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.,
Commonwealth of Massachusetts
Title 5 Official. Inspection Form ,
` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Eel River Road k
Property Address
Douglas Hart Trustr'+
Owner Owners Name
information is required for every Osterville MA 02655 10/12/2019
page. Cityrrown 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 A. Inspector Information / �1 filling out forms P
on the computer, f
use only the tab James Ford
key to move your Name of Inspector
cursor-do not Ford Septic Services, LLC
use the return key. Company Name
OQP.O. Box 49
r� Company Address
Osterville MA 02655
City/Town State Zip Code
rerun 508-862-9400 S 12482
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
(310 CMR 15.000); 1 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 luation by the Local Approving Authority
4. ❑ Fails
10/16/2019
Inspe t is Signature Date
The tern inspec r 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
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Eel River Road
Property Address
Douglas Hart
Owner Owners Name
information is
required for every Osterville MA 02655 10/12/2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
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.
*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):
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
I ,
Commonwealth of Massachusetts
(P Title 5 Official Inspection Form
SSubsurface Sewage Disposal System Form - Not for Voluntary Assessments
* !% 105 Eel River Road
Property Address
Douglas Hart
Owner Owners Name
information is
required for every Osterville MA 02655 10/12/2019
page. City/Town 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 breakout or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed. ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑' Y ❑ N ❑ ND (Explain below):
❑ obstruction.is removed ❑ Y ❑ N ❑ ND (Explain below):
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
t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�. 105 Eel River Road
u=-
Property Address
Douglas Hart
Owner Owners Name
information is
required for every Ostervllle MA 02655 10/12/2019
page. Cityfrown 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 feet of a bordering vegetated wetland or a salt marsh
b. 'System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone.1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50.feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,v 105 Eel River Road ;
Property Address
Douglas Hart
Owner Owners Name
information is
required for every Osterville MA 02655 10/12/2019
page. Cltyrrown 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 Y 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.
❑ ® 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
❑ ® 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
pp Y
❑ ® 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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Eel River Road
Property Address
Douglas Hart
Owner Owners Name
information is
required for every Osterville 'MA 02655 10/12/2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the 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 a/1 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 breakout?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is of 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
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
105 Eel River Road
Property Address
Douglas Hart Trust
Owner Owners Name
information is Osterville
required for every MA 02655 10/12/2019
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 5 per as- Number of bedrooms (actual): 5
built
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550
Description:
Number of current residents: 0
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
information in this report.) ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use?
❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)):'
Detail:
unknown
Sump pump?
❑ Yes ® No
Last date of occupancy: uknown
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
105 Eel River Road
Property Address
Douglas Hart
Owner Owners Name
information is
required for every Osterville MA 02655 10/12/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use-
Date
Other(describe below):
3. Pumping Records:
Source of information: Unknown
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
..........c�, 105 Eel River Road
V
Property Address
Douglas Hart
Owner Owners Name
information is
required for every Osterville MA 02655 10/12/2019
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):
Approximate age of all components, date installed (if known) and source of information:
Date installed - 7/2/1997
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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form ,
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
105 Eel River Road
Property Address
Douglas Hart
Owner Owner's Name
information is
required for every Osterville MA 02655 10/12/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade:
42"
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene
El 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: 2000 H-10
Sludge depth: 2
Distance from top of sludge to bottom of outlet tee or baffle 25
Scum thickness 1
Distance from top of scum to top of outlet tee or baffle 6
Distance from bottom of scum to bottom of outlet tee or baffle 15
How were dimensions determined? measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tee's were present. There was no sign of leakage. The inlet cover was 12" below. The outlet cover
was 16" below
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 .
.� 105 Eel River Road
Property Address
Douglas Hart
Owner Owners Name
information is every
OStervllle
required for eve MA 02655 10/12/2019
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: r feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
N/a
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 El metal' fiberglass ❑ polyethylene ❑ other(explain):
N/a .
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
l Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Eel River Road
Property Address
Douglas Hart
Owner Owners Name
information is
required for every Osterville MA 02655 10/12/2019
page. Cityfrown 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.):
N/a
*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 I Even
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.):
The D-box was normal
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 .
< Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Eel River Road
Property Address
Douglas Hart
Owner Owner's Name
information is
required for every Osterville MA 02655 10/12/2019
page. Cltyrrown 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:
Type:
❑ leaching pits number:
® leaching chambers number: 6-recharger
330's
❑ 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
105 Eel River Road
Property Address
Douglas Hart
Owner Owners Name
information is required for every Osterville MA 02655 10/12/2019
page. Cityfrown 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 SAS was clean There was no sign of failure A camera was used
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.):
t
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form'
y Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
•� 105 Eel River Road
Property Address l
Douglas Hart
Owner Owners Name
information is Osterville
required for every MA 02655 10/12/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction: N/a
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
r
Commonwealth of Massachusetts
p Title 5 Official. Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Eel River Road
Property Address
Douglas Hart
Owner Owners Name
information is
required for every Osterville MA 02655 10/12/2019
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
F*oar' it
ovcf h
a o A C3
3
a 3q 141
3 Ys 19
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
• f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Eel River Road
Property Address-
Douglas Hart
Owner Owners Name
information is
required for every Osterville MA 02655 1 Oil 2/2019
page. Citylrown 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 groundwater: 13' +/-
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:
Topo and water contours map
❑ Checked with local excavators, installers -(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
see above
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
�= } f b Susurace Sewage Disposal System Form -Not for Voluntary
ry Assessments
V � 105 Eel River Road
Property Address
Douglas Hart
Owner Owners Name
information is Osterville
required for every MA 02655 10/12/2019
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: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
TOWN OF BARNSTABLE
"LOCATION SEWAGE #
VILLAGE -ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) Feet
Fumished by
S10%sio
_
i
t ' cesspool:s �are
within 12
j %
From-•tI e..water table .
3 � 01
-
eo �
DATE: _2/1 1 /97
PROPERTY ADDRESS: 1.05 Eel"' River Road
Osterville ,Mass .
02655
On the above date, I Inspected the septic system at the above address.
This system consists of the following:
1 . 3-Block cesspools . Main cesspool is 1017" deep.
2.Ovexflow cesspool is 817" deep.
3 . Single cesspool for bath northwest rear is 7 ' deep.
Based on my InRo-action, I certify the following conditions:
1 . Th"is is not a title five septic- system.
2. All cesspools are. dry.
3 . Main cesspool i.s.A6611 from the ocean. High water mark.
Overflow cesspool _is 32 ' from the ocean. High water mark.
4. Cesspool north west corner rear 85' from the oceans highwater mark.
5 . . Ge spool's in flood zon_e_. Sy,stem�i-s,_.in� ailuremust be upgraded t=o`
4titIe fiee septic system'.
SIGNATURE: G %(
Name:_J. P.Macomber Jr_,_______ i
Company:I. P_Macomber &—Son_Inc
Address:__B,a.c—bb------A----,--
__Cente�rvill.e .Mass_-02632
Phone:---
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
•
JOSEPH P. MACOMBER & SON, INC.
Tanks-Cesspools-Leachflelds
. Pumpfd 4 Instslled
Town Sewer Connections
P.O. Box 66' Centerville, MA 02632.0066
775-3338 775-6412
� . U
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
W 111am F. weld
gym, Trudy Core
Arpao Paul Co a cc esead"tt tio..n,« David B.Struha
Cionvnisacew
•
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
PropertyAddrt,&& 105 Eel River Road Osterville ,MA AddressotOwner. Cambridge Trust Company
Date of Inspection: 20 /9 7 (It different) 1336 Mass . A v e
Nameoflnspe-ctor. Joseph P.Macomber Jr . Cambridge ,Mass . 02138
Company Name,Addrt:.s and Telephone Number.
JRR.P.Macomber £: Son Inc . Box 66 Centerville ,Mass . 02632 508-775-3338
CERTIFICATION STATF�iENT
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-cite sewage disposal systems. The system:
_ ?asses
Conditionally Passes
44:-s.Further Evaluation By the Local Approving Authority
Inspectoi'sSlgr:muse:-7
The System Inspector ahaili :ubmit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the approprate nv,ioaal office of the Department of Environmental Protection.
The original shoLld be sent to the system owner.,md copies sent to the buyer, if applicable and the approving authority.
INSPECTION S UM hLk121';
Check A, B, C, or D:
AJ SYSTEM PASSES:
-__00 I have not found any information which indicates that the system violates any of the failure criteria as donned in 310 CMR 15.803.
Any failure cnt ra not evaluated are indicated below.
B) SYSTEM CO ND I Tl o h ILLY PASSES:
One or more syrte:n, components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes
inspection-
Indicats yes, no, or r-oT deter..:ined (Y, N, or ND). Describe basis of determination in all instances. If"not determined",explain wby not
Tha septic tank is metal, cracked,structurally unsound, shows substantial infiltration or exAltration,-or tank&Bur*is
i miss: The system will pass inspection if the existing septic tank is replaced with a Conforming septic tank as approved
by the i.c-rd of Health.
(revised 11/03/95) 1
One Winter Straat a Boston, Massachusetts 02108 a FAX(617)5545-1049 a Telephone(617)292-UW
C� Printed on Recycled Pape
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (oontinued)
PropartyAddreo.c , 05 Eeel River Road Osterville ,Mass .
Owner. Cambridge Trust Company
Date of In.spectioLv %4/97
B)SYSTEM COM)?' :ONALLY PASSES (continued)
42VC- &.sra.ge backup or breakout or hP static water level observed in the'iatslb%itonbea is due to broken or obstructed pipes)
o:dus to a broken,settled or uneven distribution box. The system will pass inspeetioa if(with approval of tba Board of
broken pipe(s)are replaced
obstruction is removed
distribution bout is levelled or replaced
Tcvj aystam required pumping more than four times a year due to broken or obstructed pipe(s). Tb system will pass
irsp.ction if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
V2 Conditions --ist Which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public heah" safety and the environment.
1) SYSTEM Df(LL PA1S UNLESS BOARD OF HEALTH DETERMINES THAT TILE SYSTEM IS NOT FUNCTIONING IN A
MANNER ,viucH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cc s s col or pnvy'is within 60 feet of a surface.water,' _ l
privy is withi 50'fee't of a bordering vegetated wetland or a salt marsh
3) SYSTEM R-I._L FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)
DETER.I,SL'`Y.i THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY A";b THE ENVIRONMENT.
�G The _yutem has a septic tank and soil absorption system and is within 100 feet to a surface water supply or t Qxdary to a
su~r..4 avatar supply.
71a ;ystam has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
&i0 Tl a .ystxm has a septic tank and soil absorption system and is within 60 fart of a private water supply wall
72n 1 stem has a septic tank and soil absorption system and is Isar than 100 feet but 60 feet or more from a privets water
wz! unlees a well water analysis for ooliform bacteria and volatile organic compounds indicates that the well is free
5[ac rollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or Is"than 6 ppm-
3) OTHER
, Main cesspool is 47 ' From the highwater
rIl `'�_ t overflow cesspool is 3 from e high wa er mar
C . 4�ools. ar_e'.. 12-15" off the water table . Cesspools in fioo zone
Ce s ool on northwest corner is 85 " from the high water mark.
ar. 6/6-" above the water table . Related to ?,lest Bay.
(revised 11/03/95) 2
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I A ,
m / �C(�'J IL
DATA
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (oon(laued)
PropertyAdd-� 'l River Road Osterville ,Mass .
Owner. idge Trust Company
Date of Inspeo ti o 7
fDJ SYSTEM FAI15.
1 r- :- e
/, V �l Save cr.:: : the system violates one or more of the following failure criteria as d4And in 310 CUR 16.305. The basic for
this t, i :nti6ed below. The Board of Health should be contacted to determine what will be nacesaary to Correct the
failure. '
ha_ wags into facility or system component due to an overloaded or clogged SAS or Cesspool.
�d D: oading of effluent to the surface U chs ground or surface watere due to an overloaded or clogged SAS or
r.el in the gistribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
�►� Lc oearpook is lass than 6'below invert or available volume is Ism than U2 day flow,
l vq :.pint more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
h ..aes pumped
_ A f the Soil Abaorption System, cesspool or privy is below the high,groundwater elevation.
o cesspool or privy is within 100 feet of a. or tributary to a surface water supply.
i✓D Ar f a cesspool or privy is within a Zone I of a public well.
n ,- -(a cesspool or privy is within 60 feet of a private water supply well.
AZd f,ay of a ceaspool or privy is lass than 100 feet but greater than 60 foot from a private water supply wall with no
:4r quality analysis. If the well has been analyzed to be aoceptabla, attach copy of well water analysis for
a li: r a volatile organic compounds, ammonia nitrogea and Wvata nitrogen.
E) LARGE SYSTEM F C
The following tpply to large systems in addition to the criteria above:
XM The sysitzn ,« al:cy with a design Cow of 10,000 gpd or greater(Large System)Lad the system is a aigitiffeant threat to
health t ut .._ :.-J environment because one or more of the following conditions east: Phu
ew ;ra , within 400 feet of a surface drinking water supply
200 feet of a tributary w a surface drinking water supply
.:rated in a nitrogen sensitive area (Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public
The ownar or op«ra.- _: System shall bring the system and facility Into full oompliaaa with the groundwater treatment program
rvquirs man u of 314 C':y A 6.00. Please consult the local regional office of the Department for Authar information.,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOAM
PART B
CHECKLIST
PropertyAur., : 105 Eel River Road Osterville ,Mass .
Owner. Cambridge Trust Company
Date of Inspeotion:2/4/9 7 '
Coach if the following have been dons:
`l,Pump4 information was requested of the owner, occupant, and Board of Health.
Y Dons of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Lame volumes of water have not bean introduced into the system reoaatly or as part of this inspection.
4,L�As built plans have been obtained and examined. Note if they are not available with NM.
ZThe facility or dwelling was inspactad for signs of sewage back-up.
_/The system does not receive non4aaitary or industrial waste flow
The sits was inspected for signs of breakout.
ZAII.Systam components, iafcluding the Soil Absorption System, have been loco
rP Y� � fed on the site.
Ths'septic tank maahcles were uncovered, opened,and the interior of the septic tank was inspected for condition of befit— or
to",, material of construction, dimensions depth of liquid, depth of sludge, depth of scum.
L,/Ths sim and location of the Soil Absorption System on the site has been determined based on cdstiag information or
a proximatod by non•intruslve methods.
The facility owner(and occupants, if different from owner)were provided with information ormatioa on the proper maintenance of Sub
Surface Disposal System.
(revised 11/03/95) 4
, 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
PropertyAddrvw105 Eel River Road Osterville ,Mass .
Owner. Cambridge Trust Company
Date of Inspeotion.2/4/97
FLOW CONDITIONS
RESIDENTIAL•
Design slow: S�y .pllons)J Er c� y
Number of bedrooms: G— PC c'
Number of o rrant residents:
Garbage grinder(,yes or no):
Laundry connected to system(yes or no): �'S
Seasonal use(yes or no): s 7/
Water motor readings, if available:
Last data of oavpancyja
COMMERCLkL/INDUSTRLkU
Type of establis nt:_
Design flow: dons/day
Grease trap present: (yea or ao)a
Industrial Waste Holding Tank present: (yes or no)22
Non-sanitary waste discharged to the Title 5 system: (yea or no)&M
Water meter readings, if available: 1714
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:�1
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no) a�.- 0a(l j�( �, . ���
/Z�.Lv• � Ali
u yes,volume pumped: 0 gallons � '�,
Reason for pumping: /f-/A
TYPE OF SYSTEM
Septic tanh/distrtZ�ution boxlsoil absorption system
Single cesspools
Overflow cesspool
Privy
Shared system(yes or no) (if yea, attach previous inspection records, if any)
Other(explain)
APPRO)aMATE AGE of all components, date installed(if known)and source of information:
Sewage odors detected when arriving at the site: (yes or no)_._I P
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C-
SYSTEM INFORMATION (continued)
Property Address: 105 Eel River Road Osterville ,Mass .
Owner: Cambridge Trust Company
Date of Inspection: 2/4/9 7
SEPTIC TANK:km— ,
(locate on site plan)
Depth below grade:_.
Material of construction: concrete _metal _FRP_other(explain)
,44 ,
Dimensions:_ ,(J
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:A! __
Scum thickness:_ V6
Distance from top of scum to top of outlet tee or baffler
Distance from bottom of scum to bottom of outlet tee or baffle._ 4)A
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffle depth of liquid IPvel in relation to outlet invert, structural
Irity, evidence of leakage, etc.)
. . S. nti c tink s not, nr .s nt.
GREASE TRAP.1VONt—
(locate on site plan)
Depth below grade:,i40
Material of cons(rr1r•tion;v/).oncrete _metal _FRP —other(explain)
Dimension;-
Scum thickness._
Distance from top yr scum to top of outlet tee or baffle:_ _
Distance from bottom ni srurn to honom of outlet tee or bahte-
Comments:
(recommendation for pumping, condi—ri of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, eit.) _
Grease trap is not present
y
t:wlsca snsissl 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (000tlnued)
Propert7 ;tiddreu: l River Road Osterville ,Mass .
Owner: _de Trust Company
Data of l;vpootloc. 3'7
TIQHT 0 {H0LI)VV Y A/02'
Ooc&u on :ita plot} a
Depth be',-o iRa4e:_1416
MaterLl c:wastrv=: �c�nta_mat&)_FRP_other(ezplaio)
— V _
Gbh'---
Deei;a C .: -. :ay
Alarm I,,
commaizta
(ooaditioa f lalat c-,4 of alarm&ad aoat ewitchu, etc.)
I or laold, tank are not present
DISTRIL" )-PION X -
(locau on .ite plan;
Depth of l—f"d l.re: lac invert:_
Comment
(note if le, J and 61. .1 Equal, rvideace of solid, carryover, •vidanca of leak, into or out of box,ate.)
is cif uT is not present .
PUMP C.:AMBEF_
(1oc&u on :t4 p tan J
Pump. in .vr1`.ag
Comaen4:
(Zorn oondi:iou or y\._ .1r, ooaditioa of pumpe aad appurten&ncee, etc.)
ump arr�" 3 not--resent .
(revised 1/03/95; 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oonUnued)
Proporc �,Jdr,w :l River Road .Osterville ,Mass .
O nar. o `.dge Trust Company.
Date of :c:pwc'_on: /
SOIL A) °-0)3F 1 10N :—H (wA
Oocate a . a p113 0, if .. acavation not required, but may be approximated by aon-intrusive methods)
•
If not da, to t (crplain
T*nK
deal`i chi,
:i ar 77
Xa < . - a of ulic failure, level of ponce, oondition of veQetatioa,etr_)
eU%' :'_s; r. -'n' "sai�°. No signs of hydraulic failure or pond ing:
:._1 .., normal.
CESSPO '_S: )
(locate or. ,:a pi..1)
Number nA)d..0,vFr.�-uMr®,v
Depth-Op Okolt)id,re wo&-y t 1:1 r Y
Depth of Ga1jd,$ ,4)er i
Depth of srw.*t* ,y.eK
^5DaLs -1-.: a D' 7" 1- ao� S v l �oL '7�X 1
Mataria.lz' tiXQe)°�1YC��lra0 LGMQC .j
Indicaticc.a_gmwlf7k� Alf`
• (= gip- dumped as of iarpection) �r`i [i
Medi.ufq ggZjq F;4,-Ce sand';
. 1' cdnz
fa,11ure or on in
AA�-� 1eT+4T6;v t`r norma
Commant, -t4 :rx1i. 4—of hydraulic failure, level of poadin& oondition of vegetation,etc.)
See
Pam:
Common ..�a, x n!i, F. . n'Zmj of hydraulic failure, level of pondin& oondition of vegetatbn,ita.)
PriV,l .. 15 U0.2-19r�S�nt
\ y
(revised
ACE SEWAGE DISPOSAL SYSTEM INSPECTION .FORM
PART B
SYSTEM INFORMATION continued
SKETCi ' SPOSAL SYSTEM:
inclu: least two permanent references landmarks or benchmarks
locate . .: train 100 '
Centerville Ostrrville Marstons Mills
Water Company
428-6691
�11►;�a f6 0 � rlan�.� �v t
cesspools are
within 12"-1 5"
From the water table .
z
_ _ SST
. 1�i
i
DEPTH ci Z
. 1 2 1 _ pe�Dnh 'Te .1 groundwater
.on or approximati�on:
n :.. 1 ✓��. . - are theo easts-
ide of�ran To� f
c air y•over w;-.cess oo "th water A
'a ijor.m.a.L_HI DES.tS•ystem—s ou- e
4,vd_ __d in the front---of the house .
OnAsave septi`c``s.ystem 'upgrade'. Transit used. From bottom o
± cP sp Ls. 2'a yie, C,tjrface of West Bay.
s•wwn�+•-n.r�Tr•.nra..•nnr.-,rr.wrr�*rr.,'+�.rr�+�+�.+.m ntrwy nw'w►�n.eo+ �t�,rT-�-�•'...•,r-•_;
'I'OWN OF Barnstable WARD OF HEALTH
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
N1— n.r��+..+...u.+.n..n.,.r. ...n •.—err•.--„_..a
-TYPI OR PRINT CI.EARLY-
PROPERTY INSPECTED
STREET ADDRESS 105 Eel River Rnad 0st.ervilleiMaSs
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAMECambridge Trust_.. Company
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J.P.Macomber & Seii 'Inc .
COMPANY ADDRESS Rnx F,h ('ent.arvi 1 1 A Ma CR n�h��
Street ' Town or City State LIP
COMPANY TELEPHONE (508 775 - 3338 FAX ( 508 ) 790 - 1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate, and
complete as of the time of .inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one :
System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
healLh or Lhe environment as defined in 310 CMR 16 . 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System
The inspection whicl, I have con acted has found that the system fails to
protect the public health and the environment in, accordance with Title
5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature Hate '2/12/97
One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the BOARD OF HUAL1'11.
If the inspection FAILED, the owner or•`operator shall upgrade
he aYste
within one year of the date of the inspection, unless allowed ortrequiredm
otherwise as provided in 3.10 CMR 16 . 306 ,
partd .doc
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THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMVIR 15.340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Environmental Protection.
June 8. 1995
Acting Director of the ' ' ion of Water Pollution Control
CERTIFICATION Or SKETCH AND APPLICATION FOR A DISK,
WORKS CONSTRUCTION PLit.N,11'1' (1V1'I'IIOU'1' DESIGNED PLANS)
I Joseph P.Macomber Jr., :--i c�:rtil'y tlt;tt the application for disposal works
construction permit signed by me ,::aid _6/2�97_ , concerning the
property located at 10 Eel—Rive r Rond n QtPrITl o M. meets all of the
following criteria:
There are no Nvetlands within 3UO fc.t of dic proposed septic systcill
Thcre are no private wells wlthill 15o tcct of the proposed septic system
0 The observed groundwater tabl: i ftet or greater below the bottoin of the leachinb facility
There is no increase in flow and/or chanbe in use proposed
• There are no variances requested or nccdcd.
SIGNED DATE: 6/23/97
LICE SEPTIC SYSTENI INSTALLER IN THE TOWN OF BARNSTABLE NUNSER
(Attach a sketch plan of the proposed s)scm. Also if the licensed installer posesses a certified plot plan,
this plan should be sub:niucd).
I
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No. 7—3 3 ��� Fee $ 50. 0
THE COMMONWEALTH OF MASSACHUSETTS
�`" Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZIpplication for Migogof 6p.5tem Con!5truction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) XM Complete System ❑Individual Components
Location Addressor Lot No. 1 0 5 Eel River .Road Owner's Name,Address and Tel.No. 6 17—441—4 3 0 4
OstVivllee ,Mass. 02655 Jim Ladd Cambridge Trust Company
Assessors ap/Parce 1336 Mass Ave Cambridge ,Mass . 0213
Installer's Name,Address,and Tel.No. 5 0 8-77 5—3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 8
J.P.Macomber & Son Inc.
J.P.Macomber & Son Inc.Box 66 Centerville ,Mass. 026
Box 66 Centerville ,Mass . 02632
Type of Building:
Dwelling xxNo.of Bedrooms 5 Lot Size sq. ft. Garbage Grinder N0)
Other Type of Building RES No. of Persons 2 Showers( ) Cafeteria( )
Other Fixtures
Design Flow 550 gallons per day. Calculated daily flow 5 x 1 1 0 ` gallons.
Plan Date 23 97 Number of sheets Revision Date "
Title
Size of Septic Tank 2000 Type of S.A.S. 6-330 Cultee rPeliaraprs
Description of Soil Medium sand to fine sand
Nature of Repairs or Alterations(Answer when applicable) 1
Omitting cesspools . Installing 1-2000 gallon tank 1 =hnx and
six 330 cultec rechargers . tU/? 31 C). tg;V/.e,
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been iss d by t is o of alth.
Signed. Date 6/2.3/9 7
Application Approved by Date eK— Q 6 —
Application Disapproved for the following reasons
Permit No. 7.y Date Issued
No. �� 3 3� � �.;u:`4''��� i � Fee � 50/00
THE COMMONWEALTH OF MASSACHUSETTS - �Egter
4 in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
20plication for Oigaal *pgtem Congtruction Permit y, t
-Application'lication'for a Permit to Construct Repair )Upgrade( )Abandon(
pp ( ) p ( pg ( ) x9Complete System Olndividual Compotierits �
Location Address or Lot No. 105 Eel River Road Owner's Name Address and Tel.No. r
Osterville,Mass. 02655 Jim Ladd Cambridge
Assessor'sMap/Parcel 1336 Mass Ave CiambZ
Installer's Name,Address,and Tel.No. Desi ner's Name,Address and Tel.No. 5' `'+ xr t� 3j ?
508-775-3338
J.'P.Macomber & Son
J.P.Macomber & Son Inc. Box 66 Centerville
Box 66 Centerville,Mass. 02632
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Type of Building:
Dwelling XXNo.of Bedrooms 5 Lot Size sq.ft. Garbage Grinder,(,. )7,,ES
.
Other Type of Building No. of Persons 2 Showers( )I,Cafeterta.(= )�kv q7;- ,Z
Other Fixtures
Design Flow 550 gallons per day. Calculated daily flow 5 x 110 gallons '
Plan Date 6/23/917 Number of sheets Revision DateUd
Title2000
Size of Septic Tank Type of S.A.S. 6-330 Cukle,c rechar�
Description of Soil
Medium sand to fine sand, Ys� •
Nature of Repairs or Alterations(Answer when applicable) " ;
Omitting cesspools. Installin 1-2000 gallon tank '114box and
six 330 cultec rechargers. LI/171`f 3
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on`site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
Z cate of Compliance has been iss I Wb�t o�a alth. 6/23/97
Signed /r G� Date
Application Approved by Date A0�— 0 6 7
Application Disapproved for the following reasons -
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Permit No. ' Date Issued -
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( ) Repaired( y )UpgradedY(.XX)
Abandoned( )by J.P.Macomber &I Son inc.
at 105 Eel River Road Osterville,Mass. has been constructed•.in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 9 7--3 3 dated 6 9
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date Inspector �
- ---------------------------------------
No. 9 7^ 33/ Fee 90.00
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION'- BARNSTABLES MASSACHUSETTS
lwiopogaf *p.5tem Construction Permit
Permission is hereby granted to Construct( )Repair( )Upgrade KX)f Abandon( )
System located at 105 Eel River Road Osterville,Mass.
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
r;comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this
ppeermit.
Date: G y Approved by
e%,, ` ��� �� TOWN OF BARNSTABLE
LOCATION ,Q_ �a t SEWAGE #
VILLAGE_ - CS4s ►/A /l.a.. ASSESSOR'S MAP & LOT If I„ O2L
INSTALLER'S NAME&PHONE NO. „e Al A c o m ZzZ, 73 S'— Uy 8—
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type)( A,,a g c ,< - 3 ® (size) C—
NO.OF BEDROOMS
BUILDER OR OWNER =v �
4PERMITDATE: P 142 COMPLIANCE DATE: 7 2
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
C1",
P
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TOWN OF BARNSTABLE
LOCATION �FC Zt�r�2 SEWAGE #
VILLAGE Cq,1A ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.-J4&MbftA1 A c a m
SEPTIC TANK CAPACITY a"'=b -
LEACHING FACILITY: (type)� A1+A oL$4 K 3�� (size) —
NO.,OF BEDROOMS
BUILD.ER OR OWNER
PERMIT.DATE: -1 -� �/7 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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