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Commonwealth of Massachusetts
'- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1,
Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "H"
Property Address
.2
Multiple Owners
Owner Owner's Name
information is ai
required for every Osterville, MA 02655 03120/19
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 r..5
way. Please see completeness checklist at the end of the form.
Important:When
filling out forms A. Inspector Information
on the computer,
use only the tab Paul W. Davis
key to move your Name of Inspector
cursor-do not Rosano Davis Sanitary Pumping, Inc.
use the return key. Company Name
.
9 Rocky Lane
Company Address
Cohasset MA 02026
Cityrrown State Zip Code
,ate, 781-383-8888 SI 49
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 CNIR 16.000);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
03/29/19
Inspector's Sig ' ure 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 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
c Commonwealth of Massachusetts
i a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Osterville Pines-3040 Falmouth Road,Osterville, MA BUILDING "H"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02655 03/20/19
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):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "H"
Property Address
Multiple Owners
Owner Owners Name
information is Osterville MA 02655 03/20/19
required for every �
page. Cityrrown 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 ❑ 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
�u
l6Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"H"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville, MA 02655 03/20/19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 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
El ® 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.R26/2018 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
M (� Osterville Pines-3040 Falmouth Road,Osterville, MA BUILDING"H"
Property Address
Multiple Owners
Owner Owner's Name
information is Osterville MA 02655 03120/19
required for every �
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
.Yes No
ElStatic 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 Y2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ Z 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.
❑ Z Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well
❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ Z 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.
❑ Z 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
❑ E 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
h ❑ ® 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
Osterville Pines-3040 Falmouth Road, Osterville, MA BUILDING "H"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02655 03/20/19
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 C.4 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
Z ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ Z Were any of the system components pumped out in the previous two weeks?
Z ❑ 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?
Z ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
Z ❑ Was the facility or dwelling inspected for signs of sewage back up?
Z ❑ 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:
Z ❑ 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.7r26l2018 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
Osterville Pines-3040 Falmouth Road, Osterville, MA BUILDING "H"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02655 03/20/19
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220 gpd
Description:
Number of current residents: Varies
Does residence.have a garbage grinder? ❑ Yes Z No
Does residence have a water treatment unit? ❑ Yes Z No
If yes, discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? El Yes ❑ No
Seasonaluse? ❑ Yes Z No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Water meter readings were not available at time of inspection.
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Osterville Pines-3040 Falmouth Road, Osterville, MA BUILDING"H"
Property Address
Multiple Owners
Owner Owner's Name
information is Osterville MA 02655 03/20/19
required for every +
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Condominium Association on semi-annual
pumping schedule.
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1,000 gallons
gallons
How was quantity pumped determined? Sight glass on pump truck.
Reason for pumping: To determine structural integrity and
watertightness of septic tank.
t5insp.doc-rev.7r2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
ip. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Osterville Pines -3040 Falmouth Road,Osterville, MA BUILDING "H"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02655 03/20/19
Ci /Town
page. tY 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:
Previous inspections indicated installation in 1997 by Bortollotti.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
1:2Depth below grade: feeetet
Material of construction:
❑cast iron ®40 PVC ❑ other(explain): Schedule 40 PVC inlet pipe.
Distance from private water supply well or suction line: No known wells in immediate are.
feet
Comments(on condition of joints, venting, evidence of leakage, etc.): .
Inlet pipe appeared to be clean and flowing freely. No evidence of leakage.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
M - Title 5 Official Inspection Form
l Subsurface Sewage Disposal,System Form-Not for Voluntary Assessments
Osterville Pines -3040 Falmouth Road,Osterville, MA BUILDING "H"
Property Address
Multiple Owners
Owner Owner's Name
information is Osterville MA 02655 03/20/19
required for every �
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 6"w/covers to grade on inlet and
outlet.
Material of construction:
Z concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
Precast concrete septic tank.
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ .No
Dimensions: 4.5'wide x 5'deep x 9'long
Sludge depth:
2"
Distance from top of sludge to bottom of outlet tee or baffle
34"
Scum thickness
0"
Distance from top of scum to top of outlet tee or baffle 5,.
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? Measured with a tape.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Septic tank was pumped at time of inspection.Tank was structurally sound and watertight and
all effluent levels were at an appropriate height. Inlet and outlet tees in place. Recommend
installing Zabel effluent filter in outlet tee to prevent solids from entering SAS.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
S
f
Commonwealth of Massachusetts
Ip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Osterville Pines-3040 Falmouth Road, Osterville, MA BUILDING "H"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02655 03/20/19
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
Osterville Pines -3040 Falmouth Road,Osterville, MA BUILDING "H"
Property Address
Multiple Owners
Owner Owner's Name
information is Osterville MA 02655 03120119
required for every �
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes 0 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 On
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.):
Box was structurally sound and watertight and providing even distribution of effluent into
SAS.Carryover was moderate.There are no repairs recommended at this time.
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
Osterville Pines-3040 Falmouth Road, Osterville, MA BUILDING "H"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville; MA 02655 03/20/19
page. City/Town 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:
Z 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
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Osterville Pines-3040 Falmouth Road,Osterville, MA BUILDING "H"
Property Address
Multiple Owners
Owner Owner's Name
information is Osterville MA 02655 03/20/19
required for 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.):
There was no surface wetness or breakout observed There were no signs of hydraulic failure
observed.SAS a __ ...
ppeared to be in proper working order.Top of pit is down approxim 1.ately 72"
with cover 4" below grade.There are no repairs recommended at this time.
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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Osterville Pines-3040 Falmouth Road,Osterville, MA BUILDING"H
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02655 03/20/19
page. Citylrown State Zip Code Date of Inspection
D. System Information (cost.)
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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Osterville Pines-3040 Falmouth Road, Osterville, MA BUILDING"H"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville, MA 02655 03/20/19
page. City/Town State Zip Code .Date of Inspection
D. System Information (cont.)..
14. Sketcfi 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:
0. hand-sketch in the area below
❑ drawing attached separately
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t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
c Commonwealth of Massachusetts
�d - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Osterville Pines-3040 Falmouth Road,Osterville, MA BUILDING "H"
Property Address
Multiple Owners
Owner Owner's Name
information is Osterville MA 02655 03/20/19
required for every +
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
El Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: SEE BELOW
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
El Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
Previous inspections.
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
During previous inspections the high groundwater was indicated to be 22' below grade.This
determination was by USGS groundwater maps. It was by this non-intrusive method that it
was estimated that separation exists from the bottom of the SAS and the seasonally high
ground water elevation.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doe•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
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "H"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville, MA 02655 63/20/19
page. CitylTown 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.
Z. B. Certification: Signed& Dated and.1, 2, 3, or4.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
Accessed USGS maps
............ ....: ...........
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t5insp.doc•rev:7/26/2018 -r- T Title 5 Official Inspet:tion Form:Subsurface Sewage isposar5ystem•175ge 18 or 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
;M Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "H"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02655 09/18/14
page. Cityfrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer, U
use only the tab 1. Inspector:
key to move your
cursor-do not Paul W. Davis
use the return Name of Inspector
key.
Rosano Davis Sanitary Pumping, Inc.
Company Name
9 Rocky Lane
Company Address
r Cohasset MA 02025
City/Town State Zip Code
781-383-8888 SI49
Telephone Number License Number
B. Certification
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 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:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluatio b the Local Approving Authority
09125/14
Inspector's"nature 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 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.
****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.
L" 1
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�M Osterville Pines-3040 Falmouth Road, Osterville, MA BUILDING"H"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville, MA 02655 09/18/14
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) 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:
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.
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):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "H"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02665 09/18/14
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.) '
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled 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):
C Further Evaluation is Required
q ed 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.
1. 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:
❑ 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
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"H"
Property Address
Multiple Owners
Owner Owner's Name
information is Osterville MA 02655 09/18/14
required for every �
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
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 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.
3. Other:
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 cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than day flow
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
wM Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"H"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02655 09/18/14
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® 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 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 2000gpd-
10,000gpd.
❑ ® 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.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
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
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section 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.
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
f
Commonwealth of Massachusetts
a v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Osterville Pines -3040 Falmouth Road,Osterville, MA BUILDING "H"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville, MA 02655 09/18/14
page. CityTrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
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)]
D. System,Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 gpd
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "H"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02655 09/18/14
page. Cityfrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: Unknown
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail
Water meter readings were not available at time of inspection.
Sump pump? ❑ Yes ® No
Last date of occupancy: Building
occupied.
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
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�M Osterville Pines-3040 Falmouth Road,Osterville, MA BUILDING "H"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02655 09/18/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Condo Association on semi-annual pumping
schedule.
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1,000 gallons
gallons
How was quantity pumped determined? Sight glass on pump truck.
Reason for pumping: To determine structural integrity and
watertightness of septic tank.
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):
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Osterville Pines -3040 Falmouth Road,Osterville, MA BUILDING "H"
Property Address
Multiple Owners
Owner Owner's Name
information is Osterville MA 02655 09/18/14
required for every �
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Previous inspections indicated installation in 1997 by Bortolotti.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 12"feet
Material of construction:
❑ cast iron ®40 PVC ® other(explain): Schedule 40 PVC inlet pipe.
Distance from private water supply well or suction line: No known wells in immediate
area.
Comments(on condition of joints, venting, evidence of leakage, etc.):
Inlet pipe appeared to be clean and flowing freely. No evidence of leakage.
Septic Tank(locate on site plan):
Depth below grade: 6"w/covers to grade on inlet and
outlet.
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
Precast concrete septic tank.
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
4.5'wide X 5'deep X 9' long.
Sludge depth:
2"
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M Osterville Pines -3040 Falmouth Road,Osterville, MA BUILDING"H"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02665 09/18/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
34"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
4"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined?
Measured with a tape.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Septic tank was pumped at time of inspection.Tank was structurally sound and watertight and
all effluent levels were at an appropriate height. Inlet and outlet tees are in place.There are no
other repairs recommended at this time.
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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"H"
Property Address
Multiple Owners
Owner Owner's Name
information is Osterville MA 02655 09/18/14
required for every �
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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
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
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M Osterville Pines-3040 Falmouth Road, Osterville, MA BUILDING "W
Property Address
Multiple Owners
Owner Owner's Name
information is Osterville MA 02655 09/18/14
required for every �
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Box was structurally sound and watertight and providing even distribution of effluent.
Carryover was moderate.There are no repairs recommended at this time.
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.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3113 Title 5 Official Inspection Form:Subsurface •Sewage Disposal System Page 12 of 17
P Y 9
f
Commonwealth of Massachusetts
Title 5 Official Inspection Forma
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"H"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02655 09118/14
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
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:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
There was no surface wetness or breakout observed.There were no signs of hydraulic failure
observed. Leach pit is 72"deep and was dry at time of inspection. SAS appeared to be in
proper working condition. Cover is 4" below grade.There are no repairs recommended at this
time.
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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M Osterville Pines-3040 Falmouth Road, Osterville, MA BUILDING "H"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02665 09/18/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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.):
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts i
-Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "H"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville, MA 02655 09/18/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont)
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
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t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "H"
Property Address
Multiple Owners
Owner Owner's Name
information is Osterville MA 02655 09/18/14
required for every �
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: SEE BELOW
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:
Previous inspections.
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
During previous inspections the high groundwater was indicated to be 22' below grade.This
determination was by USGS groundwater maps. It was by this non-intrusive method that it
was estimated that separation exists from the bottom of the SAS and the seasonally high
groundwater elevation.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
,M ,•a''� Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"H"
Property Address
Multiple Owners
Owner Owner's Name
information is Osterville MA 02655 09/18/14
required for every �
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
Acdessed USGS maps
rt
L
1
lcc,�ILD VS�`'K
' I-4�f.N URevYJh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System F rm -Not for Vol ntary Assessments
Osterville Pines -3040 Falmouth Road, ^-••"' MA. BUILDING "W
Property Address `
Multiple Owners
Owner Owner's Name
information is •;��
required for every t^p e MA 02655 03/02/11
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not'be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer, � 5�
use only the tab 1. Inspector:
key to move your
cursor-do not Paul W. Davis
use the return Name of Inspector
key.
Rosano Davis Sanitary Pumping, Inc.
Company Name
9 Rocky Lane
Company Address
Cohasset MA 02025
City/Town State Zip Code
781-383-8888 S149
Telephone Number License Number
B. Certification
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 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:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
03'/15/11 '
Inspector's Signa ure 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 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.
****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.
t5ins-ogioe Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Se4Ds SystAm• ge 1 of 17
1
Commonwealth of Massachusetts .
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,M Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "H"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02655 03/02/11
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes: f
® I have not found any information.which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.'Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or 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 F❑ ND (Explain below):
! , ♦ S
f
F ,
t5ins•ogioa Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"H"
Property Address
Multiple Owners
Owner Owner's Name
information is Osterville MA 02655 03/02/11
required for every '
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced - ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled 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):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-ogioe Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M s Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "H"
Property Address t
Multiple Owners
Owner Owner's Name
information is Osterville MA 02655 03/02/11
required for every
page. Cityrrown State Zip Code Date of Inspection .
B. Certification (cont.)
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 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 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.
3. Other:
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
.❑ d ® 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 cesspool
❑e; �. Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
t5ins•ogioa Rosano Davis Sanitary Pumping,inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts i
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
` k
Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "H"
Property Address
Multiple Owners
Owner Owner's Name
information is Osterville MA . 02655 03/02/11
required for every. '
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No ,
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
El ® 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 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 2000gpd-
10,000gpd.
❑ ® 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.
For large systems, you must indicate either"yes or-'no"to each of the following, in addition to the
questions in Section D. '
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
If you have answered "yes"to any question in Section E the system is considered a significant threat;
or answered"yes" in Section 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.
t5ins-ogio8 Rosano Davis Sanitary Pumping,Inc 781-383-8888 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
b
I!
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
;M s Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "H"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02655 03/02/11
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
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?
El
® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® 0 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:
® ❑T Existing information. For example, a plan at the Board of Health.
® 0 Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information '
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 gpd.
t5ins-ogio6 Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
s
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"H"
Property Address
Multiple Owners
Owner Owner's Name
information is Osterville MA 02655 03/02/11.
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: Unknown.
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)):
Detail: ,
Water meter readings were not available at time of inspection.
Sump pump? ❑ Yes ® No
Last date 03/02/11 -of occupancy: Building occupied.
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Canons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
.Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins°ogjos Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"H"
Property Address
Multiple Owners
Owner Owner's Name
information is ,
required for every Osterville MA 02655 03/02/11 '
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Condo Association on yearly maintenance
schedule.
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1,000 gallonsgallons
How was quantity pumped determined? Sight glass on pump truck.
Reason for pumping: Yearly maintenance&to determine structural
integrity &watertightness of septic tank.
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):
t5ins•o9io8 Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
•
Commonwealth of Massachusetts
Title 5 Official Inspection Form.
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "H"
Property Address
Multiple Owners `
Owner Owner's Name
information is Osterville MA 02655 03/02/11
required for every '
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and,source of information:
Installed by Bortolotti in 1997 per previous inspection.
Were sewage odors detected when arriving at the site? - ❑ Yes ® No.
Building Sewer(locate on site plan):
Depth below grade: 12"
feet
Material of construction:
❑ cast iron ® 40 PVC other(explain): Schedule 40 PVC inlet pipe.
❑
Distance from private water supply well or suction line: No known wells in area.
feet
Comments(on condition of joints, venting, evidence of leakage, etc.): .
All piping appeared to be clean and flowing freely. No evidence of leakage.
Septic Tank(locate on site plan):
Depth below grade: 6"w/covers to grade on inlet&
outlet.
• Material of construction-*
- ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
Precast concrete septic tank.
If tank is metal, list age: years
•
Is age confirmed by a Certificate.of Compliance?.(attach a copy of certificate) ❑.Yes ❑ No
Dimensions:
4.5'wide X 5' deep X 9' long.
2"
Sludge depth:
t5ins.09/08 Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M s Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "H"
Property Address
- Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02655 03/02/11
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
3411
Distance from top of sludge to bottom of outlet tee.or baffle
Scum thickness y 2".
Distance from top of scum to top of outlet tee or baffle 4"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? Measured with a tape.
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Septic tank was pumped at time of inspection.,Tank was structurally sound and watertight and
all effluent levels were at an appropriate height. Inlet and outlet tees in place. There are no repairs
recommended at this time.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
a
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
t5ins•09/08 Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "H'.
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02655 03/02/11
Cit /Town State, Zip Code Date of Inspection
page. Y P P
D. System Information (cony)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tighe 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
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.):
k
*Attach copy of current pumping contract(required). is copy attached? ❑ Yes. ❑ No
t5ins•ogioe Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17.
Commonwealth of Massachusetts
Title 5 Official Inspection Form =
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"H"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02655 03/02/11
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) . F
Distribution Box(if present must be opened) (locate on site plan):
011
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.):
Box was structurally sound and watertight and providing even distribution of effluent.
Carryover was moderate. There are no repairs recommended at this time
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.):
• I
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•ogioa Rosano Davis Sanitary Pumping,Inc, 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
GM , Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"H"
Property Address
Multiple Owners ry
Owner Owner's Name
information is required for every Osterville MA 02655 . 03/02/11
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type: e
® leaching pits number:
1 -leaching pit.
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ -leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
There was no surface wetness, breakout or signs of hydraulic failure observed.,Leaching pit is
72"deep and was dry at time of inspection.There is 60"of available capacity. Cover is 4" below
grade. Leaching appears to be in proper working condition. There are no repairs recommended at
this time.
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 r
Depth of scum layer rt
Dimensions of cesspool'
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•ogios Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "H"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02655 03/02/11
page. Cityrrown State Zip Code Date of Inspection
D. System Information(cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
} e
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
A
� s
i
Y
t5ins•ogioa Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Osterville Pines -3040 Falmouth Road, Ostervilie, MA BUILDING "H"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02655 03/02/1.1
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
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
{
t
� u;
Ll
B-
(�I
0-t3ex 03
411
t5insl•ogioe Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°�M s Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING 'H'•
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02655 03/02/11
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.) ,.
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar ,
❑ Shallow wells .
F. SEE BELOW
Estimated depth to high ground water: 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:
Previous inspections.
❑ Checked:with local excavators, installers-(attach documentation)
❑ i Accessed USGS database-explain:
You must describe how you established the high ground water elevation: a
During a previous inspection the high•groundwater was indicated to be 22' below grade. This
determination was by USGS groundwater maps. It was by this non-intrusive method that it was
estimated that separation exists from the bottom of the.SAS and the high groundwater.
}
.t
` Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•ogm Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
y ,
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "H"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02655 03/02/11
page. Citylrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
Accessed USGS maps r
I • ;
r
� .
t5ins•t09/OS Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
COMMONWEALTH OF MASSACHUSETTS
w
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS T0`Nk n Or OARINSTAK
c DEPARTMENT OF ENVIRONMENTAL PROTECTION ra
0G5 MAP 29 PM 3: 5
;AP
''ARCEL r O�� DIVISION
.LOT
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 3040 Falmouth Road,Osterville Pines,Bldg H �Ov
Owner's Name: Osterville Pines Condo Trust,c/o Huntingest Management
Owner's Address: 40 Industry Rd,Marstons Mills,MA 02648
Date of Inspection: 02/20/05
Name of Inspector:Brian T.Axon
Company Name:A&K Septic Systems Plus
Mailing Address: 565 Carriage Shop Road,East Falmouth,MA 02536
Telephone Number: 508-540-6706
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of 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:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: 03/08/05 ,
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 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: System functioning fine. There is no evidence of failure criteria. System consists of 1000
gallon tank with d-bok and 1000 gallon precast leaching pit.
****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. '
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:3040 Falmouth Rd,Osterville Pines,Bldg H.
Owner: Osterville Pines Condominium Trust
Date of Inspection: 02/20/05
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303
or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass" section need to be replaced or
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:
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:
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
obstruction is removed
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS' .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 3040 Falmouth Rd,Osterville Pines,Bldg H
Owner: Osterville Pines Condominium Trust
Date of Inspection: 02/20/05
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if 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 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:
M .,
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 3040 Falmouth Rd,Osterville Pines,Bldg H
Owner: Osterville Pines Condominium Trust
Date of Inspection: 02/20/05
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
x Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
x Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
x Liquid depth in cesspool is less than 6"below invert or available volume is less than'h day flow
x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
x Any portion of the SAS,cesspool or privy is below high ground water elevation.
x Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
x Any portion of a cesspool or privy is within a Zone 1 of a public well.
x Any portion of a cesspool or privy is within 50 feet of a private water supply well.
x 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.]
no (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 indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above).
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 H 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 Section D above the large system has failed. The owner or operator of any large system considered a
Page 5 of 11
15.304. The system owner should contact the appropriate regional office of the Department.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:3040 Falmouth Road,Osterville Pines,Bldg H
Owner: Osterville Pines Condominium Trust
Date of Inspection: 02/20/05
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
X _ Pumping information was provided by the owner, occupant,or Board of Health
x ere any of the system components pumped out in the previous two weeks?
x , Has the system received normal flows in the previous two week period?
x Have large volumes of water been introduced to the system recently or as part of this inspection?
x Were As Built plans of the system obtained and examined?(If they were not available note as N/A)
x Was the facility or dwelling inspected for signs of sewage back up?
x _ Was the site inspected for signs of break out?
x Were all system components,excluding the SAS, located on site?
x _ 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?
x _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
x _ Existing information.For example, a plan at the Board of Health.
x _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[310 CMR 15.302(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 3040 Falmouth Road, Osterville Pines,Bldg H
Owner: Osterville Pines Condominium Trust
Date of Inspection: 02/20/05
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual) : 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
Number of current residents: 3
Does residence have a garbage grinder(yes or no): no
Is laundry on a separate sewage system(yes or no):no[if yes separate inspection required]
Laundry system inspected(yes or no): no
Seasonal use: (yes or no):no
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no): no
Last date of occupancy: current
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CM[Z 15.203): gpd
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: system on regular maintenance schedule
Was system pumped as part of the inspection(yes or no):no
If yes,volume pumped:,How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X Septic tank, distribution box, soil absorption system
Single cesspool
_Overflow cesspool
—Privy
_Shared system(yes or no)(if yes, attach previous inspection records,if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information: 1997,installed by Bortolotti
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 3040 Falmouth Road,Osterville Pines,Bldg H
Owner: Osterville Pines Condominium Trust
Date of Inspection: 02/20/05
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction:_cast iron _40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting, evidence of leakage, etc.):
SEPTIC TANK x (locate on site plan)
Depth below grade: 6"
Material of construction: x concrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age.-_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 8.5'x 6' x 5'
Sludge depth:I"
Distance from top of sludge to bottom of outlet tee^or baffle: 34""
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 3""
Distance from bottom of scum to bottom of outlet tee or baffle:9"
How were dimensions determined: field instruments
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):Recommend pumping every two years. Structural integrity is
fine.Liquid levels in relation to tees are fine. There is no evidence of leakage.1000 gallon septic tank to within 6"of
grade
GREASE TRAP: NA(locate on site plan)
Depth below grade:
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:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
f
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:3040 Falmouth Road,Osterville Pines,Bldg H
Owner:Osterville Pines Condominium Trust
Date of Inspection: 02/20/05
TIGHT or HOLDING TANK: NA (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/day '
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOX: X (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: at working level
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.):Distribution box is at working level.No sign of solids carryover or any evidence of
leakage.
PUMP CHAMBER: NA(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.):
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATION(continued)
Property Address:3040 Falmouth Road,Osterville Pines,Bldg H
Owner: Osterville Pines Condominium Trust
Date of Inspection: 02/20/05
SOIL ABSORPTION SYSTEM(SAS): x (locate on site plan,excavation not required)
If SAS not located explain why:
Type
X 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:
Comments(note condition of soil, signs of hydraulic failure;level of ponding, damp soil,condition of vegetation,
etc.): 1000 gallon precast leaching pit. Cover is to within 6"of grade and top of pit is roughly 18"to grade
CESSPOOLS:_NA (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 or no):
Comments(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,etc.):
PRIVY: NA (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.):
R
Pa' e10of11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:3040 Falmouth Road,Osterville Pines,Bldg H
Owner: Osterville Pines Condominium Trust 4
Date of Inspection: 02/23/05
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.
A g
Ll
. O •
3 0 '
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued).
Property Address: 3040 Falmouth Road,Osterville Pines,Bldg H
Owner: Osterville Pines Condominium Trust
Date of Inspection: 02/20/05
SITE EXAM
Slope
Surface water
Check cellar
-Shallow wells
.Estimated depth to ground water 22 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS).
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
x Accessed USGS database-explain:
You must describe how.you established the high ground water elevation:
Accessed USGS maps
WVA Lam PDSOS';`;'
ht� H C�RcvrJ�)
i
LIN COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE.OF ENVIRONMENTAL AFFAIRS
a DEPARTMENT OF ENVIRONMENTAL PROTECTION
A RECEIVE®
a
MAR 0 4 2002
TOWN OFBARNSTABCE
HEALTH DEPT,
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
•
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION,
Property Address:. a ��� PJ�[Pn -k2 0J
Owner's Name: ,Erb
Owner's Address
Date of Inspection:6zi Ahjj PEA.,& `7,04.)l r.,
Name of Inspector: please print) l ;T• P��,Dy'f1 M
Company Name
Mailing Address: PANM •
Telephone Number: &.:7'7✓ qr C/� LOT
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,.accurate and complete as of the time of 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 DE
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.00.0). The system:
V Passes
Conditionally Passes
4Fas,
ds.Further Evaluation by the Local Approving.Authority
. � .
Inspector's Signature: / , ` —~ Date: `(/d
ell—
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health.or
DEP)within 3.0 days of completing this inspection. If the system is a shared system or has a.design flow of I0,000_
d and tg ,. he 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
I
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system Will.perform in the future under the.same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11 „
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE'`SEWAGE DISPOSAL SYSTEM:INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address . ua, I)o
61
c `
Owner
Date of Inspection:
Inspection Summary: Check AAC,D or E/ALWAYS complete all of Section D
A. System Passes:
I'have not found any information which indicates that.any ofthpjailur.e criteria described in 3;10.CMR
15.303 or in 316 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System.Conditio;�&Passes:
a�:N�
One orb ,Perri components as described in the"Conditional Pass"section need to be replaced or
""repaire . e system,t completion of the replacement or repair, as approved by the Board of Health,will pass.
y
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.comp lying 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:
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:
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
obstruction.is removed.
ND explain: .
2
Page 3 of 1•I
OFFICIAL INSPECTION FORM -_NO.T.FOR'VOLUNTARY'ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address ' _ = `a - d'C c o
Owner: err
Date of Inspection:�--�mv��@'4r �Q.-I--
C. Further Evaluation is Required-by the Board of Health:
Conditions.exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless.Board of Health determines in.accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which.will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
I System will fail unless the Board of Health(and Public Water Supplier,'.if any)determines that the
system is.functioning inz 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'I 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,aseptic 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 ata DEP certified laboratory,,for coliform
bacteria and volatile organic compounds indicates that the-well is f;ee 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•copyofthe analysis must be attached to this form.
3. Other:
3
Page 4 of 11
QFFICIA ,.'INSPECTIONYORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.A
CERTIFFCATION(continued)
Property Address:
Owners fiVj
'lr � iv�
Date of Inspection: /o�)O
D. Systein.Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the-following for all inspections:
Yes No
1/ 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
itclogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded.or.clogged SAS or
/cesspool
V Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
l/ Any portion of the. SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within100 feet of a surface water supply or tributary to a surface
water-supply,
_ ✓ Any.portion of a cesspool or privy is within a Zone 1.of a public well.
Any portion of a cesspool or privy is within 50.feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but:greater than 50 feet from a private water
supply well-with no acceptable water quality analysis. [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.am.monia
nitrogena,nd nitrate nitroben.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 for
(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 indicate either"yes"or"no":to each:of the following:
(The following criteria apply to large°systems in addition to the criteria above)
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
If you have answered"yes"to any question in Section E the system is considered a significant threat;or answered
"yes" in Section 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 1.1
OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY AS
SUBSURFACE SEWAGE`DISPOSAL SYSTEM INSPECTION FORM
PART B" .
CHECKLIST
Property Address: Yf .
Owner:
Date of Inspection:Y
Check if the following have been done You must indicate"yes"or"no"as to each of the following:
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 7,
Was.the facility owner(and occupants if different from owner).provided with information on the proper
I
aintenance of subsurface sewage disposal systems
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
Existing.information.For example,a plan.at the Board of Health:
_t;�_ Determined in the,field(if any of the failure criteria related to Part C.is at issue.approximation of distance
is unacceptable)[310 CMR 15.302(3)(b))
5
Page 6 of_11
OFFICIAL INSPECTIOMFORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DTS.POSAL SYSTEM INSPECTION`:FORM
PART C
SYSTEM INFORMATION
. Property Address:'Z ,
e
Owner:
Date of Inspection: CItIc�
'Alvl-
"PLOW CONDITIONS
RESIDENTIAL'
Number of bedrooms(design):: Number of:bedrooms(actual):
DESIGN flow based'on 310 CIv1R 15.203 (for example: 11:0 gpd x#of bedrooms): c7c?�
.-Number of current residents: ',LJ
Does residence.have.agarbage-grinder(yes or no);/��"
Is laundry on a separate sewage'system (yes or no) p f if yes separate inspection required]
Laundry system inspected(yes or no 10
Seasonal use: (yes or no)� �g-..
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no):
Last date of occupanc - .' �2 �112�,ql o
COMMERCIAUINDUSTRIAL CQ�'
Type of establishment;
Design flow(based on 310 CIv1R:15,203): gpd
Basis of design flow(seats/personslsgft,etc.):
Grease trap present(yes or no):_
Industrial waste.holding tank present(yes or no):—
Non-sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER,(describe):
GENERAL INFORMATION
Pumping Records
Sourceof information:,
Was system.pumped as:part of the inspection(yes.or no): ��
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason'for.pumping: .
TYPE OF SY.STEIGI
ptic tank,distribution box,soil absorption system .
Single cesspool
_Overflow cesspool
Privy
Shared system(yes or no)(if yes, attach previous inspection records,if any)
Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be,
obtained from system owner)
_Tight tank —Attach a copy:of the DEP.approval
—Other`(describe):
proximatepo �Io onepts,date i stalled if.kno m},and source of information;
9 v :
Were sewage odors'detected when arriving at the site(yes or no): w
6
'Page7 of 11
OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE;SEWAGE DISPOSAL SYSTEM INSPECTION'FORM
PART C
SYSTEM INFORMATION;(continued)
Property Address, �'y /tad '
Owner: 1W jve7
Date of Inspection: 444ZO _hoc)
BUILDING SEWER(locate on site,plan�410' ;.
Depth below grade:
Materials of.construction: cast iron 40 PVC other(explain):
Distance from.private water supply well or suction line: ,_..
Comments(on condition of joints, venting,evidence of leakage, etc.):
SEPTIC TANK: v/ -(locate on site plan)
Depth below grade:,C.p
Material of construction: concrete_metal_fiberglass polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):-(attach a copy of::
certificate)
Dimensions: g•S�X(�' k °
Sludge depth: A
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:t �T j�A�z% 9�f2II�i,2c o/7a'i
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural..integrity, liquid levels
s related to outlet invert, evidence of leakage,etc.
GREASE TRAP 664ocate on.site plan), ,
Depth below grade:
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:
Comments(on pumping recommendations, inlet`and outlet tee or baffle condition;structural integrity, liquid levels
as related to outlet invert,evidence.of leakage;etc.):
Page 8 of 1 l
OFFIChAL_INSPECTION.FORM—NOT FOR rVOLUNTARYIASSESSMENTS
SUBSiJRFACE'SEWAGE DISPOSAL`SYSTEIVI INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address ' l�•4i • &2 -^
Date of Inspection:
TIGHT or HOLDING TANS -(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction:.. concrete. metal i fiberglass, polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm'in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc,):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
k/
Depth of liquid level above outlet invert 'aL��
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
kage into or out of box, eADO tc.
r i. i Q.
PUMP CHAMBER% ocate 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.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART. C
SYSTEM INFORMATION(continued)
Property Address:. i`
Owner: 17r [
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): locate on site plan,excavation not required)
If SAS,not located explain why:
Type
aching.pits,number:.—t
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool, number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure,level of ponding, damp soil;condition of vegetation,12
,
acy it 9
i
CESSPO.OLG: djh-(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 or no):
Comments(note condition of soil, signs of hydraulic failure, level of ponding,'condition of vegetation,.etc.):
PRIVY ,Tecate 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.):
9
Page 10 of H.
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE 3)ISPOSAL`:SYSTEM'INSPECTION`FORM
PART C
SYSTEM INFORMATION(continued)
Property Address A
Owner:
Date of Inspection.
SKETCH OF SEWAGE DISPOSAL.SYSTEM
Provide a sketch of the sewage disposal system.including ties to at least two permanent reference_landmarks or
benchmarks. Locate all wells within ]00 feet. Locate where public water supply enters the building.
Y)
O
10
Page 11 of 11
OFFICIAL INSPECTION FORM,—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_' `
"Owner: ,
Date of Inspection:
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:
Obtained from system desi&n plans on.record-If checked;date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)` .
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USG S.database=explain:`
You.must describe how you established the high ground.water elevation: .
e, '/' ►
11
ermiz Number Date
Corn d bv: ;
T_ L=�/_(_ CC(Vi�t�t',A I'I0N.
- - - - -
Site Location:
Lot No
Owner: Altz.L -t G ;y :ddres;;
r. Contractor: O. Address:
Notes:
STEP .1 Me
asare oeotn to water ble
•
::. to nearas� ....................... -
Q�
STEP 2 Using.Water-;Level.Rance Zone
and Ind'z Well Map locate
site and d termine;
4. Aporopria[e index, well..........................
B Water level ranae Zone .._.
...................... l
STEP 3 Using monthly repot `Current
Water Resources Conditions" I
dkermine current dec h•to
water level Jor index well
I :
rrianth/Year i
S P "C Using, OD{4'0I G/� J 1 C T
VVo r I � ! A d Lstm n s
for ind er well (c a EP 2A),cu{current depth
to wa�ar level Iar-Find=x well.,(S 2P'3}.,
and water-lev ! zone (S{E 23} '
oetermine.wa er'lev.el adjustnnent ,.:.: ..._:..:. .. . :_... __._..::.. �...:..: ._...__.. .-:........ .....
ri
STEP cP :o Estimate depth,to hi.ah,water
Dy's(1b2ractina the water-
level adjustment'(STEP 4)
prom measured depth to way r
_ L
evel°at stye (STEP_; 1} ....._:.....
i=ioure 1 L.=-Recrodvucbl?CO{.{putatiOn io fit:'
r
j
TOWN OF BARNSTABLE
LOCATION <70 yO Nt WAGE #
VILLAGE 6S<ILU� ASSESSOR'S MAP & LOT 031
iure'r AT t VD IQ u A 11 V c nunwuv u�
. .. ',I' i(\.V.iAVr(S(\',V •\(1 Yi Li .� l /(\:./.(\,Li 1•V• 1�" • v. Y'
SEPTIC TANK CAPACITY
LEACHING FACILITY: T (size)
NO. OF BEDROOMS "- PRIVATE WELL OR<ZVBLIC WATE
BUILDER OR Wes - A
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
I
r
I
O
5�
�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH AS 4V
l-w F�
TOWN OF BARNSTABLE �
Apphratiou for Binpnial Wur1w Tomitrurtion runfit
Application is hereby made for a Permit to Construct ( ) or Repair b4) an Individual Sewage Disposal
System at:
di
...y--------------------------------------------------------------------- _--- -------------------_- ------------------------------ --.----•----................
Location-Address or Lot No.
Ow er Address
w ` e `....'.....-------Cap 2J.......rr ----..... ... .......................Y_.__�...,.---✓t-.-k--- -----------------
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling— No. of Bedrooms______________ ------------------Expansion Attic ( ) Garbage Grinder (_--}-!t3
Pk Other—Type of Building ___________________________ No. of persons______-__________..._____- Showers ( ) — Cafeteria ( )
Q' Other fixtures ------------------------------------------------------
W Design Flow............. -------------------gallons per person per day. Total daily flow----------- -------------------gallons.
1:4 Septic Tank—Liquid capacity/0-0__-gallons Length---------------- Width______________- Diameter-----._.._ ..... Depth................
Disposal Trench—No. .................... Width.................... Total Length-------_----t------- Total leaching area....................sq. ft.
3 Seepage Pit No.---------/-------- Diameter__---_lam:....... Depth Depth below inlet------ .......... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by_....................................................................... Date........................................
Test Pit No. 1________________minutes per inch Depth of Test Pit_.................. Depth to ground water........................
GX4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water..........___________-_-
P4 -------------•------------------------------------------------------------------------•----------...........................................................
ODescription of Soil.........................................................................................................................................................................
W
U .........................................................-..............................................................................................................................................
W
U Nature of Repairs or Alteratio —Answer when applicabl .).M.'-�5�j _ ------f(/Q.
—/�---,�-�7---------p�s' ......}�-• :' l Goo--- .-P%7-77 ....tn j. .......................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliant a�en b e board of health.
Slgned ........ ................... ....... ----- _..................... -`'1--" �' S
Date
Application,Approved BY ::: . � ............ �-:'•-a�. . -�
Application Disapproved for th 011o uing rearOn.r: -------------------------- ----------------------- ---------------------------- -----------------------------------------
........ ................................................... .. ........._:................ ..._...._ -- ........................................... -----------------------------.-------
Date
Permit No. ..............°/ ' _ ...����....... Issued ..... ....e�-r o --------- t. ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Tex#ifiett#e of Tomplinure
THIS IS TO CFIZT-IF-Y That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
-,�6(L—,i ti - >> Cu� /L v ram—' GtJ
by ........_._......... ---- ---------------------------- -- ------------------ . . ...----------------------------- ------.................------......------------------------------
- Insr.0lcr
j ---------------------------------------------
at ........----------------------
0' V �L.v✓i�J-�...-- - /IO -i�-�^�1 i tJ�ti1 �i. �
- ..
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ---5...a-----t1`r�-. . -------- dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE---- P------ ------------------------------ ----- Inspector ---- -, .------- ----- --------------- ------ ---------------..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
N .........
.::. FEE... (............
MsVviittl_ nrh,5 Tumfrur#aan rrrntit
Permission is hereby granted------------------f. 'r._IJ.C�1?------------ ........................................
to Construct ( or Repair an Individual Sewage Disposal System
at No............... ------ ............f-�G.�_D- / f �r_�, -��-s---/--
Street O
as shown on the application for Disposal Works Construction Permit No.1,�___ya. - Dated..-.�
qq�/ Board of Health
DATE................ -----------------------------
FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS
No......1._S_....._.-� Fxs.................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH VA4, r�Vj- t
I w f` LV_
TOWN OF BARNSTABLE
Apphration for- Diiiipw al Morkii Tnnitrnrtinn frrnnit
Application is.hereby made for a Permit to Construct ( ) or Repair (-,/—) an Individual Sewage Disposal
System at:
D D �i O IL'i 14 IfQ A4 )LTU),J S L.b 6-) 0 ll(l
--------------•----•-----------•------------•-----------------------------............. ••--••--------•--------•-••-----••----•-•--•----•--•---••---=-•-•....-•••----••--•••......--•.....
Location- �.'
h 1 l //V t� z:Address ....Q G'�Q{�+ C�+rr/�✓�or I of N M Am t 1 L.4 .......
Owner Address
------------------------------------------- ........ ............ 1 ..........r `1
Installer Address
UType of Building Size Lot............................Sq. feet
.., Dwelling— No. of Bedrooms........................................___Expansion Attic ( ) Garbage Grinder
0.4.4 Other—Type of Building ____________________________ No. of persons..-- _.__.--_____-____.._-__ Showers ( ) —'Cafeteria ( )
04 `f Other fixtures -------------------------------------------------------------------------•------------- --------------------•-------------•--------•-----•-----------
W Design Flow..............9S- .....................gallons per person per day. Total daily flow...____.._— ..................gallons.
WSeptic Tank—Liquid capacity A_0.o__gallons Length---------------- Width................ Diameter..-------------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length-------____.�....... Total leaching area.........._.........sq. ft.
' Seepage Pit No........_/-------- Di`meter---, -_-.-- Depth below inlet----- Total leaching area..................sq. ft.
Z Other Distribution box , sing tank�( �t) f f
aPercolation Test Results -Performed/by 1 ----------------------•---------. ...•-- Date...
Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water......................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a --------•----------------------------------------------•-•••----•-•----•-•----•......--------•-••...---•-----------•••........ `
-
0 Description of Soil............................................................................................................................................-• ••-••-......---••-•---
x
c,
UW ---------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------
Nature of Repairs or Alterations—Answer when applicabl .-._.1.-M.� ----- -._.._/vljQ.!J ...... %7G_
--..724 - 4 --------- r 5--'-- ..... i�G 'L c'�� - -. res :
�'f f
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance/has been iss b t e board of health.
Signed ......--1.......... ................. -- ----- ..--...� ,/�,
-
Daze
Application.Approved BY --- ------- - - ------- Gt.,*P -� - - - -------�_!�2 .__9...`I..
Dare
Application Disapproved for the ollowing reasons;
............................... - . .... - - - - - - - - -
..-----------.---------------- --- ----- ----- ---- -------------- ------ ------- --------- -----
y Dace _
Permit No. --------------
�� - ----tl ... Issued ------------ - c'?..-. ��.
`Y Dare
[ � "1