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THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BAIRNSTABLE, MASSACHUSETTS Yes
01ppliLation for -Mispo8al *p8tem Construction permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ❑Complete System q<ndividual Components
Location Address or Lot No. 306 z�G. Owner's Name,Address,and Tel.No.
Assessor'sMap/Parcel. //S C1 c r4
installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) ry l./
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this B lth.
Signed -- Date �A
Application Approved by - Date 0
Application Disapproved by Date
for the following reasons
Permit No. ;-c))-'0' Date Issued ,0 d ' ).e Z'v
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b Enter THE COMMONWEALTH OF MASSACHUSETTS ed in computer
Yes
PUBLIC HEALTH DIVISION - TOWN,,OF BARNSTABLE, MASSACHUSETTS
Application for Misposal Opifif Construction Permit
Application for a Permit to Construct(%) Repair( ). Upgrade( ') Abandon;( ❑Complete System Individual Components « ,
Location Address or Lot No. i! '< 'Owner's Name,Address,Ad Tel.No.
Assessor's Map/Parcel r ,r x
1 Installer's Name,Address,an&Tel No. r^ � �` D'esigner's Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms 1 'Lot Size sq.ft. - Garbage Grinder( )
d -------------
,,,Other/- Type of Building r No.o ersons Showers( ) Cafeteria( -)
r
Other Fixtures
Design`Flow(min.required) gpd Design flow provided gpd
Plan Date., Number of sheets Revision Date j
A_ V. ,
Title
; _
",Size of Septic Tank Type of S.A.S.
Description of Soil
f
Nature of Repai s or Alterations(Answer when applicable) /rt!Ve 1--e4
t
Date last inspected:
Agreement:
t
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system.in operation until a Certificate of
Compliance has been issued by this Bo_ard,oHealth.
Signr _ Date d/:w ;OF 0
Application Approved by 1A Date-_ f U/ 7/>a.9-,
Application Disapproved by Date
:fit ic.^A ♦�.-' -'' a,.. __- - --... ._.
for the-following reasons
Permit No. U a-Q Date Issued d
d 7 },osu
»-._ :.-..-:��.,-..:,A _. _.<. -rc,=r.->c.s-.....:.:e_- c:w �-.r.�..ds c...-.a a:- ..-.-.-.�..t-.- -•^_ 2--.--- --•-•__. .---_.-•--. _ .a'ti.e.x`.Y
THE COMMONWEALTH OF MASSACHUSETTS
d� BARNSTABLE,MASSACHUSETTS
Certificate of Compliance,.
THIS IS-TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) y
Abandoned(r"IS)by �
at 'S,-%'? F Z ;�,y.;.r- J iclt/-� has been constructed in accordance
with the provisions of Title and the for Disposal System Construction Permit No. '20-10��% dated
Installer .�
�f1r Designer
#bedrooms Approved design flow gpd
The issuance of this permit shall note const •edd assaa guarantee that the system 'fl
Date �("} �pr-.i Inspector
No. r}y o .� 3 t l( Fee 1 7 r
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION BARNSTABLE,MASSACHUSETTS
�p8tEin Construction Vermit
Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( �
System located at ,C e� L si f�iC. iurC
and as described in the above Application for Disposal System Construction,Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this perm
Date 10 '�1 a Approved by
t
J
//5r D 0
Commonwealth of Massachusetts
113 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c 7
L�
308 Eel River Rd (A p
Property Address
Owner Simons t ,
information is Owner's Name/
required for Osteryille V Ma 10-28-2020 1
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A. Inspector Information
When filling out p
forms on the
computer, use Douglas A Brown
only the tab key Name of Inspector
to move your D.A.Brown Inc i
cursor-do not Company Name
use the return
key. P.o Box 145
"ILA Company Address
Centerville Ma 02632
City/Town State Zip Code
508-420-4534 S14297
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 Evaluation by the Local Approving Authority
4. ❑ Fails
10-28-2020
e is 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
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
v
308 Eel River Rd
Property Address
owner Simons
information is Owner's Name
required for Osterville Ma 10-28-2020
every page. Cityrrown 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:
J '
® 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:
At time of inspection this system met all minimum passing requirements. This system appears to be
original to the house from 1972. There was a seperate leach pit by it self to the left of the garage near
the fish pond that the town required us to abandon because it was not connected to a septic tank.
Riedell Plumbing re routed the plumbing into the system in the front of the property. This report can
not predict the future performance under the same or increased usage. This House has been used as
a seasonal property.
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):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
,�p Title 5 Official Inspection Form
J' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
v
308 Eel River Rd
Property Address
Owner Simons
information is Owner's Name
required for Osterville Ma 10-28-2020
every page. Citylrown 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 ❑ N FIND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N FIND (Explain below):
A
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ 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
►o Title 5 Official Inspection Form
j Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�— 308 Eel River Rd
Property Address
owner Simons
information is Owner's Name
required for Osterville Ma 10-28-2020
every page. Cityrrown 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
113 Title 5 Official Inspection Form
III� Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
308 Eel River Rd
Property Address
Owner Simons
information is Owner's Name
required for Osterville Ma 10-28-2020
every page. Cityrrown 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 'h 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
❑ ❑ 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.7/2 612 0 1 8 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
308 Eel River Rd
Property Address
Owner Simons
information is Owner's Name
required for Osterville Ma 10-28-2020
every page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the 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?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [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
�m i? Title 5 Official Inspection Form
III Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
v-
308 Eel River Rd
Property Address
Owner Simons
information is Owner's Name
required for Osterville Ma 10-28-2020
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms (actual): 3 per owner
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
There were no actual design plans found on this property but a 1000 gallon septic tank was found
along with a distribution box and a 1000 gallon leach pit surrounded with stone that appears to be
original.
Number of current residents: 2
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 0 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
2018 ----gpd was 728.7 2019 was 745gpd for the entire property including irrigation, pool , fish
pond,and pool house.
Sump pump? ❑ Yes ❑ No
Last date of occupancy: currentlyseasonal
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
308 Eel River Rd
Property Address
Owner Simons
information is Owner's Name
required for Osterville Ma 10-28-2020
every 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):
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):
Pumping
3 u in Records:p g eco ds•
Source of information:
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
4'
308 Eel River Rd
Property Address
Owner Simons
information is Owner's Name
required for Osterville Ma 10-28-2020
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. t
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1972 per construction details from Town of Barnstable. ( State recommends pumping every 2-3 yrs
for maintenance)
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
�. lip Title 5 Official Inspection Form
11. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
L
308 Eel River Rd
Property Address
Owner Simons
information is Owner's Name
required for Osteryille Ma 10-28-2020
every 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: 1000
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
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
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank was functioningproperly at time of ins ection.one tank cover is partly under the dry laid brick
p p Y p p Y Y
walkway and the d-box and pit are in the mounded mulch area off of the walkway.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
cam, Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
308 Eel River Rd
Property Address
Owner Simons
information is Owner's Name
required for Osterville Ma 10-28-2020
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
a � 308 Eel River Rd
L
Property Address
Owner Simons
information is Owner's Name
required for Osterville Ma 10-28-2020
every page. Cityrrown 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
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box looked typical for its age with some deterioration but was functioning with one inlet and one
outlet.
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
308 Eel River Rd
Property Address
Owner Simons
information is Owner's Name
required for Osterville Ma 10-28-2020
every page. Cityrrown 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:
depth
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
r: lR Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
308 Eel River Rd
Property Address
Owner Simons
information is Owner's Name
required for Osterville Ma 10-28-2020
every 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.):
pit was not opened due to depth but there was no clear signs of failure or break out in the area of the
s.a.s.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp:doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
,u3 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
L 308 Eel River Rd
Property Address
Owner Simons
information is Owner's Name
required for Osterville Ma 10-28-2020
every page. City/Town 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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
308 Eel River Rd
v
Property Address
Owner Simons
information is Owner's Name
required for Osterville Ma 10-28-2020
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
308 Eel River Rd
Property Address
Owner Simons
information is Owner's Name
required for Osterville Ma 10-28-2020
every page. Cityrrown 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: greater than 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: pate
❑ 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:
previous passing insp report( page attached)
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
1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
308 Eel River Rd
Property Address
Owner Simons
information is Owner's Name
required for Osterville Ma 10-28-2020
every 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 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
1
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
p Certifirate of Comphante
i THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
Abandoned(0'*)by �f, rF�r✓ �w°
at �k: /� has been constructed in accordance
with the provisions of Title 5 and the four Disposal System Construction Permit No..200 -4` '3 dated r J/ a-°
Installer Designer
#bedrooms Approved design flow gpd
The issuance of this permit shall not be constr edd ass a�guarantee that the system c �e ' �a:
Date f�`i c7� Inspector
Page 10 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 308 Eel Ri.vea J?oad
0etez-v.i:l e—,-ffl asp:
Owner: _lamee 00od
Date of Inspection:9/23/03
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
0
ar �
1'
r J 0� 1D1,0wr4e 000 of
core,Fay
`'�fi � cesspool"1
'Dee Get i aClnc`U C.C}vlP�iCutle
10110 pao
10
• Page 1 I of I 1
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C -
SYSTEM INFORMATION(continued)
Property Address:308 heel /2ivea /toad
a
Owner:,�ame.3 Uoo
Date of Inspection: 9/23/03
SITE EXAM
Slope
Surface water
Check cellar
Shollow wells
f
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
0 3ained f7oin s s�ede �i ,
l on record• lfehecked;date of design plan reviewed:Observed site(ab bservation hole within 150 feet of SAS)
Checked with locealth-explain: !/r�
LS Checked with local excavators, installers•Jartach documen tion) �
Accessed USGS database-explain:7MU/ W7/> 4 1.44 /)91
You must describe how you established the high ground water elevation:
ed: a�fr t�z6�fnn Plorly � 7 ?:�1 aound wate2 elevationh a&ove lea_ level.
ed:ll GS: u vafion well daia lune 7992
ed: USyS:Technical Bulletin 92-000- 1 P&te 40'2 Anaua' taa yeh o4,�ynound
water zlev a L o,nz.
UP ol wound
Leaching
Pitjl /06:eet
Groundwater` Feet Below Bottom of Pit
High Groundwater Adjustment 1.8 ft per Fnmpter Method
Therefore,the vertical separation distance between the bottom
Of the leaching pit and the adjusted groundwater table is 71
feet.
1I
� Q�It)
DATE : 9123103
PROPERTY ADDRESS: 308 Ee.P /liven Road - � r
-- --------------------- RECLE �r �
O�ste2v.iP.�e, l9ah�s.
- - - - - -------------------
__0_2.6_5_5_ OCT 2 12003
TOWN OF BARNSTABLE
HEALTH DEPT.
On the above date, I inspected the septic .system.-at the above address.
Tni$ system consists of the following:
MAP - i 1•S '
'. 1- 1000 ga2.Pon Ze/at.ic .tank.
?. 1-Di zz ,z-i.gut ion Sox. PARCEL ; 13 _
3. 2- 1000 gaieon /?2eca,6t .2each.ing /2.it3. LOT '
Saseo on my inspection, I certify the following conditions:
F. 7hi.6 ih a .titQe _�ive .septic Zyzt' m. 78 Code)
5..-7he_ ee/2 .ic 3yetem L3 in /2)co/1ea woaking^ Oadea
_. at the pae,6ent. .t.i_me.
PUmped 3e/2. .ic tank c-t t.imne o� .in,3peci_ion.
Oazte wateain #1 12.it i,6 38' &e.Pow the invent /z.ipe. #2 pit waete watea
..,6 66' &eQow the inveat /2.i/2e.
SIGNATUR
game J/. P . Macomber Jr .
- - - - - - - - - - - - - - - - ----
pmpany ,�gg�Ph ��_ M�S4m��r b_ Son, Inc .
" Caress : __@Qx _fit- ------------
QUSD,xLI-Le_.,_ Ja . -22-632- 0066
P'.one - -508 •_775_ ) 3 )8 .. ... ...
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
C
PH P. MACOMBER SON, INC.Tanks•Cesspools•Leachllelds
Pumped & Installed
Town Sewer Connections
Box 66 Centerville. MA 02632.00665
775.3338 175 6412
COMMONWEALTH OF MASSACHUSETTS
= EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5 �
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:308 £eel R-ive2 12oad
0,6te2L.i.P.2e, ma,3.6.
Owner's Name: Jamey Uood T
Owner's Address: Same
Date of Inspection: 9123103
Name of Inspector: (please print) ao,s el?h %. Macomge2 a2. _
CompanyName:j. P. 1lacomgelt & Son Inc.
Mailing Address:Box 6 6
rp tpayiiiA. ma, A, 02632
Telephone Number: _ 5 O R_7 7 5_ 3 3 3 R
CERTIFICATION STATEMENT
1 certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
f�
,Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority '
Fails
Inspector's Signature: Date: g
The system inspector shall ebmit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. if the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner.shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
****This report only�describes conditions st: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. _ m
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address308 Eee.2 /2.ive/z . Road
0,31 e�2e, l'la.6.s.
Owner: _lame',6 Idood
Date of Inspection: 9123103
Inspection Summary: Check A,B,C,D or E/ LA WAYS complete all of Section D
System Passes:
A) I have not found any information which indicates that any of the fallure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
Tho ,soRt �,A art R20/Re2 wo/zkinq o2de2 ai .the
B. System Conditionally Passes:
One or more system components as described in the "Conditional Pass"section need to be replaced or
repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes, no or not determined (Y,N,ND) in the for the following statements. If"not determined"please
explain.
The septic tank is.metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
•A.metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
4 Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain: ,
Nd 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 pipes)are replaced
obstruction is removed
ND explain: r
2
Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INVECTION FORM
PART A
CERTIFICATION(continued)
PropertyAddress:308 fee.2 Rivet Road
Owner: Jame,3 Qood
Date of Inspection: W 3/03
s�>.
C. Further Evaluation is Required by the Board of Health:
-426 Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
I. 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:
A` Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the
system is functioning in a manner that protects the public health, safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet W 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 coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:308 feel /2.ive2 Road
0�te2u� PPe, Na.6e.
Owner: ;amee ltlood
Date of Inspection: 9/23/03
D. System Failure Criteria applicable to all systems:
You must indicate "yes"or"no"to each of the following for all inspections:
Yes No
/Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool.
�/ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
T cesspool , ;�,�A)
_ Liquid depth in cevpeoi is less than 6"below invert or available volume is less than :S_day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped).
y portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or I tributary
water supply. tary to a surface
/
!� Any portion of a cesspool or privy is within a Zone 1 of a public well.
1�iAny portion of a cesspool or privy is within 50 feet of a private water supply well.
T Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.)
(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must 'ndicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above) r
yes no
ethe 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
Y the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—1WPA)or a mapped
Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered.
"yes" in Serction D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of I I
OFFICIAL. INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 308 Eeei Rive z Road
Owner. 1ame� blood '
Date of Inspection: 9123103
Check if the (0.1lowing have been done. You must Ind 11 icate ' s"or"no" as to each of the followin :
Yes No
umping information was provided by the owner, occupant, or Board of Health
Were any of the system components pumped out in the previous two weeks
v _ 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 art of ' o• / p 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 ? u
�L Were all system components,—0cluding the SAS,located on site ?
(� Were the septic'cank manholes uncovered,opened, and the interior of the tank ins
pected for the
of the baffles or tees, material of construction,dimensions, depth of liquid, depth of sludge and depth of scumnditlon
Z_ Was the facility owner(and occupants if different from owner)provided w' 'i
maintenance of subsurface sewage disposal systems ? p tth tnformation on the proper
The size and location of the Soll Absorption System(SAS)on the site has been determined bascd on:
Yes no/
_ Y Existing information. For+example, a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of di
is unacceptable) (310 CMR 15.302(3)(b)J stance
Page 6 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION ,
Property Address: 308 fee.P Riye2 Road
Owner: jame.6 tdood
Date of Inspectlon: 9/23,/03
FLOW CONDITIONS �,..�.
R,ESIDENTLAL
Number of bedrooms(design): Nuunber of bedrooms (actual):
DESIGN flow based on 310 C 15.203 (for example: 110 gpd x M of bedrooms):
Number of current residents:
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage syste ( e or no).tfif yes separate inspection required)
Laundry system inspcctcd_(,cs or no):
Seasonal use: (yes or no):
Water meter readings, if air tlable (last 2 years usage (gpd))�00I=303, 000 ga.P.Pon,6=8 30. 14 GhD
Sump pump(yes or no): 2002=253, 000 gas Rionz 6 93. 15 ChD
Lut date or occupancy
COMMERCIAUINDUSTRIAL
Type of establishment: J� a-
Design now(based on 310 CMR 15.203): d
Basis of design now(seau/persons/sgft,etc.): 40
Grease rap present(yes or no):
Industrial waste holding tank present (yes or no):,f
Non-sanitary waste discharged to the Title 5 system(yes or no):,jL,4
Water meter readings, if available;
Last date of occupancy/use.
OTHER(describe):
Pum ping Records GENERAL INFORMATION
Source of information:
Was system pumped as pan'ot the inspection (yes or no):
If yes, volume pumped: /�2 gallons -• How was quan ry pumped determined?
Reason for pumping:HearJy scum & .6oPid.3 zaye2.6 sae.3en .
i
OF SYSTEM
ptic tank, distribution box, soil absorption system
ngle cesspool
verflow cesspool
vyared system(yes or no)(if yes, attach previous inspection records, if any)
novative Alternative technology. Arch a copy of the current operation and maintenance contract (to be
obtained from system owner)
Tight tank 0 Arch a copy of the DEP approval
yCZ Other(describe): Z)d
Ap rox' ate age of all components, date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):,jo
6
Page 7 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 308 Eee.2 Riven Road
0,6te2v�22e.
Owoer:Jame.6 blood
Date of Inspection: U23n 3
y
BUILDING SEWER (locate on site plan)
Depth below grade 1 x,'Zj30�
Materials of consnvction: Zc&st iron ✓40 PVC Mother(explain): 40
Distance from private water supply well or suction line: 60 71-
Comments (on condition of joints, venting, evidence of leakage, etc.):
2Pini.s a-pponn tight No _eyidanry 04 .44akaae. 7hp- 6U,6tam i,5 vent-ed
th1tough .the Zook vent.5.
SEPTIC TANK: Z(Iocate on site plan) /D0 9 ,b�;S
Depth below grade: /oi Material of construction: l�/concrete metal,( fiberglass,�polyethylene
/1/)other(explain) zx_
If tank is metal list age:&J Is age confirmed by a Certificate of Compliance(yes or nol}d(attach a copy of
certificate)
Dimensions: a 04
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle; Q
Distance from bosom of scum to bottom of outlet tee or baffle:
How were dimensions determined: _louml2ed at tame ot en,3/2ectton,
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
. as related to outlet invert, evidence or leakage, etc.):
-1OUmR tom/) it i uriO1U a9 /GI �oiae `...s 11 .Sent Tn1�of R
Oof foot nno in \nOnro 7ho fnnh !.A ,tfnurfunrzUy Angnd rinr/
zhow.6 no evidence o eeakage.
GREASE TRAPlocate on site plan)
Depth below grade:Z—c/X
Material of construction;.,concrete,(Ameta(VAfiberglasslpolyethylenOg other
(explain): ,to
Dimensions: M
Scum thickness: Aj,4 _ .r,
Distance from top of scum to top of outlet tee or baffle: �J�¢
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
2ea�se t2a� i-- no /22ezen ,
7
Page 8 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 308 feel Rivea Road
Owner: jamez Qood
Date of Inspection: 9/231Q,3
TIGHT or HOLDING TANKtY�(tank must be pumped at time of inspect ion)(locate on site plan)
Depth below grade: ~
Material of construction: concrete metal A#fiberglass / polyethylene o_other(explain):
Dimensions: _
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: _e Alarm in working order(yes or no):
Date of last pumping: _ A
Comments(condition of alarm and float switches, etc.):
7i4h•t oa hoiding .tankz ate not /2/te,3en
DISTRIBUTION BOX: Zif resent must be o ened locate on P p )( site plan)'
Depth of liquid level above outlet invert:
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.):
[�i.st2i�r�tion Sox haz , one -eatelta.Q. No evidence o/ .so 1jdz ca22y
gve2. No evidence o,1 ieakczge into oiz ou o e ox
PUMP CHAMBERek,(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no): '
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
��rim� champ 2 no•t �2e�en•t
8
t
Page 9 of l 1.-
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C <•
SYSTEM INFORMATION(continued)
Property Ad 30dress. 8 (�ee2 /2.ive2 Road ,
e Z e zT.c
Owner: ;arnez blood
Date of Inspection:9/23/03
SOIL ABSORPTION SYSTEM (SAS): Zlocate on site plan,excavation not required)
2- 1000 aaiion n prn st Ppnrhing 4114
If SAS not located explain why:
Located See aaae 10
e
4.�leaching pits, number:,,2
Alb leaching chambers, number:
A leaching galleries,number:$
A.b leaching trenches,number, length:
leaching fields, number,dimensions:
VDoverflow cesspool, number:
6 innovative/alternative system Type/name of technology:..z2y �✓G� ` 7�C4��
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of ve etation,
etc.):
Loam.y nand to "one coalzze sand No .sign � c/� �[��i� aid/gip
o2 12ond.eng. So i.P, ate d2u Vegetati rn i,t o no
#1 12ii : Oazte waten iz 38" ge.Pow the invent /2,j/2e #2 t wa.6te.
�mIDaasust fot?sed 4b/O (cessPooepump part pection)(locate on site plan)
Number and configuration: 0
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 or no):
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
C8,34.ann.P,t aae nnf pRoApni
r
PRIVYL(locate on site plan)
Materials of construction:
Dimensions:'
Depth of solids: ZM
Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
/ -
7n i u[[ ;'A nnf n
9
s
Page 10 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 308 Ee-9 /2cve2 /load
Owner: �ame,6 blood
Date of Inspection:9123103 r
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
p
Y oaa
' h
10
Page I I of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C 1 -
SYSTEM INFORMATION (continued) '
Property Add ress:308 LeeP /2.ive2 Road
Owner: amen oo
Date of Inspection: 9123173
SITE EXAM
Slope
Surface water
Check cellar >
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
0 ed�iburtin
stem desi plans on record - If checked, date of design plan reviewed:
bscrve grope bservation hole within ISO feet of SAS)
Checkedcal Boar o Health•explain: Aim
GS Checked with local excavators, installers attach documen Lion)
Accessed USGS database-explain: �', ,f 7'zw, zeaedv4 /n�
You must describe how you established the high ground water elevation:
,ed: a 2ound wate2 e.Pevat.ion.6 agove eea .PeveP.
red:Jrg'S: 0 7e2vat.ion we.P.P data. tune 1992
,ed: USES: 7echn.icai Pu$2et in 92-000— 1 / .Pate #2 Ranua.P Zan e.s 014 aa.Qund
. water e�evat.con� '
Leaching
Pit& /Ob;cct
Groundwater: f-cct Below Bottom of P.it High Groundwater Adjustment 1.8 ft per Frimpter Method
• Therefore, the vertical separation distance between the bottom.
Of the leaching pit and the adjusted groundwater table is 71
feet.
11
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TOWN OF LIOARD OF HEALTH
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
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- -TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS308 Eeei Rivez Road 0zi_e/Lviiie, lea3.3.
ASSESSORS MAP, BLOCK AND PARCEL # 115-073
OWNER' s NAME aame,s ldo od
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J P Macomber & SoR Inca:
COMPANY ADDRESSBox 66 Centerville Mass. 02632
Strvvt Tovm or City Staty ZIP
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 5Q8 ) 790 -1 578
CERTIFICATION STATEMENT "
I certify that h have personally inspected the sewage disposaj system at
this address and that t)le information reported is true , accurate , and
omplete 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 ne :
//j system PASSED . _
The inspection hhich I have conducted has not found any information
which indicates that the system fails to adequately protect public
heRILh or the environment as defined in 310 CMR 15 - 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILEll*
The inspection whicll 'I have con tcted 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 .
ZInspector SignatureAIK Date
e copy of this c rtification must be provided to theOWNER, the BUYER
On
where aPpl ioable ) and the I30ARD OF HEAL7111.
* If the inspection FAILED, the owner orl`operator shall u pg ' aYste
within one year of the date of the inspection, unless alloweddorthe requiredm
otherwise as provided in 3.10 CMR 16 . 306 .
Partd . doc