HomeMy WebLinkAbout0142 GREAT BAY ROAD - Health 142 GREAT BAY ROAD, OSTERVILLE
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Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
142 Great Bay Road 's
u�
Property Address
Robin Young
Owner Owner's Name
information is required for every Osterville MA 02655 2/19/2020 t
page. City/Town State Zip Code Date of Inspection 4j
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector Information s/., � Kv
filling out forms
on the computer,
use only the tab James Ford
key to move your Name of Inspector
cursor-do not Ford Septic Services, LLC
use the return Company Name
key.
P.O. Box 49
rae Company Address
Osterville MA 02655
City/Town State Zip Code
� 508-862-9400 S 12482
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4 ❑ Fails
2/26/2020
Inspe rs Signature Date
The y tem inspect r shall submit a copy of this inspection report to the Approving Authority (Board
of He h 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Foam
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
142 Great Bay Road
V�
Property Address
Robin Young
Owner Owner's Name
information is Osteryille MA 02655 2/19/2020
required for every
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. F
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
b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
142 Great Bay Road
Property Address
Robin Young
Owner Owner's Name
information is required for every Osterville MA 02655 2/19/2020
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ 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
PI Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c � 142 Great Bay Road
Property Address
Robin Young
Owner Owner's Name
information is required for every Osterville MA 02655 2/19/2020
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier,if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
*'This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No ,
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
iI; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
!% 142 Great Bay Road
u-
Property Address
Robin Young
Owner Owner's Name
information is required for every Osterville MA 02655 2/19/2020
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/z day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ® the system is within 400 feet of a surface drinking water supply
❑ ® the system is within 200 feet of a tributary to a surface drinking water supply
❑ ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
V � 142 Great Bay Road
Property Address
Robin Young
Owner Owner's Name
information is required for every Osterville MA 02655 2/19/2020
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
{
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed.-The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
❑ ® Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection- Form
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
!% 142 Great Bay Road
Property Address
Robin Young
Owner Owner's Name
information is required for every Osterville MA 02655 2/19/2020
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
440
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
unknown
Sump pump? ❑ Yes ® No
Last date of occupancy: unknown
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
/;
142 Great Bay Road
u
Property Address
Robin Young
Owner Owner's Name
information is required for every Osterville MA 02655 2/19/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: pumped in 2017- per owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
J
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u � 142 Great Bay Road
Property Address
Robin Young
Owner Owner's Name
information is required for every Osterville MA 02655 2/19/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
installed on 4/20/84 per as-built
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
142 Great Bay Road
Property Address
Robin Young
Owner Owner's Name
information is required for every Osterville MA 02655 2/19/2020
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 511
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 H-10
Sludge depth: I
Distance from top of sludge to bottom of outlet tee or baffle 24
Scum thickness 1
Distance from top of scum to top of outlet tee or baffle 6
Distance from bottom of scum to bottom of outlet tee or baffle 15
How were dimensions determined? measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The Tee's were present. There was no sign of leakage.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u—
142 Great Bay Road
Property Address
Robin Young
Owner Owners Name
information is required for every Osterville MA 02655 2/19/2020
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):
N/a
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank{tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass '❑ polyethylene ❑ other(explain):
N/a
Dimensions:
Capacity: gallons
Design Flow: gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
c Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
I1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
142 Great Bay Road
u�
Property Address
Robin Young
Owner Owner's Name
information is required for every Osterville MA 02655 2/19/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.) -
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
N/a
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Even
Comments (note if box is level and distribution to outlets equal; any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
The D-box was normal and no solids were present.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
c � Commonwealth of Massachusetts
�v ,r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form,- Not for Voluntary Assessments
142 Great Bay Road '
Property Address
Robin Young
Owner Owner's Name
information is required for every Osterville MA 02655 2/19/2020
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.):
n/a
= k
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 3 Flow Diffussors
16x28
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
IIb Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
!% 142 Great Bay Road
V�
Property Address
Robin Young
Owner Owner's Name
information is required for every Cisterville MA 02655 2/19/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The flows were dry and clean. There was no sign of failure. The flows are in the stone driveway. Per
info from concrete manufactor flow diffussors are H-20. BTG was 3'
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.):
n/a
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
I Subsurface Sewage Disposal System Form Not for Voluntary Assessments
............c� / 142 Great Bay Road
Property Address
Robin Young
Owner Owner's Name
information is required for every Osterville MA 02655 2/19/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction: N/a
Dimensions
Depth of solids
Comments (note condition'of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
c Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
<�I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
142 Great Bay Road
Property Address
Robin Young
Owner Owner's Name
information is required for every Osterville MA 02655 2/19/2020
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
Door
Moor
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t
a —A
I 3 i
o °
y :07a
I
i
A 8 c
136 a-1
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3 194 a96
Y y8 I I3
I
15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
I a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
!% 142 Great Ba
Y Road
Property Address
Robin Young
Owner Owner's Name
information is required for every Osterville MA 02655 2/19/2020
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
® Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 4.5 +/
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
topo and water contours maps
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Ground water was found 4.9' below the bottom of the flow diffussors. The high groundwater
adjustment was .4'for this site MIW 29 Jan. 2020 The high groundwater level is 4.5' below the flows
Diffussors
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1,
u—
142 Great Bay Road
Property Address
Robin Young
Owner Owner's Name
information is required for every Osterville MA 02655 2/19/2020
page. Cityrrown State Zip Code Date of Inspection.
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
BITER & NYE, INC.
' Professional Land Surveyors and Civil Engineers
812 Main Street •Osterville, Massachusetts 02655 Tel. (508) 428-9131
FAX (508) 428-3750
WILLIAM C. NYE, P.L.S.-President ^� ^ 2 PETER SULLIVAN, P.E.-Vice President-Engineering
RICHARD A. BAXTER, P.L.S. -Vice President J
I
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART D
CERTIFICATION
Inspector: Peter Sullivan PE
Location : 142 Great Bay Road Osterville1
Date .,:February 2, 1995
Certification Statement
I certify that I have personally inspected the sewage disposal system at this address
and that the information reported is true, accurate and complete as of the time of
inspection. The inspection was performed and any recommendations regarding
upgrade, maintenance and repair are consistent with my training and experience in
the proper function and maintenance of on-site sewage disposal systems.
I have not found any information which indicates that the system fails to adequately'
protect public health or the environment as defined in 310 CMR 15.303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of this form.
__Ile ruly yours
eter Sullivan P
Baxter & Nye Inc.
Distribution: b ��
Original to system owner v PMR .
Buyer SULLIVAN
No.. Board':o Heath; �
aT
` �c3AlAL
MEMBERS OF
CAPE COD SOCIETY OF PROFESSIONAL ENGINEERS AND LAND SURVEYORS I AMERICAN CONGRESS ON SURVEYING AND MAPPING
MASSACHUSETTS ASSOCIATION OF LAND SURVEYORS AND CIVIL ENGINEERS
I Az
SUBSURFACE SEWAGE DISPOSAL SYSTEM INBPECTION FORM ,
Address of.' property
Owner ' s name..:.
Date of Inspection
PART A
CHECKLIST
Check if the following have been done: .
V Pumping information was requested of the owner, occupant and
Health. _ t\ibw_a ,��,� , Board of
` None of' .the system components have been pumped for at least two weeks
and the system has been receiving normal flow rates during that
period . Large volumes of water have not been introduced into the
system recently or as part of this inspection.
As built plans have been obtained and examined. Note if they are not
available with N/A.
The facility .or dwelling was inspected for signs of sewage back-up.
The site wa,s inspected for signs of breakout.
All system components, excluding the SAS, have been located on the
site .
The septic tank manholes were uncovered, opened, and the interior of
the septic tank was inspected for condition of baffles or tees,
material of construction, dimensions, depth of liquid, depth of
sludge, depth of scum.
The size. :and location of the SAS on the site has been determined }used
on existing,, information or approximated by non-intrusive methods.
✓ The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSOS.
4.
rAz-�� 1� 3 , �o
ISLs+.ry D
SUBSURFACE GEWAGE DISPOSAL SYSTEM INSPECTIO FORM`��
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential.
number Of bedrooms
number of current,Oor
idents
garbage `grinder, no
laundry connected to s stem, es or no
seasonal, .us.e, yes or no
If nonresidential, calculated flow:
Water meter readings, if available:
C`2------ �`f Last date of occupancy. p ncy
Ckwe;cn.
GENERAL INFORMATION
Pumping records and source of information:
o 0 CtOO DS
System pumped as part of ins� ,.�,e,�cti n, yes or
if yes, volume pumped to
Reason Reason for pumping:
I r vj P�s -i-t M C �..
5
0r Ol rr l �
Type of system
✓ Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy,
Shared system (yes or no)records, if any) (if yes, attach previous inspection
Qther (explain)
Approximate age of all components. Date installed, if known. Source rce of
Q6 Sewage odors detected when ar
riving at the site, yes or no
:at
9
� e «F--
t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
y SYSTEM INFORMATION continued '
SEPTIC TANG:.';'
(locate on;'sit" ' pl'an)
depth belo ::gr,ade;'
material of construction: concrete metal FRP other(explain)
dimensions,:,—,
imensions:, b#--'r.`r X Lw a•L
sludge: dept,h::'
'2 ��distan:ce from top of sludge to bottom of outlet tee or baffle
l2 scum thickness
distance .from top of scum to top of outlet tee or baffle
Z„ distance from bottom of scum to bottom of outlet tee or baffle
Comments .
(recommendatio.n:" for pumping, condition of inlet and outlet tees or baffles,
depth of liquid: level in relation to outlet invert, structural integrity,
evidence of leakage, recommendations for repairs, etc. )
Qr:�vQ CnDrU VEV 5 , 2 G = -
- _� ►Lc- o u w� 6 G -
�-
DISTRI BUTI.ON:;,B.O.X:
(locate on.:"site plan)
depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out' of box, recommendation for repairs, etc. )
1 600 C M o 1 NXO Yu
PUMP.-.'CHAMBER: IV
(locate on: site plan)
pumps in, working order, yes or o
Comments:
(note condition of pu h er, condition of pumps and appurtenances,
recommendations for ma • en or repairs,ete. )
5A4
d
05T I Lce iQ
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION INFORMATION continued
. SOIL ABSORPTION SYSTEM (SAS)
(locate on site plan, if possible; excavation not required, but ma be
approximated by non-intrusive methods) y
1M,
I.f' not determined to be present, explain:
Type
1 s and number
aching chambers and number TAQP_e 4 x c'ocu�,. rLc �,FFus�
leaching galleries and number zs FZ A,
leaching trenches, number, length, ,� x Z8 F�E�D
leaching fields, number, dimensions
overflow cesspool, number
Comments: .,
(note candi,tion of soil, signs of hydraulic failure, level of ondin
condition of vegetation, recommendations for maintenance or repairs etc. )
',' E� ►.� Lt�tar�t8c�2 cL-osEs 7 �
WE►ZLor�VirlC HCtG Nc� sYEN o F
CESSPOOLS..:(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 '(cesspool must 'be pumped as
part-: of inspection)
Comments:
(note condition of soil, signs of hyd ulic failure, level 'of ponding,
condition of' .vegetation, recommendations for maintenance or re airs p ,etc.
PRIVY: t„
(locate on site plan)
materials of'
' Construction
dimensions
depth of solids .
Comments:
(note condition .of soil, signs of hydraulic ailure, - level of. o
condition of. vegetation, recommendations for maintenance or repairs,�etc. _
.i. � ..N�e"d7•Jd!' 2 N•< .. . . ,. . . :� ., . ,.V�sy�;x:_ Yt ..
A
r C)5TUej
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM y
PART B
SYSTEM INFORMATION continued
SKETCH_ OF...':SE_WAGE: -DISPOSAL SYSTEM:
include t i,
ts' to- at least two permanent references landmarks or benchmarks
10 :ate all ,,Wells within 100 '
..
� cam.i,.,l �41 Aj-•�Q_ �U v�,t uy 6c� •
(oFO Tb
ACiu I rG e.S
------------------------
a,.
fb?oF TAru`� 9 ps' N6v�
ali r— — / — — — — — — — —
DERTH0 "GROUNDWATER
,,,3s 92f . • �.oaysrcp 1-���E,
depth to groundwater
method of determination or approximation:E �+— `
�f e2 to U IBC \A-I C �- -� 9 �i2 l�C�'F 5, -T l�E ►7 ::11 t6
10
rye vt LL-e 12
S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined" , explain why not)
hLO Baokup,.,o:f. sewage into facility?
Discharge or pond`ing of effluent to the
surface of the ground or
surface waters.,?
AD ' Static :Liquid level in the dis
tribution box above outlet invert?
Liquid depth `in cesspool <6" below invert
flow? or available volume< 1/2 day
Required pumping 4 times or more in the last year.?i —.
� number of times pumped
K10 Septic tank is metal? cracked? structurally
substantialun .
infiltration? substantial exfiltration? tankufailure imminent
n1 r �J
N O Is any portion of the SAS, cesspool or privy:
N below the high groundwater elevation?
t�c> within.,50 fe.et:.of a surf
ace water.
"D within • 1'00 f.,eet of a surface
wate'r' supply? water supply or tributary to a surface
with.4.n ....a ;.Z.one I of a ubl is
P. _......__.well .
.wit'hin 50 feet of a bordering
•{cesspools and privies only,
vegetated wetland or salt marsh
A� Y, Lot the SAS) .
Ind within 50 feet of a private "
p ate water supply well?
less than l00 feet but greater
supply well with no acceptable water 5quality 0 feet fanalysrom is?vaIf Later
has been analyzed to be acceptable, attach co he Well
for coliform bacteria, volatile r anic compounds, ammonia nitrogener
and nitrate nitrogen. R;`g p ' . g
: CisT C_e_vI L.c
kEY NUMBER <7922 >
NAME <DORSEY, JAMES B, DR > B-C 1 B-C 2
B-C 3 B-C 4
STREET 42 SARATOGA CIRCLE-BRICK RUN
CITY SARATOGA ST NY ZIP 12866-1028 REF 1 REF 2
PHONE ( ) - REF 3 REF 4
METERNO. < 7427> DATE READING CONS
STREET <GREAT BAY RD NO. 142> 12/31/94 1494 . 143
CITY OST S L2 ST LOC 06/30/94 1351 47
PHONE ( ) - 12/31/93 1304 168
06/30/93 1136 33
ROUTE NUMBER .117 . 12/31/92 1103 38
SERVICE DATE 04/27/84 06/30/92 1065 25
METER DATE 05/17/84 12/31/91 1040 142
CAPACITY 7 06/30/91 898 11
STYLE T8
SIZE 2 RATE SCHEDULE
KEY PIT PLASTIC X
NOTE RR RIGHT SIDE ADDITIONAL CONS 0
ALTERNATE MIN 0
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0
o ,
JQ� e
2
5
o
C6tZT►F 1Et-D P LbT' Pt_./-s,,1`1
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CGZZTIF`{ T14AT' A RSP'1=zEy.IGE_
-lEQE0�1 GOrV�PL�(S �l/ IT4-� 'f WG: �jlT7ta.l.t►-1�
ut> . SE'r$ItCIC WEQV IZEftENTS OF T" l�v I
:otc1U of �AP�.I �-r�1�r31 >r- A�.tD 1S
_vGAT�� WITNt T/Pz
l.r
IQ
�ATC-, I f'?' REG(SCC-JZL-to, LA.4�1p SU�v�.YotzS
S ►-1 OT B AS E'l7 U A W O 5 T E 2V I L.l!✓
yiT�tJMEIJT SUQV�`f ¢ m4c- QPPLI C.4,F-1T'
0CATION SEWAGE. PERMIT NO.
VILLAGE
OsTilaly
ALL ER'S NAME a ADDRESS
s -
d
R UILDER OR OWNER
DATE PERMIT ISSUED /7
DATE COMPLIANCE ISSUED � �
i
O
4
"��L
THE COMMONWEALTH OF MASSACHUSETTS
BOARD Ofj HEALT
...........vo ........OF.............. ....... ...... ....V"'e.........
Application for Disposal Works Tonsh-Winn jlrrmit
Application is hereby made for a Permit to Construct A or Repair an Individual Sewage Disposal
system at:
....... .. . ...... ... .. .. ..... L_Z?
.... . ......�71.. -0............
-Ad Tess
. . ......... . ............C;. ...4
Owner Address
........................... ..................../ILK......2.............................. ................................................................................................
Installer Address
. !JjrType of Building Size Lot. ....Sq_ e
Dwelling—No. of Bedrooms...........................�.........Expansion Attic Garbage Grinder (�...�^'`
Other—Type of Building ............................ No, of persons............................ Showers Cafeteria
04 Other fixtures ......................................................................................................................................................
Design Flow................. dons per person per day. Total daily flow............. .............gallons.
Septic Tank—Liquid capacity_._ ons Length___. Width.._.'Z-%X Diameter................. Depth...
Disposal Trench—No.........I........... Width....... Total Length........ Total leaching area...."g..sq. f t.
Seepage Pit No..................... Diameter....._...___._._____ Depth below inlet_...___..........._. Total leaching area.................sq. ft.
Other Distribution box ( .4--' Dosing to ( )
Percolation Test Results Performed by.........Z. 0-Qw=A.j41P-?. Date.._...': ......
.. ..........
Test Pit No. I...j4�.��n.minutes per inch Depth of Test
�_l . It__... ...i��... Depth to ground water.......
0-4
44 Test Pit No. 2................minutes per inch Depth of.Test Pit...........(�V... Depth to ground water.._.._.."......._...
......... .............. ..........
ii---j -. ...............
...... ............................
0 Description of Soil_........ ....... L ............
-----------------------------------------------*------ ......*-------------*......................*------------------- ---------"------*--*--*.......
........................................................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE; 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b i u the boar of Ii h
.,S ed . .. .. .
. . ... .............. ... ........ .....
Date,
ApplicationApproved By............... ... .................................... ... .............. .............. �p.....
Date
Application Disapproved for e 110 ng,rea'sons:M,....-_1..........................................................................................---
0
.........................................�L................ ............ .................................................................................................................
Permit No..___..-1/1....................................7 Issued..........................................Date......
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................:.....................OF...................................I..........................I.............I........
Grfifiratp of Toutpliaurr
THIS IS TO CERTIFY, That-the Individual Sewage Disposal System constructed (woelo"'r Repaired
by.........:;O". ._...�..•--
4_�
............. I�'_
......... ... .......... .. ... ................................... -------------- ....................Installerpe7at, .. .... .. ..........................................2 ............................ ........ ...................
has been installed in accordant 'w* the provisions of TITLE 5 of The State Sanitary/&ds d r* ed in the
nstruction Perm d
applicationdated_.. ''. , ,.__
...................
for Disposal Works o it No.... .............. te
T
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A UAR NTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....................................... ................... Inspector........................... .....................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. ...........................................OF...............
v - ...... .......*......
No.f!�.....Q....... Fitz...r..................
Disposal Works Tonstrudion Permit
Permission is hereby granted-. .............-:=I---
............................. . ............ ...............................................................----
'a., Iixdividuiaj1,,e&.wa e is Sy
to Construct or Repair
atNo............................0 ......
........... ................................Z..... .................
s
as shown on the application for Disposal Works Construction Per t o..................... ... .. .. .. .. ..............
................................ .... ....... ... ...............................................
Health
DATE...............................................
...........
FORM C-1255 CITY& TOWN FORMS, INC.369-9708
- ... . STAMP:
�jVk 1 fQ C7 00 5535
20':9yq 10-10%" _ l
w mm
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SHADED AREA LL qqEq
•m• REPRESENTS PORTION OF
- DECK WITHIN 50'BUFFER. U S
� �Z
\ NEW DECK AREA BEYOND - - _o '
50'SETBACK-400 SF W a
IN OF
EXISTING DECK ~ s
Ii ,..._ —. _ .._ _._ _ "`� 3` "s' ss' • O
a
EXI TING DECK U
2
_ v TO BE REMOVED
Q m
� AREA BEYOND 50'
` SETBACK 70 SF
EEKi6-BE-REM bzx
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EXISTING-P-INE '�„sM+rc-awe .,.�v. .r ae rc�{" ':�vs emu:•.r -"a`msx roars aa� - '' +
TO-BE-REi'IOV -
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PECK I I
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DCK i FLOOR EL.-+11.22' W N
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- - - - - - I KITCHEN
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I DATE ISSUED:
r 09/22/2010
REVISIONS:
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DRAWN BY:
TWS/SYJ
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5 PROJECT#:
DRAWING NO.:
�s FLOOR PLAN
SALE: 114"=1'_D° PERMIT SET
R:
09/22/2010
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€I�fX.UDES Rpimf A9D1:GAR.AGc} .
- _ DATE ISSUED:
06/26/08
REVISIONS:
DRAWN BY: BD
PROJECT M j.
L1 DRAWING NO.:
_ STAMP: .-
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• NEW WINDOWS AND DOORS IN - - NEW PREFINISNED R6R WHITE - NEW MAHOGANY DECKING AND
Ii EXISTING OPENINGS THROUGHOUT CEDAR SHINGLES OVER TYVEK CELLULAR P.V.C.TRIM OVER
HOUSE- PROVIDE NEW CELLULAR .HOUSE WRAP UNDERLATMENT ON EX15T.CANTILEVERED DECK
ALL EXTERIOR WALLS FRAMING. PROVIDE NEW 36'
P.V.C.SILLS AND CASING AT ALL
HIGH DECK RAILING WITH'CAB
RAIL SYSTEM'BETWEEN.POST
NEW MAHOGANY DECKING AND NEW 36' IIIGH DECK RAILING WITH
CELLULAR P.V.C.TRIM OVER 'CABLE RAIL SYSTEM'BETWEEN -
EXIST.CANTILEVERED DECK PO5T5 -
FRAMING..PROVIDE NEW 36'HIGH ixw
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_ POSTS, TYP.--SEE
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NEw (2)2 X 6 P,T.KNEE I I I
NEW(2)21X P.T.KNEEI I I. I I I I I. I I I I I - BRACES-CONSTRUCTION I I SIMILAR TO�CKER' SHOWN I STAIRS DOWN TO 1 I-
I BRACE- TRUCTION 1 I NEW nAHOG/UJYI DECKING AND 1 SIMILAR TO'KICKER'SNOwN NEW 12° DIAM. CONC. -
SIMILAR TO'KICKER'SNOI�N 1 1 1 1 I NEW 'KICKE�1f LPPORT 1 I —/ i - I ON I/A3.0 GRADE LEVEL. W Q
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P.T. DECK F 1(IING.PROVIDE - l BIGFOOT FOOTINGS, 4B' l - J \ L-_.1 L_-1 PROVIDE CONC.PAGERS-1 v Q
L--1SEE I/A3.Q.-_1 J - A J - _ _
L--� NEW 36'H{GH R 1FING WIT
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-- 'CABLE PAL EM'BETWEEN - TO SUPPORT BOTTOM OF - Y Q O Q
. - POSTS - - - STAIR STRINGERS - V (Y Gc
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W Q W
REAR ELEVATION 0 0 / ;(/nn °° J
- SCALE: .I/4"=1,_0„ N V
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NEW PREFINISNED R6R WHITE - -
CEDAR SHINGLES OVER TYVEK
HOUSE WRAP UNDERLAYMENT ON
ALL EXTERIOR WALLS -
ELEVATIONS
NEW MAHOGANY DECKING AND -
CELLULAR P.V.C.TRIM OVER
EXIST.CANTILEVERED DECK -
FRAMING.PROVIDE NEW 36'
HIGH DECK RAILING WITH'CABLE - -.--- _
RAIL SYSTEM'BETWEEN POSTS
DATE ISSUED:
NEW MAHOGANY DECKING AND -
CELLULAR P.V.C.TRIM OVER NEW WINDOWS AND DOORS IN 09/22/2010 -
P.T.DECK FRAMING.PROVIDE EXISTING OPENINGS THROUGHOUT - REVISIONS:
NEW 36'HIGH RAILING WITH HOUSE -PROVIDE NEW CELLULAR
'CABLE RAIL SYSTEM'BETWEEN P.V.C.SILLS AND CASING AT ALL
POSTS .
3 FLOOR —
s �o Q
a NEW P.T. 6 X 6 WOOD - DRAWN BY:
s POSTS, TYP. - SEE - 1YJS�SW-
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j PROJECT#:
NEW 12' DIAM. CONC. ,
B'
TO I, __ ___ ________'
______________________ -
DRAWNG NO.:
a SONOTUBE ER5 2B GRADE LEVEL
FOOTNGON
BIGFOOT BELOW GRADE, TYPICAL. ) ) L--1 L--� '
SET FLUSH WITH GRADE - ____________________________________________
a �`-PROcrtDE'CONC-PIKERS_______________________ ..
NEW(2)2 X 6 P.T.KNEE. TO SUPPORT BOTTOM OF PERMIT SET �,
- STAIR 5TRINGERSA-2 .BRACES-CONSTRUCTION - -
SIMILAR TO'KICKER'SHOWN
Aa ON"`3'0 09/22/201 O
LEFT SIDE ELEVATION
SCALE: - 1/4°=1'-0" - - • _
AV _ -
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