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Home My WebLink About0136 EAST OSTERVILLE ROAD - Health 136 East Osterville Road, Osterville W -7A=- , 1 T a } a o t L 214 ct Commonwealth of Massachusetts +13 I, Title 5 Official 1 �} Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 East Osterville.Rd __.........._...W _ Property.Address Owner Champney information is Owners Name required for Osterville ma .8-25:=2020 ___-_ ....... .-...... ............ . ......... ........ ..... ......... every page. City/Town State Zip Code' Date-of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form.. Important: A. Inspector Information formsnthing out. p b forms on the computer,use Douglas.A Brown _ _.................. __._............_._..............-----...__.._._ ...... ...._. only the tab key Name of Inspector to move your D.A.Brown Inc cursor-do not ......--- .__.__W .:......... ._._.— ...._....... .,_ pany. __ _.....: _ . ._.__..._............_ Com . use the return .Name key. Ro Box 145 -...............................................-.._ ._.................................. __ _ Company Address r Centerville_ __...... ............ __ Ma 02632 __ _ ....._._— .._....... City/Town. State. Zip Code 508-420-4634 SI4297 .. ........ . .......................... ........_.... ............_.... _ — .. �A Telephone Number License Number B. Certification I certify that: I am a.DEP approved system inspector in full compliance with Section 15.340 of Title 5(31.0 CINR 15.000); i have:personally inspected the sewage disposal system at the property address listed above; the information reported below is true; accurate and complete as of the time of my inspection;:and the.inspection was performed based,on my training and experience in the proper function and maintenance of on-site.sewage disposal'systems. After conducting this inspection I have determined that the system: 1. Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ .Fails y s_ -kT sec Ignature 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 DER 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 perfo.m in the future under the same or different conditions.of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts if--.- Title 5 Officialr I' Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 1.36 East Osterville Rd _.._.......... .. ........ —.:..._....—......._.._....---............_........_..................._._ Property Address Owner Champney _............__....._._......................_._...._..___.............. _.__....:.......... information is Owner's Name required for Osterviile ma 8.25-2020 ......._. . .._...................._.....__._..........._ ._...._____._....._ __..__ .....:..... _ ........_— . _......_._:....— ......._...—._.........._— every page. City/Town state Zip Code Date of Inspection C. Inspection Summary Lnspectian'Summary: Complete 1, 2, 5,,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 15.503 or in;310 CMR 15.304.exist.Any failure criteria not evaluated are indicated below. Comments: At time of inspection this.system met all passing requirements. This report can not predict the future performance under the same or increased usage. This system is'from 1978. The current owners have used this house seasonaly. _................... _._.__............ ........... __ .............____...._.._..............__------_......_- 2) System Conditionally Passes: [] One or more,system components as.described in the"Conditional Pass"section need to be replaced or repaired. The system,,upon completion of the replacement or repair, as approved by the Board of Health,;will pass, Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined, please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)'is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. f * 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, 0 Y ❑ `N ❑ ND (Explain below): __..........._...._._........._.......__..._....................._ ....._.__..............._.............................._.._.........................._...._.._..........._......................_................................_..................................._................_.._......._............_.._........................._._..................._....................... ........... .......... t5insp.doc•rev.712fa2018 Title 5 Official inspection Form Subsurface Sewage Disposal System r Page 2 of 18, r 4 t Commonwealth of Massachusetts _ 7 r��' �� Title 1 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 136 East Osterville Rd ......__.............._....._. _.. ........ Property Address Owner � _ --_ ............ m ..._____................_. ....._ _... ........�_....................._..._......... . Cha ne information is Owners Name required for O:stervill. —- --.._ 4._ .._____...._... ................ _,_. every page. City/Town State Zip:Code, Date of Inspection C. Inspection Summary (coat:) 2) System Conditionally Passes (eont) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): distribution box is leveled of replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): �_......__._—._..__..... __. 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation.by.the.Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health.determines in accordance with 310 CNIR 1&303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the.environment: tsinsp.doc•rev;7126r"2018 Title 5,Official-Inspection Fonn:Subsurface.Sewage Disposal System•Page 3 of 18- Commonwealth of Massachusetts T --------- Title. 5 Official Inspection Form Subsurface Sewage Disposal System Form.- Not for Voluntary As5essments 136 East Osterville Rd Property Address Cham.pney................__......_ Owner -.........-1 _.._...................__...-._..........___._.............. -..._.....__.....__- _............... _............... .......... - information is Owner's Name required for Osterville ma 8-25-2020 _ _..._ ..... --- ........_ _ every page. Cityrrown State Zip.code Date of Inspection. C. Inspectiloh Summary (cunt:) [] Cesspool or privy is;within.50 feet of a surface.water El Cesspool or privy is within 50 feet of a bordering vegetated wetlarid 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. 0 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. El 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---.-..--..-- ...._.- 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No to each of the following for all inspections: Yes No El ® 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 o.r clogged SAS or cesspool. t5insp.doc•rev.712612018 Title 5 Offidal Inspection Form:Subsurface.Sewage.Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title Official ® Inspection ,r r i'-) Subsurface Sewage Disposal System Form - Not for'Voluntary Assessments 136 East Osterville Rd. v Property Address Owner Champrley information is Owner's..Name ------. . required for Osterville ma 8-25-2020 every page, City/Town State: Zip Code Date of inspection C. Inspection, Summary .(cont.) 4) System Failure Criteria Applicable to All Systems: (coot.) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Q Liquid depth in.cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: [) Any portion of the..SAS, cesspool or privy is below high ground water elevation. El ED Any portion of cesspool or privy is within 100'feet of a.surface water supply or tributary to a surface water supply. ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ Any portion of a-cesspool or privy is within 50 feet of a private water supply well. El 0 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.] a ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact-the Board of Health to determine what will.be necessary to correct.the failure. 5) Large Systems:: To be considered a large system the system must serve.a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes' or"no"to each of the following, in addition to the questions in Section CA. Yes No 1 0 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 LI of'a public water supply well t5insp.doc•rev.7/2612018 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 OfficialInspection r Subsurface Sewage Disposal System Form Not for Voluntary Assessments 4 . g P Y rY :. ' 136 East Os .... le Rd Property Address Owner Cham_pney information is Owners Name required for Osterville ma. 8-25=2020 .........,_.. ................�.._._._............ ��...... __.w .......... every page.. cityrrown State Zip Code Date of nspection C. Inspection Summary (eont.) _. If you have answered "yes'to any question in Section_C.5 the system is considered a significant threat, or answered"yes.!to any question in Section C.4 above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade.the system in accordance with 310 CMR 15,304. The system owner should contact the appropriate regional office of the Department: 6. You.must indicate ".yes" or"no" for each of the following for all inspections: Yes No El M 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.inspecti&n? Z ❑ Were.as built plans of the system obtained and examined? (If'they'were not available note as N/A) Z ❑ Was the facility or dwelling inspected for signs.of sewage back up? Was the site inspected for signs of break out? ❑ 0 Were all system components., excluding the SAS, located on site? Z ❑ 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 exarnple, 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.7/26/2016 - Title 5.Official Inspection Formr.Subsurface Sewage Disposal System•Page 6 of 16 cam, Commonwealth of Massachusetts. Official. - GI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments F> 1.36 East Osterville Rd 1._ Property Address Owner Champney._,..........._......_ .._..._._......._......_._....... _ i --.__.._......._._..........._-.._ information is Owner's Name required for Osterville ma 8-2. _ ---....._...._._.__.__......-_.._...._ every page. City/Towin State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions Number of bedrooms (design): 3 Number of bedrooms (actual): ?--............ -------- DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Aseptic tank and:a leach pit were located on the property. --. .... _.. ._..._._ __. ._ _.._............. Number of current residents` -_..___............................................. Does residence have a garbage grinder? ❑ Yes ❑ No Does residence have a water treatment unit? ❑ Yes ❑ No If yes, discharges to: ....... -----_---- _ __.:......................_.... -- -- Is laundry on a separate sewage system? (Ihclude laundry system.inspection ❑ Yes: ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? Z Yes ❑ No Water meter readings; if available (last,2 years usage (gpd.)): - - -......-................ --- Detail: Not available at time I typed„this report. ....................................._..._.-......................................_W.............................._..............................._.._.......:............................:_.. _._. Sump pump? ❑ Yes ❑ No Last date of occupancy.: Date t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts aisTitle 5 OfficialInspection t Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `j 136 East Osterville Rd Property Address mpne owner _,Gham ne.y...__ ...._.— —. —. .......— information is Owner's Name .......... ....� _._—_ ....... . . . required for Osterville ma 8-25-2020 every page. City/Town State Zip Code Date of inspection D. System Information (cunt.) 2. Commercial/Industrial F16W Conditions: Typeof Establishment: ...._......................._.—.._......................._....._...._.................._ Design flow(based on 310 CMR 15.203): ............_ ......... _....:.._....._............ _....._..,._._ ._ Gallons per day(gpd) Basis of design flow(seats/persons/sq,.ft., etc:): _.._._................_............—._..................I...._..— ........................ Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑. Yes ❑ No If yes, discharges to: __.. _..:...... _ —....... ....... _ _-............... _ Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: _ ... ............_—.._.................__.................. ................. Last dete of occupancyluse: .__._......._—....._ .. ...._..._ _. . _._._.—......____...... Date Other(describe.below): 3. Pumping Records: Sourceof information: .............. .................................:....................._.....:..................__......._....................._.............-......... Was system purnped as part of.the inspection? ❑ Yes ® No If yes, volume pumped: ..................... ._.-.............. . ._.__............... ..........._.---- ......... ___............_.......................... ......... gallons Howwas quantity pumped determined? ..............._..........._.._........._...._........_..._................-..-............_................_.__ ....._..--._._..._...._.._....__ Reason for pumping: _ ............. _...........__ ........ ... .............. ......_............. --- t5insp.tloc.rev..7126I2618 Titla 5 official.Inspection form Subsurface Sewage Disposal System-Page 8 of 18 Commonwrealth of Massachusetts _P7. Title 5 Official Inspection Form s=} Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Tay y 136 East Osterville`.Rd ...:...........__......__... ......:..........-.._................. __...................._ _.. Property Address Owner Champey n information is Owner's Name required for Osterville ma 8-25-20N _.... _ ......._. - ._........, - every page. GityTTown State ZIp:Oode Date of Inspection De System Information (cone) 4. Type of System: ,Septic tank, distribution box, soil absorption system Single cesspool Overflow cesspool ❑ Privy Shared system:(yes or no) (if yes; attach previous inspection records,.if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.;Attach a.copy of the DEP approval. Other(describe): Tank and pit no D-box'located Approximate age of all components, date installed (if known) and source of information: 1978"per previous inspection report Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: _......._..,,..._..__ _.,_.....__ feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): -- Distance from private water supply well or suction line: -----_.. ._.... ...... ...._ _............... ' -feet Comments(on condition of joints, venting, evidence of leakage, etc:): 16insp.do,•rev.7126,1201.8 Tide_5 Offi cial Inspecfon Form:SubsuHac,-Sewage Disposal sysiern•Page go,1e F Commonwealth of Massachusetts @ � i iOfficial 1. Subsurface Sewage Disposal System Form Not for Voluntary Assessments ;= 136 East Cisterville Rd Property Address Owner Ch.gMpnney information is Owner's Name _.................... ....... ..................__....._. required for Osterville ma 8-25-2020 .._.. _._.. _._. every page. City(Town State Zip Code Date of Inspection D. System Information (cone:) 6. Septic Tank(locate on site,plan): Depthbelow grade` 11 f e..e_._t.. ............---.................................... .~._._.......-...................................... 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 imensions: 1000 gallon ..............I................._ Sludge depth: .............................................._-—._�- .........._.... . Distance from top of sludge to bottom of outlet tee or baffle ..... --- ....._....._............. ....................... Scum thickness traee. - -- Distance from top of scum to top of outlet tee or baffle -~ -- ---- Distance from 'bottom of scum to bottom of outlet tee or baffle ..._ .. ---~ How were dimensions determined? -- Comments (on pumping recommendations, iniet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage; etc.): If tank has not been pumped,in the previous 3 yrs 1 recommend pumping at time of transfer and every 2 3 yrs there after for maintenance. ,5msp.doc•rev.7??i MIB Tge;S,Ofiirdal i�speciann-Fn n:Subsurface Sews Dispos23 System•Page 10 of 1£S Commonwealth of Massachusetts 1 = Title 5 OfficialInspection 'I 'I 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 136 East Osterviile Rd Property Address Champney ......._-_._........... ....._.__.._.......... . _... _.. . Owner �_ ._:. ................ _,.,,. ............. ........ information is Owner's Name required for Osterville ina $-25-2020 ......._-.........................:............___.. .................._...........__._._...._...__-_......... ............ ..........._..... .- every page. CiiyfTown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: .........................._..................:........._ _.._..................................... _._..._..__.._ feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): ,Dimensions: ..........._._.............._....__................ ...............:. Scun 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: Dare Date__.................. ..._....._.................._..........._. Comments(on.pumping recommendations, inlet and outlet tee or baffle condition; structural integrity,. liquid levels as related to outlet invert, evidence of leakage; etc.): S. Tight or Holding Tank(tank must be pumped at time:of inspection) (locate on site plan): Depthbelow. grade: _..............._.......... _........................................._...... Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑'polyethylene ❑ other(explain): Dimensions: _._ _.__.__..............._..._W......._ _._......_........................... _...... _____._.. Capacity: ga. _ons.................._.........._.........__........................,.._........................................_.........:................._.._._......................................_.. ll DesignFlow: ....................._........._.__._ ................._.....__........ gallons per day 15insp.doc•rev,7128/?_018 Title 5 Official Inspection Forml Subsurface Sewage Disposal System-Page 11 M 18 Commonwealth of Massachusetts, 1; IX, Title 5 Official_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 136 East Osterville Rd Property Address Owner Champney .................__..-__ ___...,.,._. information is Owner's Name required for Ostervi.lie ma 8-25-2020 --- __. .... ..__._..._._... ......—_.._-....— _. _ _ _-..... ._.... .....,.. _ every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont_) 8. Tight or Holding Tank (coat:) Alarm present: ❑ Yes ❑ No Alarm level: _.._........._................._..__w-.............._........_...... Alarm in Working order: ❑ Yes R. No Date of last pumping: 1.--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) N.Depth of liquid level above ou#let invert .._� __ ..........__ .................. ..... . ... Comments (note-if box is level and distribution to outlets.equal, any evidence of solids carryover, any evidence.of leakage info or out of box,-etc, I .......... __:......_..._....__......... _.............................:.:..............................._........._................__.,,..........................,__.._................._....................................._....... ............... _.......___........._............................_........... ... t5in5PAM-rev.712612018- Ti1lc S official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 . Commonwealth of Massachusetts Gil Subsurface Sewage Disposal System Form Not for Voluntary Assessments 136 East Osterville Rd, Property Address. Champn_eY _..~._.. _._...~_........_ .........:..... ._......—_....:_. —_..... _-..... Owner Owner's Name information is required for Osterville ma $-25=2020 - - . .... .._.:__..._ ........_ _ _ ........._.-.-.. every page. CitylT'own State. Zip Code Date of Inspection D. System information (coat.). 10. rump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No; Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): ......................................__..........................................:_._....................................__..............__....-.................._..............................__....................................._............................_.....................---...............~..............-..-....................._..-................._........._.........._.......... -- If pumps or alarms are not in Working.order, system is a conditional pass. 11. Soi1 Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why, Type: ❑ leaching pits number: .......___.....---_........._.......... 1 z leaching charnbers number: - ~----..—.._..............__...._. ❑ Teaching galleries number: —~~ ❑ leaching trenches number, 'length: ~- - ❑ leaching fields number, dimensions: --~ - ---- ~ ~— ❑ overflow cesspool number: -- -- ❑ innovative/alternative system Type/name of technology: .................._......_ ......_..................._........................._.................._..._................................. ............................_........... .._--__ tSinsp.aoc•rev.71261201,8 Title 5 Official Inspection Four:,Subsurface Sewage Disposal System-Page13 of 18 < �. Commonwealth of Massachusetts ci 1Officialt1 ^ } Subsuirface Sewage.Disposal System Form. Not for Voluntary Assessments. `.- }� 136 East Osterville Rd Property Address Owner Champney _ _ information is Owner's Name required for Osterville ma 8-25-2020 —. _. �... . _ ..._.__ —:.:.._ ._....._ ---- _.._ __._._... __... ................... ... .._ every page. City/Town State Zip.Code Date of Inspection D. System Information (cont:,) 11. Soil Absorption System. (coat:) Comments (note condition ofsoil, signs of hydraulic failure; level of pondin;g', damp soil, condition of vegetation, etc.): Pit was openendTand was d with no sins of failure. Stain line was at about 2 ft from bottom of pit. 12. Cesspools (cesspool-must be pumped�as part of inspection) (locate on site plan): Numberand configuration _.._..._._................................._........._._.,...__..._.................,_._.............. Depth —top of liquid to inlet invert �......................w.............................._..........................._.._....__......__....._,_ 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.): t5in<_p.c+oc•rev.7/2 612 01 6 Title 5.Official Inspection Form;Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Subsurface Sewage Disposal System Form,-Not for Voluntary Assessments _` - 136 East Osterville Rd .._..,............... .......V.�......._.....__..............I——.............._......_......._......._..._,....................._..._........._._._..................._.._....._..._____..........__............._...___.......____......._._....._.._ _.._............_.____-- Property Address Owner Champney _.._.___.. ____......... __.._.,___ __.__._ _........w....... information is owners Name required for Osterville ma, 8 25 2020 ......_ —...._.. ..._ . ..____..,:.....__._..._. ........................ every page. City/Town State Zip Code Date of Inspection D. System Information (coat:) 1"3. Privy (locate on site plan): Materials of construction: _.. _. .__ _.................._ ..._.............. Dimensions __w............_......................._.................................__."__.__................................._..........._._......._................... Depth of solids .............. . .. . Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ._..................._.........................................................................._._................ _..__..................._..................___.._.._._................................................_..................................._....._..........................._..m................................._.............. ...................... t5insp.doc rev,?126/2018 Title 5 Official inspection Porm:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 �Offolcolal Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ^A-' 136 East Osterville Rd ... .....;_. _..1_.1. ..... ._..�.__"_ .................... .................. _ .... ............._..._........ ..... Property Address OwnerCham ne __........ _._........_..........._.................... .............................................._.�M._......._...................._...._.....�.__................._._...................._.................__...__..........._�........................._. _.........._...�.....Y.._......_.... information.is Owner's Name requiredfor Ostervi. ........._._._.__..._... _.._.____. . .. ...... _. _,.....,._ _. ......... _.__.: ..._._._.. .............�........ ... ...._-_._ every,page. City/Town State Zip Code Date of Inspection D. System Information (cont.). 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within_100`feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately i 3 15insp,doc-rev.7J26-2018 7itla.5 Offidal lnspaction farm:Subsurface Sewage disposal System Page 16 of 16 Comm,onvvealth of Massachusetts e l Subsurface Sewage Disposal System Form Not for Voluntary Assessments 136 East Osterville Rd Firp.._rty..._.....:_-._Addre_:.ss......_.. m_........................._.......... _ _____-.................Prope P Owner Cham nIe_y __.... _ information is Owner's Name required for Osterville ma 8-25-2020 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water Check cellar ® Shallow wells Estimated depth to high ground water:, 12+ feet. Please indicate all methods used to determine the high ground water elevation: FJ Obtained from system design plans on record If checked, date of design plan reviewed, _ Date Observed site(abutting property/obse'r_Vation 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: pervious passing inspection report _..... Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5insp.doc-•.rev.7126/2018 Title 5 Offic4 inspection Form:Subsuiface.Sewage Disposal System-Page 1,of 18 Y Commonwealth.of Massachusettsit Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 136 East Osterville. Rd —._:.....:.. ....................... ..._......._...__......_........... ......... ..__......._....._._ _.......__ . :Property Address Cham ne Owner —. P .......y._._....._ Or's Name information is __ wne . _. required for Osterville ma 8-25-2020 ....__.-._ .__ ..............W ........ ......... every page. City/Town State Zip code Date of Inspection E. Report Completeness -Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information: Complete.all fields.in this section. B. Certification Signed & Dated and 1, 2,�3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist) completed D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System:drawn on pg. 16 or attached For 15: [Ekplanation of estimated depth tobigh groundwater included t5insp.doc-rev.712 612 01 8 Title 5.Offciai Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM;INFORMATION'(contlnued) Property Address 138 E.0sterv+ilfe Rd.bsterviffe Owner: Mary Martus:.Z Howard Rd.,Chetford Ma.01.82Y Date of inspection,4115197 SKETCH Of SEWAGE DISPOSAL.SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells;within 100' '.71 g1h�1 J tJ LJVI DEPTH TOG ROUNDWATER Depth to groundwater:I? fleet method of determination or approximation:_.,_.- ,, w ...... ... ...._., USGS flaps and Charts (revised 11115)95j commorwveci th of MossochUSetts John Grad ExecL Ne office Of Er)v1rOP] mintO!AffUrs D.E.P. Title V Septic Inspector Department of P.O. Sox 2119 Teaticket,MA 02536 Environmental Protection (5108) 564-6 i 9 � 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A f� ,,t1 CERTIFICATION AP p ' �T £t�sT 40 Tom .� 5 -�99 Property Address: 136 E. Osterville Rd. Osterville Address of Owner: of A" Date of Inspection:4115197 (if different) D1 24 M'...." �qlf 4r Name of Inspector:John Graci Mary Martus:2 Howard Rd.Chelford Ma. Company Name,Address and Telephone Number: -V g , CERTIFICATION STATEMENT i certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X Passes This Inspection Is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is Conditionally P ses performing at the time of the Inspection.My inspection does _ Needs F he valuation By the Local Approving Authority not Imply any warranty or guarantee of the longevity of the Falls septic system and any of its components useful life. Inspector's Signature: Date: 4121197 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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 Department of Environmental Protection. copies sent to the buyer,if The original should be sent to the system owner and cop Y applicable and the approving authority. INSPECTION SUMMARY: Check A, B,C,or D: A] SYSTEM PASSES: X I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: _One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined",explain why not.) _ The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is iinininent.The system will pass Inspection If the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11115195) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 176 E.Ostervllle Rd.Ostervllle Owner: Mary Martus:2 Howard Rd.Chelrord Ma.01924 Date of Inspection:4115197 _ Sewage backup or breakout or high static water level observed in the distribution box is due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced _The system required pumping more than four 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 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 the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm. 3) OTHER D] SYSTEM FAILS: _ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage in facility or system component due to an 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 cesspool. SAS is in hydraulic failure. (revised 11115195) - 2 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) e I Property Address: 196 E.Ostervllle Rd.Ostervllle Owner: Mary Martus:2 Howard Rd.Chelford Ma.01924 Date of Inspection:4115/97 D] SYSTEM FAILS(continued) _ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume its less than 1/2 day flow. _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil_Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area (IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further Information. (revised 11115195) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 135 E.Osterville Rd.Ostervllle Owner: Mary Martus:2 Howard Rd.Chelford Ma.01824 Date of Inspection:4115197 Check if the following have been done: X Pumping information was requested of the owner,occupant, and Board of Health. X None of the system components have been pumped for at least two weeks and the and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. naAs built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened, and the Interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge,depth of scum. X The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11115195) 4 SUBSURFACE SEWAGE DIS POSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 136 E.Ostervllle Rd.Ostervllle Owner: Mary Martus:2 Howard Rd.Chelford Ma.01924 Date of inspection:4115197 FLOW CONDITIONS RESIDENTIAL: Design flow: 220 gallons Number of bedrooms: 2 Number of current residents: 9 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): Yes Water meter readings,if available: n1a Last date of occupancy: n1a COMMERCIAL/INDUSTRIAL: Type of establishment: n1a Design flow:U gallons/day 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: n1a Last date of occupancy: n1a OTHER:(Describe) nla Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System has not been pumped in the last year. System pumped as part of inspection: (yes or no)No If yes,volume pumped: u gallons Reason for pumping: n1a TYPE OF SYSTEM X Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes,attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all.components,date installed(if known)and source information: 1079 Sewage odors detected when arriving at the site: (yes or no) No (revised 11115195) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 136 E.Osterville Rd.Osterville Owner: Mary Martus:2 Howard Rd.Chelford Ma.01924 Date of Inspection:4115197 SEPTIC TANK: X (locate on site plan) Depth below grade: 2' Material of construction:X concreate_metal_FRP_other(explain) 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: 25' Scum thickness:0 Distance from top of scum to top of outlet tee or baffle:6' Distance form bottom of scum to bottom of outlet tee or baffle: 0 Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) Septic tank and all components are structurally sound.Recommend pumping system every two years for maintenance. GREASE TRAP: (locate on site plan) Depth below grade: n1a Material of construction: _concrete_metal_FRP_other(explain) Dimensions: n1a Scum thickness:nia Distance from top of scum to top of outlet tee or baffle:n1a Distance from bottom of scum to bottom of outlet tee or baffle:n1a Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) Na (revised 11115195) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 136 E.Ostervllle Rd.Ostervllle Owner: Mary Martus:2 Howard Rd.Chelford Ma.01824 Date of Inspection:4115197 F TIGHT OR HOLDING TANK: (locate on site plan) n Depth below grade: rVa Mate rial of construction:_concrete_metal_FRP_other(explain) Dimensions: n1a Capacity: n1a gallons Design flow: n1a gallons/day Alarm level: n1a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Na DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: nla r Comments: (note if level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box etc.) n1a PUMP CHAMBER: (locate on site plan) Pumps in working order.(yes or no) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) n1a t (revised 11115195) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 136 E.Ostervllle Rd.Ostervllle Owner: Mary Martus:2 Howard Rd.Chelford Ma.01924 Date of Inspection:4115197 SOIL ABSORPTION SYSTEM(SAS):x (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: nfa Type. leaching pits,number: 1,60o gallon leach pit leaching chambers,number:nfa leaching galleries,number: nfa leaching trenches,number,length: nfa leaching fields,number,dimensions:nfa overflow cesspool,number:nfa Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) The overflow was empty at the time of the Inspection.Has never had more than V in it. CESSPOOLS: (locate on site plan) Number and configuration: nfa Depth-top of liquid to inlet invert: nfa Depth of solids layer: n►a Depth of scum layer: nia Dimensions of cesspool: nfa Materials of construction: nfa Indication of groundwater: nfa inflow(cesspool must be pumped as part of inspection) nfa Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) nfa PRIVY:_ (locate on site plan) Materials of construction: nfa Dimensions: nfa Depth of solids: Na Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) nla (revised 11115195) ry 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 136 E.0sterville Rd.Osteiville Owner: Mary Martus:2 Howard Rd.Cheiford Ma.01824 Date of Inspection:4115197 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' r Q 4� CA 3� DEPTH TO GROUNDWATER Depth to groundwater:12 feet method of determination or approximation: USGS Maps and Charts (revised 11115195) 9