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Commonwealth of Massachusetts
Title 5 Official- Inspection Form
! i Subsurface Sewage Disposal System•Form -Not for Voluntary Assessments a
28 Galahad Cir
Property Address r '
Joann Desrochers
Owner Owner's Name
information is
required for every Osterville -t - MA 02655 5-7-20 '
page. City/Town a 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.
ej
r.
A. Inspector Information
.Shawn Mcelroy
Name of Inspector . , „� ,• •,. t _ ,
Upper Cape Septic Services - ' • "
Company Name t"'
P.O. Box 73 r
Company Address
East Falmouth , , MA r ,r 02536
City/Town State Zip Code
508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000);I have personally inspected the sewage disposal system at theproperty address listed
above;the information reported below is true, accurate and complete as of the time of my inspection; and
the inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.After conducting'this inspection I have determined that
the system: t '
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority k ,;3.
4. ❑ Fails
5-7-20 _
Inspector's Signature Date `
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 y
Commonwealth•of'Massachusetts
rip Title 5 Official Inspection Form
l i.) Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
W>` 28 Galahad Cir
Property Address
Joann Desrochers -
Owner Owner's Name
information is required for every Osterville MA 02655 5-7-20
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.
t
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:
System is in good working order with no sign of failure.
2) System Conditionally Passes:
4 ❑ One,or more system components as described in the "ConditionalPass" 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 existirig 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
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
._ ? 28 Galahad Cir ,
Property Address
Joann Desrochers
Owner Owner's Name
information is Osterville is MA 02655 5-7-20
required for every -
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired. - I
o
❑ 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):
' 4
❑ 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 El ❑ ND (Explain below):
❑ obstruction is removed ❑Y ❑N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:-. -• i
❑ 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 orthe 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
3 Title 5 Official Inspection Form
I� ws•
<�i-I Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments'
28 Galahad Cir
J'
Property Address
Joann Desrochers
Owner Owner's Name
information is required for every Osterville MA 02655 5-7-20
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
El ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ®, Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts ,
hill 11, Title 5 Official Inspection Form
i.l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments,
28 Galahad Cir
Property Address
Joann Desrochers
Owner Owner's Name s
information is Osterville MA 02655 5-7-20
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.) t ,
4) System Failure Criteria Applicable to All Systems: (cont.) ,
Yes ..No
r' 0 ® Static liquid level in the distrbution_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
a than"/2 day flow '
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion.of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
Well. ,
❑ ® '#',A6y 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 adesign flow of 2000 gpd-
❑ ® 10,000 gpd. . .
❑ ®:*. The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
r system owner should contact the Board of Health to determine what will be
.necessary to correct the failure. , .•r -
5) Large Systems:To be considered a large system the system must serve a facility with a design
flow of 10,000 gpd to 16,000 gpd. 'U
For large systems, you must indicate either"yes",or`,'no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is Within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
y Title 5 official Inspection Form
_ „
I i Subsurface Sewage Disposal System Form Not Voluntary Assessments
9 p
y rY
�r-
28 Galahad Cir
Property Address
Joann Desrochers
Owner Owner's Name
information is required for every Osterville MA 02655 5-7-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is'considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for aU inspections:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
`® ❑ Was the site inspected for signs of break out?
® ❑ Were'all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Wasthe facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® E Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
,w Title 5 Official Inspection Form
i i Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments -
W
28 Galahad Cir
Property Address
Joann Desrochers
Owner Owner's Name
information is
required for every Ostefville MA 02655 5-7-20
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): 3
DESIGN flowbased on 3.10 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
Number of current residents: 2
Does residence have a garbage grinder,?.," Yes ® No
Does residence have a water treatment unit? - _ , ., •3; s i ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry sy%em�inspection .,. El 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:
Sump pump? ❑ Yes ® No
Last date of occupancy: ^.,t 5-2020Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
c Commonwealth of Massachusetts '
Title 5 Official Inspection Form
wa
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Yii '
28 Galahad Cir
Property Address
Joann Desrochers
Owner Owner's Name
information is required for every Osteryille MA 02655 5-7-20
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 trapresent?
p El 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:
N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: --u
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts i
3 Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments °
28 Galahad Cir
Property Address
Joann Desrochers ,
Owner Owner's Name
information is Osterville MA 02655 5-7-20
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) r .
4. Type of System: ,
® Septic tank, distribution box, soil absorption system,
❑ Single cesspool , is
❑. , , 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 ii
❑ Tight tank. Attach a copy of the DEP approval. A
❑ ' Other(describe):
Approximate age of all components, date installed (if.known) and.source of information:
2004
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate,on site.plan): 4 -
Depth below grade: 36"
c feet
Material of construction: T
® cast iron ® 40 PVC ❑•other•(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Good condition.
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18•,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
w
iCbi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
•_ „>
.,_T.,. 28 Galahad Cir
Property Address
Joann Desrochers
Owner Owner's Name
information is required for every Osteryille MA 02655 5-7-20 '
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
30"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: •
1500 gal
Sludge depth: 1211
Distance from top of sludge to bottom of outlet tee or baffle
20" I'
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
6" �
Distance from bottom of scum to bottom of outlet tee or baffle
15"
How were dimensions determined? 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.):
Tank is in good condition with baffles installed and no sign of leakage.
4'
t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
i
Commonwealth of Massachusetts '
r� Title 5 Official Inspection Form
i6l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
/ 28 Galahad Cir
Property Address
Joann Desrochers
Owner Owner's Name
information is Osteryille MA 02655 5-7-20
required for every `
page. City/Town v State Zip Code Date of Inspection
D. System Information (cont.j
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: r
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 _v
Commonwealth of Massachusetts
a Title 5 Official Inspectionform'
'61i Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments
�� Irlp
28 Galahad Cir
Property Address
Joann Desrochers
Owner Owner's Name
information is required for every Osteryille MA 02655 5-7-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
Alarm present: ❑ Yes ❑ No '
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No,
9. Distribution Box (if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 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.):
Good condition with water at working level and no sign of back-up from field.
r t
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
t� 3 Title 5 Official Inspection Form
ri Subsurface Sewage Disposal System Form -Not for Voluntary,Assessments r
28 Galahad Cir y;
Property Address
Joann Desrochers
Owner Owner's Name
information is Osterville MA 02655 5-7-20
required for every '
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) -� _ , ..►
10. Pump Chamber(locate on site plan): ,
Pumps in working order: ' ' "t ❑ Yes ❑ No"
Alarms in working'order: '` { ` _` ` y ' `❑ 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):t ,
If SAS not located, explain why:
Type:
❑ 'leaching pits_' "number: '
® leaching chambers number:
3----3050's
❑ leaching galleries number:
❑ leaching trenches - number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 - Ttle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
c Commonwealth of Massachusetts
a 3 Title 5 Official Inspection Form
Fri Subsurface Sewage Disposal System Form =Not for Voluntary Assessments
1�. ?�`' 28 Galahad Cir
Property Address
Joann Desrochers
Owner Owner's Name
information is required for every Osterville MA 02655 5-7-20
page. _ City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.) A
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach chambers in good working order and empty at inspection with no sign of back-up into d-box or
surrounding stone.
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 MassachusettsJ, ,.
f, Title 5 Official Inspection Form;
hI Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments;
28 Galahad Cir
Property Address
Joann Desrochers
Owner Owner's Name
information is required for every Osterville MA 02655 5-7-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) s
13. Privy (locate on site plan):
Materials of construction: F ` '
Dimensions C
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): i
r
a ;
t
f
` a
•`Y
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
�- Title 5 Official Inspection Form
.�A 67C�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
28 Galahad Cir
Property Address
Joann Desrochers
Owner Owner's Name
required for
is Osterville MA 02655 5-7-20
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
G' � i V
"3 - 31
e%3 6
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System°Page 16 of 18
Commonwealth of Massachusetts rx
Title 5 Official Inspection Form~
�i Subsurface Sewage Disposal System Form Not for$Voluntary Assessments
z ,> 28 Galahad Cir
Property Address b ,
Joann Desrochers
Owner Owner's Name :
information is Osterville -MA 02655 5-7-20
required for every
page. City/Town Z State ° Zip Code Date of Inspection
D. System Information (cont )
15. Site Exam: t' .,
❑ Check Slope t t}• f .. ;� 4 =� e. 1 F� . ^ I : •,
❑ Surface water j,, , >' t s•• Fr ,�,:
❑ Check cellar
❑ Shallow wells qol,
Estimated depth to high ground water:„ t.. °-� 12'+
• - 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: �, Y
- - Date'
® Observed site,(abutting property/observation hole.within'150 feet.of SAS)
® Checked with local Board of Health -explain:
® Checked with local excavators, installers—(attach documentation)
❑ Accessed USGS database - explain:
k
You must describe how you established the high ground water elevation:
Original design plans show no groundwater at 12':
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018' , Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
,w Title 5 Official Inspection Form
A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
28 Galahad Cir
Property Address
Joann Desrochers
Owner Owner's Name
information is required for every Osterville MA 02655 5-7-20
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
Commonwealth of Massachusetts l� �
w W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
28 Galahad Circle
Property Address I
Deborah Cumming
Owner Owner's Name
information is required for every Osterville Ma 02655 8/17/17 91
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, v 1
use only the tab 1. Inspector:
key to move your
cursor-do not Michael DiBuono
use the return Name of Inspector
key.
DiBuono Sewer and Drain
Company Name
35 Content Ln
Company Address
Cotu it MA 02635
Citylrown State Zip Code
508-364-9587 SI 13522
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
1
1/10/18 Revised
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system 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.
0 V5
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pa e 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 28 Galahad Circle
Property Address
Deborah Cumming
Owner Owner's Name
information is required for every Osterville Ma 02655 8/17/17
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:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Sytem contains a 1000 Gallon septic tank. As well as a concrete distribution box and 3 infultrators
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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
28 Galahad Circle
Property Address
Deborah Cumming
Owner Owner's Name
information is required for every Osterville Ma 02655 8/17/17
page. Cityrrown 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 (cunt.):
❑ 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):
I
❑ 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 28 Galahad Circle
Property Address
Deborah Cumming
Owner Owner's Name
information is required for every Osterville Ma 02655 8/17/17
page. CitylTown 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
El ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
28 Galahad Circle
Property Address
Deborah Cumming
Owner Owner's Name
information is required for every Osterville Ma 02655 8/17/17
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.
❑ ® 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
28 Galahad Circle
Property Address
Deborah Cumming
Owner Owner's Name
information is required for every Osterville Ma 02655 8/17/17
page. Citylrown 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): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
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
, 28 Galahad Circle
Property Address
Deborah Cumming
Owner Owner's Name
information is Osterville Ma 02655 8/17/17
required for every
page. Cityfrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
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
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage 248 Gpd
9 ( Y 9 (gpd))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Date
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
In
dustrial waste holding tank present. El 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 28 Galahad Circle
Property Address
Deborah Cumming
Owner Owner's Name
information is required for every Osterville Ma 02655 8/17/17
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: Pumped 8/17/17
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1,000
gallons
How was quantity pumped determined? Site glass
Reason for pumping:
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
28 Galahad Circle
Property Address
Deborah Cumming
Owner Owner's Name
information is required for every Osterville Ma 02655 8/17/17
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:
8/16/2004
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 3.5
feet
Material of construction:
® cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
System is vented at field
Septic Tank(locate on site plan):
Depth below grade: 3
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1,000
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins•3/13 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 28 Galahad Circle
Property Address
Deborah Cumming
Owner Owner's Name
information is required for every Osterville Ma 02655 8/17/17
page. Cityrrown 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
24"
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle
42"
Distance from bottom of scum to bottom of outlet tee or baffle " Sludge stick
How were dimensions determined? Tape Measure
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tee's are in place
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
l5ins•3113 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
28 Galahad Circle
Property Address
Deborah Cumming
Owner Owner's Name
information is required for every Osterville Ma 02655 8/17/17
page. Cityrrown 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
W Title 5 Official Inspection Form s. �
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 28 Galahad Circle
Property Address
Deborah Cumming
Owner Owner's Name
information is required for every Osterville Ma 02655 8/17/17
page. City/Town 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 Level and at normal 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.):
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
N W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 28 Galahad Circle
Property Address
Deborah Cumming
Owner Owner's Name
information is required for every Osterville Ma 02655 8/17/17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 3
❑ 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.):
Field was dry and clean at time of inspection
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
W Title 5 Official Inspection Form R
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'°M 28 Galahad Circle
Property Address
Deborah Cumming
Owner Owner's Name
information is required for every Osterville Ma 02655 8/17/17
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 28 Galahad Circle
Property Address
Deborah Cumming
Owner Owner's Name
information is required for every Osterville Ma 02655 8/17/17
page. Cityrrown 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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
28 Galahad Circle
Property Address
Deborah Cumming
Ownfoner Owners Name
requiredfo is Osterville Ma 02655 8/17/17
required for every
page. City/Town 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: 10+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: 8/16/04
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Test hole data on plan
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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 28 Galahad Circle
Property Address
Deborah Cumming
Owner Owners Name
information is required for every Osterville Ma 02655 8/17/17
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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
1/11/2018 Assessing As-Built Cards
TOWN OF BARNSTABLE
LOCATION JA Ci k, 40 CzEd C SEWAGE r
VILLAGE 0 SIX V/C LE- ASSESSOR'S MAP&LOT S L0(,5'
INSTALLER'S NAME&PHONE NO. X446 Z�6 775;�PQo
SEPTIC TANK CAPACITY
LEACHING FACILITY:(typcl4.5�lA1 (size) so.3S X Ir�-•r✓lo Xa'
NO.OF BEDROOMS
BUILDER OR OWNER (_UMMZNG
PERMrrDATE: 3 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Ar Pl%,-, Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by OAA360
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Gr�e
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63- 'f7 3 ue
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http://www.townofbarnstable.us/Assessing/HMdisplay.asp?mappar-145068&seq=1 1/2
�� � +TOWN OF BARNSTABLEC-
LOCATION nS�S C7/�L l�H D rC« SEWAGE # —
VILLAGE 0 STEX UIC� ASSESSOR'S MAP & LOT S -O6?
INSTALLER'S NAME&PHONE NO. X446 60(IC0
SEPTIC TANK CAPACITYX� i ld '
LEACHING FACILITY: (typ 3 �tJ �lTy1y1A��r- 3 0'S (size)30- 35-X
NO. OF BEDROOMS_
BUILDER OR OWNER 1 U041QJ&
PERMITDATE: 8 ��I COMPLIANCE DATE:
Separation.Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Pei` Pl4•-% Feet,
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) IVIA Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) /+ Feet ,
Furnished by C R1UCG�
1
RED oC H
c3
3
No. —7 ` Fee�/es
yTHE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZIppYication for Migogar *pgt-ern Congtrurtion Permit
Application for a Permit to Construct( . )Repair(./fUpgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. J8 I,4� Cj Owner's Name,Address and Tel.No.
Assessor's Map/Parcel /qs—
Installer's Name,Ad*s&ag TO NPICO Designer's Name,Address and Tel.No.
-Main Street mc/ c/ Co'l-�
W. Yarmaut� MA 02673 /- �'
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other TI pe of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 396 gallons per day. Calculated daily flow 3 3 O gallons.
Plan Date 1-/" Y Number of sheets Revision Date �✓�
Title Si f-c — .rekw ct
Size of Septic Tank /4,y p Type of S.A.S.
Description of Soil !'s f 4.1 T
Nature of Repairs or Alterations(Answer when applicable) r— /�4.4n
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of
Signed Ou A A Date 8 !3 A
Application Approved by Date
Application Disapproved for the following reasons
Permit No. ` '` y _! f LT_ Date Issued 1
f U �'
No... Fee /0fr/1%
1-u
t
THE COMMONWEALTHI d in
OF MASSACHUSETTS computer:
PUBLIC HEALTH DIVISION TOWN OAF BARNSTABLE., MASSACHUSETTS-
Yes
11autication' for Ziop'05al bpotem Conotruction Permit
Application for a Permit to Construct Repair(.00)Upgrade Abandon E3 Complete System 0 Individual Components
Location Address or Lot No. 6�,+141-1,4(fl Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Narne,Address and Tel.No.
1�.?eXC r
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder
Other Type of Building No.of Persons Showers Cafeteria
Other Fixtures
Design Flow 396 gallons per day. Calculated daily flow 3 gallons.
Plan Date - <je Number of sheets Revision Date A-11
Title SC L,--4 C 7.
Size of Se tic Tank /000 pe of S.A.S.'
—Ty
Desc'ription of Soil Pe-r PIA --7
Nature of Repairs or Alterations(Answer when applicable) A 11
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Health.
Signed C.C,t A- All" Date 6//3 A/-
7—
Application Approved by Date Application Disapproved for the following reasons
Permit No. Date Issued 21 -31 P.014
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Comphafire to
THIS IS:I`O CERTIFY,that the On-site Sewage Disposal System Constructed Repaired L.�)Upgraded
Abandoned b
at 4/1,4 d C;r J has been constructedlin accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 'D pu-11 dat;i
Installer Designer f f
The issuance of this permit shall not be construed as a guarantee that the syste will!functioVas-designe
k-
Date o Inspector� kv VW 5 ) V
V
——————————————————— —---————--
No. Fee /acj
CIA-
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Miqooal *patent Construction Permit
Permission is hereby granted to Construct Repair Upgrade Abandon
System located at �,4 1A AA
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Tide 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the da of this oe t.
Dat6: ) I3 Approved bv
let_
Regulatory Services
Thomas F.Geiler,Director
• BABNSTARM
9� ' Public Health Division
' Eo. uc+° Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office:.508-8624644 Fax: 508-790-6304
Installer&Designer Certification Form
Date: 00 y
Designer: Me, Installer: At 6 0"6D
Address: . P,0- &J X -t$( Address: 3130 RD v+c z g
e h Sao w i mi MA 6 2S37 W. t mo uT74 MA 02,673
3 o CANStree®On was issued a permit to install a
(dafel
�l W. Yak , e ,A 02673
septic system at 2 D 6 A-l.,A f+ft-D Nu e based on a design drawn by
(address)
M EIJ EA daied /�--���'� I Z,Od
(designer) --""t'
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor"approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system)but in accordance with State &Loc ons. Plan revision or
certified as-built by designer to follow.
J,V( O7
D
(Installer's ignature) #i 140 2
C SN
(Designer's Signature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:Health/Septic/Designer Certification Form
4
TOWN OF BARNSTABLE
LOCATION AA 6/��--IQ /�� CSC(. SEWAGE#62aOILI
VILLAGE 1//U45- ASSESSOR'S MAP & LOT 5 '�6
INSTALLER'S NAME&PHONE NO. I (YAICO -775_;gWa0
SEPTIC TANK CAPACITY
LEACHING FACILITY: { pef,���I i�� 360S (size)s �• 3S X��''fit°X�e
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: �l3/y COMPLIANCE DATE:
Separation Distance Between the:- /
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility` �14.-1 Feet.
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) �� Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) R Feet
Furnished by
C_
OLT
RED oC Ha.15( _i
k 39 I
IL
c3=
• ��cx
' THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF 'HEALTH
Application is hereby made for a Permit to Construct
or Repair an Individual Sewage Disposal
Syst
... ......... ix./z el"L.......................1,7........................ ... ...........
cat, Address I
Cdn
Installer
Ad ess
z Other Distribution box ( ) Dosing tank ( )
Test Pit No. /.minutes per inch Depth of Test Pit------- ... Depth to ground water.../k/V1.........
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TAIT LE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of lie5*.
Date
Application Disa roved for the following reasons:.......................
Date
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF H�ALTH
......... ...... _-)-----------------------------------
has been installed in accordance with the provisions 5 f The ate Sanitary Code s described in the
application for Disposal Works Construction Permit �y -�-,
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
THE COMMONWEALTH OF MASSACHUSETTS
BOAR�DF H�A�TH
Permission is
to Construct or Re air ',n pdurl�o,al S age Dis
WS
____
Board of Health
DATE................................................................................
ronM /ams *omaowWARREN. INC., puoLIsxEns
_
No...:........ . Fimz.......... ..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F• HEALTH
Application for Disp.aiial Works Tonatrnrtiun ramit
'Application is hereby made for a Permit to Construct ( %r Repair, ( ), an Individual Sewage Disposal
cati Address Lot
Ow4er Add ss /
....
a }, Installer A dress
''J. Type of Building "} Size Lot... a " _._Sq. feet
Dwelling—No. of Bedrooms............3............ ........ .Expansion Aitic ( ) Garbage Grinder ( )
a
WOther—Type of Building ............................ No. of persons...........................• Showers ( ) — Cafeteria ( )
d : Other fixtures --•-- •.... •--•••---•-------•------••-•••---------•••......--•-•---...............................................................
(=1 a
Design Flow. 4/2 ...... �P.. gallgri§, er person per ay. Total daily flow..:... ..............gallons.
Ra Septic jank_Liquid''capac>ty_ gallons Length_.. Width. Diameter____ ;. Depth-,..............
Disposal Trench '�10 Width__ Total Length_!.._.� z kTotal leaching area_._, ' .._sq. ft.
Seepage.,Pit No ,.,_.........;_ iameter........6117be th below inlet...: ........... Total leachingarea_ s ft.
Other'Distribution:box Dosing tank q
Z ,. ( ) g ( ) "`Percolation Test Resi Date F
ans Performed by........................ ...... ....._....___.-_---- .._.._.
Test Pit No. 11.........�..minute4per inch Depth of Test Pit......I /--- Depth to grot lAd water...01rOtt
fi, Test Pit No. 2........:.......minutes per.inch Depth of .Test Pit................. Depth to ground water....................
R+' ........
O Description of Soil.,....... ....... r ! .lk-.-
U r� % ............................... ..............--•-
a'
W
-
.....................:.. ------------------------
V Nature of Repairs or Alterations—Answer when applicable __-_-_?p.a ................. ......... ...............................................
..-•--------••••••••--•-•--•••- ......................•.....____ ---••••••••--•-- ..........................................................................................-.........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System inAa&e rdance with
the provisions of J..i. •5 Of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of heqAh. q.
Sign d_ .� ......_
. ..n F'_ Date
^^ t
Application Approved By 't'
7,s; Date
Application Disapproved for the following reasons------------------------ ........................................................ ...........................
•-•...................••---•----------••-------...--•-------•----...-------... ---.........
Date
PermitNo....................----.................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS 4
BOARD"' OF 'H ALTH
1.. . ......... ..OF.. G �' ...
Trrtif irate of (Somplianr
THIS I Q C �TIF That the Individua Sewage isposal Syste constructed � r Repaired ( )
atru
by.......... ---_... ,.._._... -, �r ._._.: ?. .................
• � Insta 2.r _.
at........... t X ! / F
3 _._. ___ �'......... ...........Y.__ __ _
-,has been installed in accordance with the provisions of T j of The State Sanitary Code s described in the
application for Disposal Works Construction Permit No................ . ............. dated__-.- --` �+
/�
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
.:............. 'x.'x Inspector--•---
DATE....•.................................:j -• ._.....-----------.-•-•-
THE COMMONWEALTH OF MASSACH jSETTS
BOAR OF HEALTH
s
........-... 0
F1.. .:: .....c?: ram ................ E
---..... . ........ Fi ........ ..........
i �rrrt rk lanr irn ernta
Permission is eby granted.... ..:.�...... ...�-2.-:�._.---------- ...................
to Construct (� or ly2epair}ij )�an nd' ual Sgt�rage Dis osal stem
at No..-••--•.3---`or+ _- { /�fl✓,�y' s! �`et 1 �. %f?----
- :.C_ _�_
R
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated....7"_vl?'. .r.............--
....-•--•----• •------------=---• -
-
"'' ti • Board of Health y'
DATE...........
.............................................................. k
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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To vErt=ttMt uE wT t_ WS4.
AssEssoRs MAP : NOTES:
�.u) n ►45 TEST HOLE LOGS
1 �
.Rn SUBSTANTIAL OMPLIANCE WITH
1 T INSTALLATION IN UBSTAN AL C
PARCEL : C3Gag )
HE INSTALLAT O MUST BE S
SOIL EVALUATOR : Y"` ifIS PLAN, 1995 MASSACHUSETTS TITLE V & TOWN OF
g�� FLOOD ZONE �OCZ A'Y2--O WITNESS : NOT. Rl;. V L BOARD OF HEALTH REGULATIONS.
A * y� 4 r .A REFERENCE: Ceti : �I���� DATE: _�u ,r 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES,
If rp PERCOLATI0 RA E: �-_2 AI�wG SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO
9P INSTALLATION.
' I tr UN95 � S-o c�� LTA=o,�K � y
TH- 1 �L: ,(��} TH-2 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION
ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE
MpStD� r� .. L(... DETERMINATION.
y csc 3 �. "° LdAM O 4) ALL PIPING TO BE 4" SCHEDULE 40 @ 1/8 "/ FOOT. (UNLESS
�� . SPECIFIED OTHERWISE)
n '
!Y
LOCATION MIA P(N'-r.5). 5HM QV � S) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A
Lo" GARBAGE DISPOSAL.
75n � 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED)
TINS - MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON
A4,551a`I fl A BASE OF 6"OF CRUSHED STONE.
2.SY6� 7) FXls'h! Caw _AWN.--F(T To.. Tat PVAWiF'D 1 �kuSt D
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3 r I LLe p_Pei- TI r-L.F_V. . ._ .. ..
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SCPT I (., SYSTEM DESIGN
/-I o VA •►.+ JC `5: >�oM 7 2 tt, V OR...TGwn)
FLOW ESTIMATE
J BEDROOMS AT I�� GAL/DAY/BEDROOM -330 GAL/DAY
Sv LOT' 37
SEPTIC TANK
�iC�ST�RK( ?��GAL/DAY x 2 DAYS - GAL
Pti` 4$ o `� USE ( }p� GALLON SEPTIC TANK --EKr•S'lZ� 61°t. E � 500 6At�c.o�/
T€7� 1. � � E PT't t, pIw dam• I(-r r_JR-d LC-rJ`�D"av>
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SOIL ABSORPTION SYSTEM OR, UAfV6 L.St 2.&_&,0_
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Hzo ( Aim_o INr-u mA-fiag- 3�50 -GSMITS
41 STotic ON 'k�zl�EsL
SIDE AREAV30.35
30TTOM AREA: .3O .3 x I Z,16 x 2,73 . fi b
3%13 qP0
GA 733o GP
SEPT I SYSTEM SECT I ON
qz
v, PLA46 TES
wh K G a �41 Sh `� N aox
\I3 ` 4rx R rXrsTaN * l0 6✓)sfal( ,c� Etr
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D1r BOx 3
000 GAL
SEPTIC TANK ��uC/�te 3 r3a 3S 3a
47, ---� -.� EK rS f2 N� - 3t).35 i� x 1 Z•/tr'W ---------f
6.20
Tit - ro n
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VSG S dA-TVM 65504W Z
s fool SITE AND SEWAGE PLAN
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LOCAT I ON : '!�tc c
K OF M o.
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A RE G W, I-O 48
'r
N PREPARED FOR : eumm IN
e $ 60(10
o G�sT���O SCALE
o _ SgN�TAR�•PN DARREN M. MEYER, R.S.
uj
t1_ DATE:
43 VINE STREET
5 Pt,At) o� LAlNO By . P WTIU< &*V,6V*tS DUXBURY, MA 02332
DATE HEALTH AGENT (7`81) 585-0293
3
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