgew-- --------- --------------- Board of Vth DATE................................................................................. FORM 1255 HOBBS & WARREN. INC., PUBLISHERS