HomeMy WebLinkAbout0194 EBENEZER ROAD - Health -- 194 Ebenezer Road
- Osterville
A= 146-078
LZI
Commonwealth of Massachusetts o
Title 5 Official Inspection Form
r .
ie Subsurface Sewage Disposal System Form -Not for Voluntary Assessments +
194 Ebenezer Rd.
Property Address
Rubia Ceranto
Owner Owner's Name
information is
Osterville Ma. 02655 October 4, 2018
required for every .�
page. City/Town'. State Zip Code Date of Inspection 1�0
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information S/ 33[�0
on the computer, Thomas Roux
use only the tab
key to move your Name of Inspector
cursor-do not
use the return Company Name
key.
89 Mayflower Lane
Company Address
East Wareham Ma 02538
City/Town State Zip Code
774-678-9066 S14531
Telephone Number License Number
B. Certification
I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000);I have personally inspected the sewage disposal system at theproperty address listed
above; the information reported below is true, accurate and complete as of the time of my inspection; and
the inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that
the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
qj z
l_ AT
Insp -toes Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
194 Ebenezer Rd.
Property Address -
Rubia Ceranto ,
Owner Owner's Name
information is required for every Osterville Ma: 02655 October 4, 2018
page. Cityrrown State Zip Code Date of Inspection t.
C. Inspection,Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® 1 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:
t
2) System Conditionally Passes:
El One or more system components as described.in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑N ❑ ND (Explain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�' ra Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
194 Ebenezer Rd.
Property Address
Rubia Ceranto
Owner Owner's Name
information is required for every Osterville Ma. 02655 October 4, 2018
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y . ❑N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y El ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑Y ❑N ❑ ND (Explain below):
❑ obstruction is removed ❑Y ❑N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
Commonwealth of Massachusetts.
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
194 Ebenezer Rd.
Property Address
Rubia Ceranto
Owner Owner's Name
information is'
required for every Osterville Ma. 02655 October 4, 2018
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50#eet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form. .
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
i
194 Ebenezer Rd.
Property Address
Rubia Ceranto
Owner Owner's Name
information is required for every Osterville Ma. 02655 October 4, 2018
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any,portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ Z Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems:To be considered a large system the system must serve a facility with a design
flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
I
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
,i Title 5 Official Inspection Form
I� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
194 Ebenezer Rd.
Property Address
Rubia Ceranto
Owner Owner's Name
information is required for every Osterville Ma. 02655 October 4, 2018
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
® ❑' Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been,introduced to the system recently or as part of
this inspection?
❑ ® Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Wasthe facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on: .
❑ ® Existing information. For example, a plan at the Board of Health.
❑ 0 Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1' 11. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
194 Ebenezer Rd.
Property Address
Rubia Ceranto
Owner Owner's Name
information is required for every Osterville Ma. 02655 October 4, 2018
page. Citylrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): No design Number of bedrooms(actual): 2
DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): +220 gpd
Description:
Number of current residents: 3
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection.Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
194 Ebenezer Rd.
Property Address
Rubia Ceranto
Owner Owner's Name
information is required for every Osterville Ma. 02655 October 4, 2018
page. Cityrrown 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): canons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
r
How was quantity pumped determined?
Reason for pumping:
/
i
t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments
194 Ebenezer Rd.
Property Address
Rubia Ceranto
Owner Owner's Name
information is Osterville Ma. 02655 October 4, 2018
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) ;
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):
Septic tank and single pit.
Approximate age of all components, date installed (if known)and source of information:
41 years, House was built in 1977.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 2.8
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: +10'feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
�n I Title 5 Official Inspection Form
j' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
194 Ebenezer Rd.
Property Address
Rubia Ceranto
Owner Owner's Name
information is required for every Osterville Ma 02655 October 4, 2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade:. feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
81 x 5.67'W x 5.67'H
Sludge depth:
2"
Distance from top of sludge to bottom of outlet tee or baffle
34"
<1„
Scum thickness
9„
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
16"
How were dimensions determined? measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The septic tank will be pumped out. The outlet baffle will be replaced with a SCH-40 PVC tee. The
outlet end of the septic tank will also have a riser installed. (This work will be done by a licensed
installer).
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
-d� 194 Ebenezer Rd.
Property Address
Rubia Ceranto
Owner Owner's Name
information is Osterville Ma. 02655 October 4, 2018
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal -❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
194 Ebenezer Rd.
Property Address
Rubia Ceranto
Owner Owner's Name
information is required for every Osterville Ma. 02655 October 4, 2018
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level.' Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert N/A
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.):
There is no D-Box
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
' 194 Ebenezer Rd.
Property Address
Rubia Ceranto
Owner Owner's Name
information is required for every Osterville Ma. 02655 October 4, 2018
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in'working order: ❑ Yes ❑ No*
Alarms in working order: ❑,Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not,required):
If SAS not located, explain why:
The pit was found and dug up. The pit had about 2' of water in it, this provides over 600 gal. of
available capacity. There will be a riser cover added to the pit for easy access in the future.
Type:
® ,leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology;
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts ,
Title 5 Official Inspection Form
' a Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments
194 Ebenezer Rd.
Property Address
Rubia Ceranto
Owner Owner's Name
information is.
required for every Osterville Ma. 02655 October 4, 2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS)'(cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The pit was found and dug up. The pit had about 2'of water in it, this provides over 600 gal. of
available capacity. There will be a riser cover added to the pit for easy access in the future.
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.):
r
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection.Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
194 Ebenezer Rd.
Property Address
Rubia Ceranto
Owner Owner's Name
information is Osterville Ma. 02655 October 4 2018
required for every ,
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
e r.
i
t5insp.doc-rev.7/26/201 S Title 5 Official Inspection Form:Subsurface Sawage Disposal System-Page 15 of 18
r
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
194 Ebenezer Rd.
Property Address
Rubia Ceranto ~1
Owner Owner's Name
information is required for every Osterville Ma. 02655 October 4, 2018
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: below 10.5'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: 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:
A test hole was dug adjacent to the pit(By a licensed soil evaluator). The test hole was dug deeper
than the bottom of the pit structure to prove that the pit structure is not in the groundwater. (See
attached soil report).
t
r
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
l� Subsurface Sewage Disposal System Form Not for Voluntary Assessments
194 Ebenezer Rd.
Property Address
Rubia Ceranto
Owner Owner's Name
information is .required for every Osterville Ma. 02655 October 4, 2018
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
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
�� Title 5 Official Inspection Form
�° a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
194 Ebenezer Rd.
Property Address
Rubia Ceranto
Owner Owner's Name
information is required for every Osterville Ma. 02655 October 4, 2018
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form. `
Important:When filling out forms A. Inspector Information
on the computer,
use only the tab Thomas Roux
key to move your Name of Inspector
cursor-do not
use the return Company Name
key.
89 Mayflower Lane _
4:1
Company Address
Osterville Ma. 02538
Cityrrown State Zip Code
sewn 774-678-9066 S 14531
Telephone Number License Number
B. Certification
I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000);I have personally inspected the sewage disposal system at theproperty address listed
above; the information reported below is true, accurate and complete as of the time of my inspection; and
the inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that
the system:
1. ® Passes '
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system 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
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
194 Ebenezer Rd.
Property Address
Rubia Ceranto
Owner Owner's Name
information is required for every Osterville Ma. 02655 October 4; 2018'
page. Cityrrown 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
F +
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t5insp.doc•rev.7/2 61201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
194 Ebenezer Rd.
Property Address
Rubia Ceranto
Owner Owner's Name
information is
required for.every Osterville Ma. 02655 October 4, 2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
a
® Check cellar
® Shallow wells
Estimated depth to high ground water: below 9.5'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: 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:
A test hole was dug adjacent to the pit(By a licensed soil]evaluator). The test hole was dug deeper
than the bottom of the pit structure to prove that the pit structure is not in the groundwater. (See
attached soil report).
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
1 ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
194 Ebenezer Rd.
Property Address
Rubia Ceranto
Owner Owner's Name
information is required for every Osterville Ma. 02655 October 4, 2018
page. Cityrrown 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:
r
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
i
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
Hazardous Materials Inventory Sheet Checklist
�! Date
Physical Street Address-Check database to ensure it exists
Working Phone Number
Actual Amounts - ( ie. gas being used to fuel machines, thinner to
clean brushes all count as hazardous materials)
L-----Storage Information -location of storage, how long is storage for?
If none, note that.
1--- Disposal Information -where and who? If none,note that.
1 Applicant Signature' understand what is listed and noted
Staff Initial -any questions, know who to ask
FV Irr Vehicle Washing/Rinsing? -provide a vehicle washing policy and
) _,..-explain it - note that it was given
!� Attach the Business Certificate with your sign off and comments
"The inventory form should explain what the business consists of and the procedures
e doin . Notes need to be left to explain what you discussed y' +
YOU WISH TO OPEN A BUSINESS? TWIN of tic RE
For Your Information: Business certificates (cost 40.00 for 4 years). A business certificate ONLY REGISTERS YO Ui
QMElntpgvAjij 6which you
must do by M.G.L. it does not give you permission to operate.] You must first obtain the necessary signatures8°rtlgs i at 200 Main St., Hyannis.
'Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is
required bylaw.
DATE: v Fill i{ p1,6ase
APPLICANT'S YOUR NAME/S: C, Loge's
^" BUSINESS YOUR HOME ADDRESS: C B
0 Illy, -
TELEPHONE # Home Telephone Number_�C 5 6142;
NAME OF CORPORATION:
NAME OF NEW;BUSINESS f TYPE OF BUSINESS P07
� f hJ'r
IS THIS A HOME OCCUPA I YES NO
.
--S ` MAP/PARCEL NUMBERTADDRESS OFBUSINES [Assessing] _•
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of -
Barnstable, This form is intended to assist you in obtaining the information you may need.. You MUST GO TO 200 Main St. - (corner of Yarmouth
Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your usi`n-dss in this town.
1. BUILDING COMMISSIONER'S OFF E
This individual'has beep-infor d of any er it requirements that pertain to this type of business. -
,,
u orized Signature MUST COMPLY WITH HOME OCCUPATION
COMMENTS: ,. AWLES i r i S E TO
2. BOARD OF HEALTH
This individual h� infor of he per it requirements that pertain to this type of business.
Authorize S' ature** WJST COMY VATH AM
COMMENTS: HAZARDOUS MATERIALS RECAATIM
3, CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature**�•
COMMENTS:
Date: q/ /
TOWN OF BARNSTABLE
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF'BUSINESS: (L t PA I PT I1U6-
BUSINESS LOCATION: kP� r2 y7VC /1 U J 1A INVENTORY
MAILING ADDRESS: TOTAL AMOUNT:
TELEPHONE NUMBER:
CONTACT PERSON: Frl(.l pf 110 P4
EMERGENCY CONTACT TELEPHONE NUMBER: SOX 3C4 - 6' 4L MSDS ON SITE?
TYPE OF BUSINESS: PA fail
INFORMATION / RECOMMENDATIONS: Fire District:
Waste Transportation: Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers)
Diesel Fuel, kerosene,#2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease,
Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED -
Degreasers for engines and metal Printing ink
Degreasers for driveways&garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt& roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (including carbon tetrachloride)
❑ NEW ❑ USED Any other products with "poison" labels
(including chloroform,formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous (please list):
Metal polishes ' 1 V �J OT S T®,r E WY A lV r
Laundry soil &stain removers R" _
(including bleach) S TA I P Q K L;A R-N 1 S 14 lk f 11 a ut F-S
Spot removers&cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash "4�L
C
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's nature Staff's Initials
Date:/f
TOWN OF BARNSTABLE
TOXIC AND HAZAR(D�O S MATERIALS
NAME OF BUSINESS: R,!E-01 kw
BUSINESS LOCATION: --O-)a INVENTORY
MAILING ADDRESS: TOTAL AMOUNT-
TELEPHONE NUMBE : Off- 36-4 —
a
CONTACT PERSON: Ol
EMERGENCY CONTACT LEPHONE NUMBER: �FjO�- P MSDS ON SITE?
TYPE OF BUSINESS: 0^\,k
INFORMATION/RECOMMENDATIONS: Fire District:
Waste Transportation: Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111 Section 31 of th
e e General Laws of MA hazardous material p a use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The board of health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas
Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease,
Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED
Degreasers for engines and metal Printing ink
Degreasers for driveways &garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt& roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (including carbon tetrachloride)
❑ NEW ❑ USED Any other products with "poison" labels
(including chloroform, formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other.products not listed which you feel
Floor&furniture strippers may be toxic or hazardous (please list):
Metal polishes
Laundry soil &stain removers
(including bleach)
Spot removers &cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash 0
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials
yJ
No. 3v� Fiz$.. .J...w..............
THE COMMONWEALTH OF MASSACHUSET•fS
�q BOARD OF HE L H
o . n� of .. .. . . . .4-�...5.T, .... . 1.,e� � d
Appliratiuu -fur R-qVuuttl Worko Tomitrurtiun Pumiti
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewag/Disposal
System t: p ///��7�A�//)//
_ ^.. ._ .. !f.:..C�C................................ .......e'.4 ......p ................................................
� Address ^ or Lot No.
........ ................ ... ....`iCY_.¢..........................................:... ..------------ --- -- - - - ..........................................
c Qw � d ss
Instal Address
Type of Building Size Lot_4
--------- feet
Dwelling—No. of Bedrooms.-__-2-----------------------------------Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ._......................... No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures _..
d - -- -•------••----------------------------•-----------------•----------------------------•--•------
WW gFrJ - -(llons per pet-son Per daY h dailYflow.....A®-Q.....--•----•-•-----------gallons.
Septic k—Liquid 'gallons Length.. Wdt . .
Diameter................ Depth.--.__-__._----
x Disposal Trench—No. .................... li-------- Length____.__.____... __- T leaching area.--.--.-__-_..-_----sq. ft.
Seepage Pit No... ................` r- al leaching area_?z.® ..sq. ft.
Z Other Distribution box ( Dosing tank
aPercolation Test Results Performed bY---------------------------------------------------------- --- Date---------------------------------------
,a Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water...--..--.-------_.----
f� Test Pit No. 2....._____------minutes per inch Depth of Test Pit.................... Depth to ground water_-.-_.---__.-_-.___-----
.
j - --- - ---- -------- - ---- --- -----------
Descri o of Soil--. . 0-`.lr' . - - — z- ,llw�J
x a
W
r -�1--� . ---------------------------------------------------------------------------
UNature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------
--------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the.4board pf health.
................... ----
ate
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Application Approved BY------ ------ --- ------ ---•- --- --- - - - -- •--------------------- -------
Date
Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------•-----------------
.--•----•------•----------•-•-•----------•------------------•-------------••---._...---•------------------------•--------...----••---------------------------------------------_.._.......-----••-----
Date
c:
PermitNo....................•-................................... Issued..... ...W 7•-••............------.
Date
No..•-•3 v-----•• Fus ........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....7.. .1n. -. J... .. ....
Appliration -fur Diripoiial Workii C onMrurtiou Vrru it
Application is hereby`made for a Permit to Construct ( �orRepair ( ) an Individual Sewage Disposal
System at•
.............sz ` /t Gar �Jn s/11 ° / .......... +
� Locati n-Address or Lot No.
! . ' == Ada
�i` r Ow r
, f cess
Insta�l,q Address
UType of Building Size Lot.:/K. :�_6..._...._.Sq. feet
Dwelling—No. of Bedrooms....,,2...................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
dOther fixtures _.F-v,.,r�s "------------------------ -- ------
Design Flow-..._.-.._!:-+ .........................gallons per person per day. Total daily flow......_�_a_6.�_......._._...-_..........gallons.
w ,
9 Septic Tank—Liquid capacity allons Length---------------- Width....... ........ Diameter........-------- Depth--------_.......
x Disposal Trench—No. ........... .... Width .-----.--_----- - Total Length----------------/ T�gtdl leaching area....................sq. ft.
Seepage Pit No----1Z - D 4iiet6� - -...-_�-T�a b'�1'i i.i le'f�'S� Yal leaching area. . -!..sq. ft.
z Other Distribution box ( Dosing tank ( ) —'�U6` /�� — �' /,T- 77
Percolation Test Results . Performed by-------------------------------------------------------------------------- Date---...-.....---------------------------
Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
LLI Test Pit No. 2................minutes per inch Depth of Test Pit------.............. Depth to ground
water......---/__'------...__.-
........... — --------------------------
-----
fo ,o re-
Descri -.-----
. � -lz`
w
U Nature of Repairs or Alterations—Answer when applicable...................................................................... .......................--
---- ---------------------•--------•-----------------------------------...-.-...-----------•------------------•---------------
Agreement: `
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
,rrr
Si ed `�=t �_�._.........!s.��...... '- fir /
/' Date
Application Approved By--------- 9----- -f---------------- ---- - 77-.._...
Date.-......
Application Disapproved for the following reasons---------------------------------------
...........................•--------.....-------------------------------...------------------•-------•------------------.------------------------------------------------------------------------------
Date
PermitNo......................................................... Issued---' ` -----------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
' �'
01rrtifiratr of IVS.lamphaurr
THIS IS TO CERTIFY, That t 4 Individual Sewage Disposal System constructed or Repaired ( )
by......., `''.�. .�*: .: '-C ! - .&l.7 -- ----------------- --- ----- ----
/'' Installer
at ---p ---- �`'° - e"'11 / r"� 1 � -a---
---••---------------•--------------------------
- ...--- . ;- a
has been installed in accordance wit the provisions of Ar is XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No._12V._Z, �2--------------- dated__..._3_A_-_Z.7----_-..-_...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector------------------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
7)-7 ...
No. ... ...... f.5
....... . FEE=•--------------••--•--
�i��>���tl
Permission sreby granted _-_.r �'A�- �!'
to Construct,,,-�) or Repair ( ) an Individual Sewage Disposal Says e f
at ------ ----- --1--'- `'x`A -��'
�• t l._ r Street
as shown on the application for Disposay'Corks Construction Pern-ft'No---- ---------a.---. ated....�--,�U-- 77.............
............. .-. ---- ''�A _
Board o ealt
DATE------.L. -------------------------------------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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