HomeMy WebLinkAbout0089 GUNSTOCK ROAD - Health 89 Gunstock Road ',.'. ..
Osterville P
Al= 121 1.11
r'
Commonwealth of Massachusetts
Title 5 Official Inspection Forma
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments.
89 GUNSTOCK ROAD `
Property Address t
STEVE NELSON
Owner Owner's.Name t
information is MA 02655 6/6/2020 �-
required for every OSTERVILLE
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form.Inspection forms may not be altered'in.any
way. Please see completeness checklist at the end of the form.
Important:sum®" A. Inspector Information mil•# /y5 f
filling out forms
on the computer, DANIEL B. JOHNSON
use only the tab _
key to move,your Name of Inspector
cursor-do not DSD, INC.
use the return
key. Company Name
P O BOX 2406
Company Address
S. HAMILTON MA 01982,
City/Town State Zip Code
(978)768-7600 81962
Telephone Number License Number
B. Certification
I certify that: 1 am a DEP approved system Inspector in full compliance with Section 16.340 of Title 5
(310 CMR'15.000); I 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
6/6/20�0
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.
t5lrrep.00c•rev,7f2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pege t'of 1e
Commonwealth of Massachusetts
Title 5 Official Inspection. Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1 89 GUNSTOCK ROAD
Property Address
STEVE NELSON
Owner Owner's.Name
information is OSTERVILLE MA 02655 6/6/2020
required for every
page. CkyNwn 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,#o 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 e4iltration 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):
IStnsp,doc rev.7126/2018 Title 5 official Inspection form;Subsurfece Sewage Disposal System•Pagw2 of 18, _
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form-Not for'Voluntary Assessments
89 GUNSTOCK ROAD
Property Address
STEVE NELSON
Owner Owner's Name
information is OSTERVILLE MA 02655 6/6/2020
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.
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 pipes) 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).
q). Further Evaluation lr3 Ftaqwirocl by the Board of 1.10altfir
❑ Conditions exist which require further evaluation by the Board of Health in order to d0drmine,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/Zt3/2018 Tdle S Official Inspection Form:Subsurface 8ewage Disposal System•Page 3 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface"Sewage Disposal. System Form Not for Voluntary Assessments
89 GUNSTOCK ROAD
Property Address m
STEVE'NELSON — -
Owo it Owner's Name
information is OSTERVILLE MA 02655 6/6/2020.
required for every
page. Citylrown State tip 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-hat a septic tank and SAS and the SAS is within a Zone 1 of a publicwater
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 JS less than 160 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
coliforrn 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) b"tem reilure Gritei-sa Applicable to All Sy®temec
Y.ou;gIgg indicate"Yes" or"No"to each of the following for_a11 inspections:
Yes No
❑ Backup of sewage into facility or system component due to ovedoaded: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
15insp.doe,•rev.7/26120t6 Title 6 official Inspedion Form:Suburfaoe Sewage Disposal System•"Page 4 of 1e
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
89 GUNSTOCK ROAD
Property Address
STEVE NELSON
Owner Owner's Name
information is OSTERVILLE MA 02655 6/6/2020
required for every
page. Cityfrown State Zip Code Date of inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to.All Systems: (cone:)
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 %day flow
® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
Ej X 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 watersupply
well.
Any portion of a cesspool or privy is within 50 feet of a private mater 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 15.30.3, therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correctthe 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;4n addition to.the
questions in Section CA.
Yes No
❑, ❑, the system is within 400 feet of a surface drinking watersupply
❑ the system is within 200 feet of a tributary to a surface drinking water supply
El Area
system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area-IWPA)or a mapped Zone II of a public water supply well
f5lrep.doc•rev,MAWS TjUe 5 01 idal inspection Form:Subsurface Sewage.Disposal System'Page 5 of18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal`System Form-Not for.Voluntary Assessments
r 89 GUNSTOCK ROAD
Property Address.
STEVE NELSON
owner Owner's Name
information is -- OSTERVILLE MA 02655 6/6/2020
required for every
page. City)Town State Zip Code Date of Inspedfon.
C. Inspection Summary (cont.)
If you have answered"yes'to any question in Section C.5 the system is considereda significant
threat, or answered"yes"to any question in in, 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 31.0 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 NIA)
X 0 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 ZOO'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 isat.issue;
approximation of distance is unacceptable)[310 GMR 15.3020)).
Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page of;1 s.
t6insp.doc-rev,7/26/2018
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
" 89 GUNSTOCK ROAD
Property Address
STEVE NELSON
Owner Owner's Name:
infbanatioh is OSTERVILLE MA 02655 6/6/2020
required for every
page., city/Town State Zip Code Date of inspection
D. System Information
1.. Residential Flow Conditions:
3
Number of bedrooms(design)-. 3 Number of bedrooms(actual):
DESIGN flow based on 310 CMR 1,5.203 (for example: 110 gpd x#of bedrooms);
330" .
Description:
"BASED ON THE ABOVE THE DESIGN FLOW IS 330 GPD,
2
Number of current residents:
Does residence have a garbage grinder? ® Yes E] 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
Seasonal use? �. Yes ❑ No
218 GPD:`_
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
*WATER.METER READINGS BETWEEN 12/31/17 AND 12/31/19(159,000 GALLONS) HOUSE IS
OCCUPIED'INTERMITTENTLY THROUGHOUT THE YEAR,(USED MORE CONSTANTLY ,
BETWEEN LATE SPRING THROUGH THE FALL)
( Yes No
Gump pump?
PRESENT
Last date of occupancy: Date
e 5 MOW hup8c ion Form:Subaurfaoe Sewage 0,'ispgsai System•Page 7 of 18 _
tSinsP•d�'rev.7l26t20tB _ Titl
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System,Form Not for Voluntary Assessments
89 GUNSTOCK ROAD
Property Address
STEVE NELSON
Owner Owner's Name
lnfomation is OSTERVILLE MA 02655 6/6/2020
required for every,
page. `cityabwn State Zip Code Date of Inspection'
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.2W):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq:ft:, etc.):-
Greasetrappresent? ❑ Yes ❑ No
Water treatment;uni.t present?" ❑; Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes No
• Non-sanityry 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:
TANK LAST PUMPED IN APPROXIMATELY 24
Source of information: YEARS AGO-OWNER
Was system pumped as part of the inspection? ❑ Yes No
If yes; volume pumped: gallons 4
Howl was quantity pumped determined?
Reason-for pumping:
_ t5lnsp.doc•rev.7f282018
Titles official Inspection Forth:Subsurface sewage Disposal System•Pap,A of"s
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
r 89 GUNSTOCK ROAD
Property Address
STEVE NELSON
Owner 'Owner's-:Name
information is OSTERVILLE . MA 02655 6/6/2020
required for every
page. Cityrrown State tip'Code Date of Inspection
Q..System Information (cont.)
4. Type of System:
Septic tank, distribution box, soil absorption system
Single cesspool
[] Overflow cesspool
❑. Privy -
( Shared ystem(yes or no) (if yes, attach previous inspection records,,if any)
El 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:
SEPTIC SYSTEM INSTALLED ON 2/27/81—AS BUILT CARD(INFORMATION TAKEN.FROM
.PREVIOUS T 5 INSPECTION REPORT
_ -Were sewage odors detected when arriving at the site? ❑ Yes No:
5. Building Sewer(locate on,site plan):
3-5' (EST).
Depth below grade: feet
Material of construction:
cast iron ( 40 PVC other(explain)
D15tanGe from private wtator euppiy weii or 6u.ciion line:
feet
Comments(on condition of joints,venting, evidence of.leakage, etc.):
CONCRETE JOINT
i5lnsp:doe•rev.7128/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 9 of I*
Commonwealth of Massachusetts
Title 5 Official Inspection Form.
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
" 89 GUNSTOCK ROAD -
Property Address
STEVE NELSON
Owner Owner`s Name
information is OSTERVILLE MA- 02655' 6/6/2020
required for every
page. City/Townstate Zip Code_ Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
32" (FROM OUTLET COVER)
Depth below grade: feet
Material of construction:
concrete ❑metal ❑fiberglass ❑polyethylene Z other(kolain)
If tank is metal; list age: years
Is age•confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
81 X 5`8"W X 4'H (EFFECT.)
Dimensions:
4"
Sludge depth:
28"
Distance from top of sludge to bottom of outlet tee or baffle
< 1/2" -
Scum thickness
7,,
Distance from top of.scum to top-of outlet tee or baffle
16"
Distance from bottom of scum to bottom of outlet tee or baffle
SEPTIC MEASURING POLE
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity;
liquid levels as related to outlet invert, evidence of leakage, etc.):
INLET PVC TEE AND OUTLET PRECAST CONCRETE TEE APPEAR TO BE IN GOOD
CONDITION. TANK APPEARS TO BE IN GOOD CONDITION. NO SIGNS OF LEAKS. LIQUID
LEVEL AT OUTLET INVERT. NO NEED TO PUMP SEPTIC-TANK, NOTE: OUTLET COVER HAS
NO HOOKS TO ASSIST IN REMOVAL AND AN ABANDONED IRRIGATION LINE'18 LOCATED.
OVER A.PORTION OF THE.OUTLET COVER.
prev.•rev.MAWS 5 oficlet Inspection Form:Subsurface Sewage Disposal System•0ege-16 or 1S
Commonwealth of Massachusetts
Title 5 Official Inspection Form
4
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments.
89 GUNSTOCK ROAD
Property Address
STEVE NELSON
Owner Owner's Name =-
information is - OSTERVILLE MA 02655 6/6/2020
,required for every
page. city/Town 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):
i
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: bate
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:
E concrete ❑ motet ❑fiberglass ❑polyethylene, (�other(explain):
Dimensions:.
Capacity: gallons
Design Flow: gallons per day
,t5insp.doc•rev.712=M
Tlde 5 Oftidal Inspedlon Form:Subsuitace sewage Disposal System Page 11 of 1a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal.System Form Not for Voluntary Assessments
89 GUNSTOCK ROAD
Property Address'
STEVE NELSON
Owner Owner's Name
information ie OSTERVILLE MA 02655 6/6/2020
required for every
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
.Dateof'last pumping: Date
Comments(condition of alarm and float switches, etc:):
. t
Attach copy of current pumping contract(required). Is copy attached? ❑ 'yes ❑ No
9. Distribution Box(if preserit must be opened) (locate on site plan):
0 w_
Depth of liquid 1evel above outlet invert
Comments(note if box is level and distribution to outlets equal; any evidence of solids,CarryoYer;::any'
evidence of leakage into or out of box, etc.):
D-BOX LEVEL WITH EVENDISTRIBUTION (ONLY ONE"OUTLET LATERAL EXISTS). D BOX IN
FAIRIGOOD CONDITION (SIDEWALLS IN GOOD CONDITION).. NO SCUM OBSERVED 2"OF
DIRT/SLUDGE OBSERVED. NO SIGNS OF LEAKS. TOP OF COVER AT 33" BELOW GRADE.
COVER IN FRAGILE-CONDITION),
F
t5insp.doc•rev:7l2812078 °
Title 5 pifidel Inspedlon form:Subsurface Sewage Mpg sal System•Pop: of 18,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for.Voluntary Assessments
89'GUNSTOCK ROAD
Property Address
STEVE NELSON
iOwner tion is owner's Name - -
requited for every
OSTERVILLE MA 02655 6/6/2020
page_. CityMown State Zip Code Date of Inspection
D. System Information (Cont.)
10. Pump Chamber,(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order ❑ Yes ❑ No
Comments(note.condition of pump chamber, condition of pumps and appurtenances, etc.):
•If pumps or alarms are notr 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,
• 1
leaching pits number:
❑ leaching chambers number:
leaching galleries number: -
❑' leaching tr®nche a riur»ber; length:
leaching fields number, dimensions:
❑I overflow cesspool number:`
El innovative/alternative system
Type/name of technology:
l5insp.doc•rev.7P261Z018 Title 6 Official Inspection Perm:Subsurface Sewage Disposal System•Page 13 of t e
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System form-Not for Voluntary Assessments
89 GUNSTOCK ROAD -
`Propegt ddress
STEVE NELSON
Owner Owner's Name
information is OSTERVILLE, MA 02655 6/6/2020
required foraVery
Page.. citv/rown State Zip Code _Date of Inspection
D. System Information (cont)
11. Soil Absorption System(SAS)(contI
Comments(note condition of sail, s.ignS of hydraulic failure,level of ponding,damp soil, condition"of
vegetation, etc:):
NO SIGNS OF HYDRAULIC FAILURE"OR PONDING'. VEGETATION`(GARDEN)OVER,SAS
APPEARS NORMAL.
'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'
Qimensions 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.):
40POor rev.712WOiO
Title 5 Official Inspection Form:Subsurface sewage.Disposal Sgstarri•Poo 14 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
89 GUNSTOCK:ROAD - - -
Propetty.Address
STEVE NELSON
`Owner Owner's Name
information is -
required forevery
OSTERVILLE MA 02655� 6/6/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
-.Depth of solids. -
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of:vegetation
etc:);
mnsp doc+rev.MEMO Title 5 Official inspection Form:Subsurface Sewage 0isposai system-paga'15 or wl _..
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal'System Form-Not for Voluntary Assessments
89 GUNSTOCK ROAD
Property Address
STEVE NELSON -
Owner Owner's Name
information is OSTERVILLE MA 02655 6/6/2020
required°far every
page. Citylrown 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 perrri9nent.refdrenc6
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
'Arawing;attached separately
$4 rz a�"e td
16' b� P EI
Aa Z 1 fa
-99 Z3,4
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oar-Lvr odor. ($'&rie r,,�Alt) A4 3 6W 6 9 W
L t'®.O6 601.C.W
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t5insp.doc•ram.7/28/2018 Tftle 5 OfficialMspedion Form:Subsurface Sewagabisposal System•Page 16 of 18,
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 GUNSTOCK ROAD
Property Address
STEVE NELSON
Owner Owner's Name
information is MA 02655 6/6/2020 .
required for every OSTERVILLE
page. City/Town state Zip Code Date of Inspedion
D. Syste4n Information (cont.)
15. Site Exam:
Check Slope
Surface water
Check cellar
Q Shallow wells
> 9'
Estimated depth to high ground water: feet
Please indicate all.methods used to determine the high groundwater elevation:
Obtainedfrom 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,,
TOPOGRAPHIC AND WATER CONTOUR MAPS (TAKEN FROM PREVIOUS T-5
REPORT
C1 Checked with local excavators, installers-(attach documentation)
EJ Accessed USGS database-explain.
You,must describe.how you established the high ground water elevation:
BOTTOM OF PIT AT APPROXIMATELY 9' BELOW GRADE. BASED ON THE BARNSTABLE
TOPOGRAPHIC AND WATER CONTOURS MAPS,THE MAPS WERE SHOWING
APPROXIMATELY 25' (+/-)TO GROUNDWATER AT THIS SITE(THE ABOVE INFORMATION WAS
TAKE FROM THE PREVIOUS T 5 REPORT). BASED ON THE ABOVE, IT APPEARS THAT NO
HIGH GW INTERFERENCE EXISTS WITHIN THE SAS. IF A SOIL TESTIS PERFORMED.ON THE
PROPERTY IN THE FUTURE THE.ftE3ULT;5 OF Tt113 REPORT MAY BE MODIFIED.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp,doo•.rey.7l26l209B Title 5 Official Inspection Form:Subsurface Smogs Disposal System•Page 17 of 18'
Commonwealth of Massachusetts
Title 5 Official Inspection Form.
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
89 GUNSTOCK ROAD - - -
Property Address
STEVE.NELSON
Owner Owner's Name T
information is - OSTERVILLE MA 02655 6/6/2020
required for every State - Zip Code Date of Inspection
page. CitYlTown - _ _E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
Z A. InspectorInformation: Complete all fields,in this.section.-
B. Certification: Signed &Dated,and 1, 2, 3, or 4 checked
Z 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
S orW
_Sewage Disposal System Pape
t5insp.d=-rev.MOWS -
Title 5 Oflirdel Inspection Form:Subsurface • '
CUSTOMER STATEMENT
613/2020
pST Na6;652.
DNI APOLI,DEBORAH,A
2!gA<TION:
89 GUNSTOCK RD'
OST LQT;. 1141
ni�P&PARC_ 12011
Consumption HistOry
DATE READ CO9
12/31/19 lk 71.5
06130/19' 666 9
12/31118 657 93
06/30113 564 S
12/31117 556 47
006/17 509 9
12/31/.16. 500 51
06/30/16 449 11.
7 3 o atS
C-A Ll-
i
f®r.y® r iS jc,Sy r pips lt®. �®ad Tr®�a�Il�
rt'The waste water,leairing... house comes from, Keeping these components functioning wellis relative ly simple if you follow these tips:
sinks,toilets;showers;and,the washing machine r -
-+. 4 Do have your tarik-pumped out and sys� Don't drive or park over any part of your
and dishwasher It.carnes solids, :grease, dirt,
chemicals;bacteria andrviruses. it needs quite a tern inspected every three to five: system)
"bit of cleaning,before t can safelybe dumped into
years. Contact your Board of Health Don,1 plant shrubs or trees over your sys-
for a septic contractor licensed in. tem! Roots may clog and damage
a pond>or into,the.ground water. Your septic sys- i
tern.does just your town. your lines or leach field-
a Do keep a record of pumping, inspec- .Don't use your toilet.as a trash can or for
While not all septic systems are the same,,most -
.modern ones (constructed since 1978)consist of i
tions and repairs. Itwiill come in food disposal!
a septic tank, a distribution box,,and a leaching handy when you wiant to sell or rent Don't dispose of cooking oil;fat and grease
'n
facility. your house. i s t
, your eptiasys ern.
DQ; practice water conservation Repair Don'
In your septic tank;the solidssettle to the;bottom drips and leaks. Use.water-saving tu se commercial septic system addi-
(sludge)and the grease:floats to the.top (scum). showers,toilets and faucets.Avoid tives.At best they are harrrtless:and
heavy�use of water at any-one time..
The partially clarified water Troves from the tank �. - a waste of money;at worst they hurt
your system.They are not an alterna
into the leaching facility wheie it leaches through i -
Do use your garbage disposal sparingly. tive to regular maintenance, which
a layer of soil before it reaches the underground It a hea uts burden on our_se
water table.The soil and the microbes and baste- p heavy • Y p is cheaper in he long run.
ria living in it help to purify the waste water. (Older ;tic system,. _
Don. f make or allow any repairs to yoursys-
systems, often called cesspools, do not.have a Do_divert roof drains and surface water tern without fhe'properpermits from
leaching facility andare°considered inadequate run-off away from your septic system: your Board of Health.
treatment:) Do keep a map of the location of your. ,Don:g pour hazardous household chemicals
• system components and make sure - down the drain:
all household members are aware of.- e
I,
'what is underground.
..............tx� to Pdaitl t9ta Rbrts b aln
. t �. ? bleach, 5anduch toi
............... . . ,
Do use ho sehold chemicals
.............. ... lea is'nfectants dr ,
let bowl cleaners in accordance,with
product labels. NONDEGRADA""BEES^Tee grease, disposable
diapers plastics, Gtc
outlet: '
Inlet•sewage treated a
enters from �' arastewater' -
house goesto s. �` POISONS:
Cibudon box _
an ,gasoline, oil,paint
ddrelnReld '
r
p n:thinner,pesticdes,
nt�f
a reeze, etc.
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
d!AP
PARCEL
w0T
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 89 Gunstock Road
Osterville, MA 02655
Owner's Name: Claire MacDonald
Owner's Address:
Date of Inspection: October 29. 2004 [� � �
r
Name of Inspector: (Please Print) James M. Ford ® 2004
Company Name: James M. Ford
Mailing Address: P.O.Box 49 HEF��H�^�S AgIE
Ostervflle.MA 02655-0049 tov�,'N�F pEP�
Telephone Number: (508) 862-9400
CERTIFICATION STATEMENT.
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection., The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: November 4, 2004
The system inspector shall submi copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
""This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 89 Gunstock Road
Osterville, MA
Owner: Claire MacDonald
Date of Inspection: October 29, 2004
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 89 Gunstock Road
Ostervdle.MA
Owner: Claire MacDonald
Date of Inspection: October 29, 2004
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. _ System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
. Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 89 Gunstock Road
Osterville. MA
Owner: Claire MacDonald
Date of Inspection: October 29, 2004
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/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 well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what mill be necessary to correct the failure.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system'is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed. The owner,or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 89 Gunstock Road
Osterville MA
Owner: Claire MacDonald
Date of Inspection: October 29, 2004
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:
Yes No
✓ _ 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(3)(b)].
5
Page 6 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 89 Gunstock Road
Osterville, MA
Owner: Claire MacDonald
Date of Inspection: October 29, 2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.20.3 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: I
Does residence have a garbage grinder(yes or no): Yes
Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy:, Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment: 4
Design flow(based on 310 CMR 15.203): Qpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:_ Pumped on 5/61'04-per treatment plant
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: _gallons--How was quantity pumped determined?
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)
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 2127181 -per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 89 Gunstock Road
Osterville, MA
Owner: Claire MacDonald
Date of Inspection: October 29, 2004
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 3'
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 2"
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: 12"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Cement tees were present. The liquid level was even with the outlet invert. There did not annear to be any signs of leakage.
The inlet cover was 3"below grade.
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 89 Gunstock Road
Osterville. MA
Owner: Claire,MacDonald
Date of Inspection: October 29, 2004
TIGHT or HOLDING TANK: None (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: allons
Design Flow: allons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
/ Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
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 level. No solids were nresent.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 89 Gunstock Road
Osterville, MA
Owner: Claire MacDonald
Date of Inspection: October 29. 2004
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 1 -6'x 6'(1000 ag_I)
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
Innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
The leach nit had 4'ofliauid on the bottom The scum line was at the same level There did not appear to be any signs offadure.
The cover was Y below grade The bottom of the leach pit to grade was 9'
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil,signs of hydraulic failure,level of ponding;condition of vegetation,etc.):
PRIVY; None (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.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 89 Gunstock Road
Osterville. MA _
Owner: Claire MacDonald
Date of Inspection: October 29,2004
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
Fro T A
Q 0 a
is a.
3
3
as ;L3 y
KO3 10
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 89 Gunstock Road
Osterville, MA
Owner: Claire MacDonald
Date of Inspection: October 29, 2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 25+/- feet
Please indicate(check)all methods used to determine the high groundwater elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic 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:
The bottom of the pit to grade was 9'. Using Barnstable topographic and water contours maps the maps were showing_
approximately 25'+/-to ground water at this site.
1
This report has been prepared and the system inspected and passed as of the date of inspection.This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees,either expressed, written or implied, relating to the system,-the inspection and/or this report.
11
TOWN OF BARNSTABLE
LOCATION q� 6Un shil C SEWAGE #
VILLAGE— o S-zry,Ili ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY UW
LEACHING FACILITY: (type) ��� �x (size)
NO.,OF BEDROOMS 3
BUILDER OR OWNER C��l�c, ✓!'��LGVnnI G
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leachin�facihty) �^ Feet
Furnished by ��►SOGU`l l tk. C o r e
(3 -
-
1 '
3
3a
a a3� y
y
036 Sa-
9T°. W PERMIT N
IOCiTION � 'SEWAGE0•
go
VILLAGE f'
INSTA LLER'S jNA�ME i ADDRESS
BUILDER OR OWNER
DATE PERMIT ISSUED
" r2 �
DATE C0M ►11ANCE ISSUED
1-
' �� I D' i
\�� '�
22 � ! `�
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3
i
4
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No..8.4. 6 75
THE COMMONWEALTH.OF MASSACHUSETTS
/BOAR® OF HEAL
&...---.....OF..... .�?? l�...........................
.............: .
®r.�� / ... ._
Appliration for DiupuuFai Works Toustrurtiurt Prrmit
Application is hereby made for a Permit to Construct (y() or Repair ( ) an Individual Sewage Disposal
System at: .�
ion-Address o t No.
Q t. �........._..fy, �,tc.lo.__. .---- ---• �,�.......:----•---
Owner ddress
a ?�1/I...N....... �G.
nstaller Address .►
Type of Building Size Lot... �Q_�_Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............0.......... Showers — Cafeteria
Q' Other fixtures ------------------------•--••--• - -------------------•--------------------------
--•-----------------------
W Design Flow............................................gallons per person per day. Total daily flow___.___..____.___.__._._______________.__.__gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length.....................Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter................_--- Depth'below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing t nk ) C A f
a Percolation Test Results Performed by.._... �1 !-.___J ..__/U1______________________ Date__________,_
a Test Pit No. 1..&Z___minutes per inch Depth of Test Pit____________________ Depth to ground water........................
Gr4 Test Pit No. 2 ..._minutes per inch Depth of Test Pit____________________ Depth to ground water........................
O Description of,Soil..-' ` 1 _&a _ _4_�.r-------Z -- -------/1.eVe._��-! ------�- _�Z------------------
w -----------------------------------------------------------------------------------------------------------------------------
•-------••--------•-----------------------------•-------------••-------•-----•----•--------•--------------•-••-------------------------•-----••---•••----•-•-._._...--•-------•--------•---------------
V 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 iITLL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been-istlued by the board o he . -
Si ned.__ _
--- ----- • - -•---•-------------
,r j Dat
Application Approved By......... ---- ----------------------- !._. �/ .... _�� ....V P
------------
Date
Application Disapproved for the following reasons:................................................................................................................
-----------------=---•----....----....__...--•----•-----------------•------------------•----•--------•---•---------•-------•-••---•--•••---•--•---•---------•---------•----------------•----•-------•---
Date
PermitNo......................... •---------------
No,f
THE COMMONWEALTH OF MASSACHUSETTS
----�' BOARD OF HEAL
oF � ... -- .........................
Aplrliration for Disposal Works Cfnnstrurtivn 1hrutit,
Application is hereby made for a Permit to Construct (y() or Repair ( ) an Individual Sewage Disposal
System at:
........._ .......... . --------- -------
o t� ' •.-• tion Addre s ---
7L. _�/� � 4-t? �................7 x:. ?? c/ l.SCy 1.r f.. ..__..........
Owner Address
Installer Address .+
Type of Building Size Lot_._. __ _0-. _.Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
a Other—T e of Building No. of persons...........Z.- Showers — Cafeteria
Otherfixtures -------•----•------------------------------------•--------------------------•----------------------------•-•------------........---------••----------
w Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No......................Width.....................Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area -----
ft.
Z Other Distribution box ( ) Dosing nk )
Percolation Test Results Performed by__.... i I. _!��- ._._1 �� L) / / /�
Date �-1/- `•-_
1.4 Test Pit No. 1.4.4....minutes per inch Depth of Test Pit.................... Depth to ground water.......................'
Grq Test Pit No. 2Gc. ._minutes per inch Depth of Test Pit.................... Depth to ground water........................
Description of_Soil... �—!PA S6 ...................�--- ! 1 ?t o J --•--•-------------
x c
v d Lr..t��?..--� f.. ----- ----- ----------------- ---------------- ------•---------------•---------------w
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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 TITLZ' 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b-en i ued by the board o h t
Signed____ ,,/
l
�� Date
Application Approved By. -.____._�._�1.
i;r/ Date
Application Disapproved for the following reasons-------------•-----------......---•-----------------------------•---------------• -----•--..-------------•_._..
-------•--••---------------•-•---...------•--•----•---------....---......-•----------........-------•-•-----------------------•-•----•------------------•---•-------------------------------------------
Date
PermitNo........................................................... Issued.------------•----- ...............................
• Dattee
THE COMMONWEALTH OF MASSACHUSETTS
BOARD" OF HEALTH
......./00/1V......OF...... / f...' '�---�Gz�-t�v
Trrtifiratr of Tompliana 'ate
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (�or Repaired ( )
by..l �J.i ... '= jj�� ---------------------------------------------------
at Ile
has been installed in accordance with the provisions of TI T LF 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..................a-.........................—� 7
/.....------..._...._._._.. Inspector.-•---- -.........
.........................--•-----......._......................--
L
THE COMMONWEALTH OF MASSACHUSETTS
°---'' BOARD-�OF HEALTH
S y
OF �Z..v /'
No...... �...... FEE......... ...
�i��r�a ttl irk ��n,��rnr�uan prntt�
Permission is hereby granted...--V e lf/ -----=.. -Y.................. •-••----•-•-•......................................................
to Construct (, or Repair ( ) an Jndiv'dual Sewage .D'• osal�l
at No.. D/...._...!. f�-'': C l-� / ,... � f /✓// /
-----------------------------------------••----
' Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
' �Health �
DATE.............-..................................................................
B oard of
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
N Z yi c{Y) !��wr •n'}•• t ,t r \/Y,'�.•• / Y" � � 1 wl P •v ✓r' /� �� /♦•� , .! - �'.�� R.F I,t'1 y. fie.�b
„YG s,� S a i f•7 }�. _.,_..— ..--. .. 3/ I^ .�..'0 p .... C .. r am{.�«, ,,.. -�«..-..._,<:..•.....,. Y: T , ?i
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LEGEND ,.�
>.� � :,-----�•--f---.��RTI'r�0'Ew r'LOT P L AN'--
EXISTING .
EXISTING SPOT fLEVATI9N Ox0 , •='=`;
'�': E3fI8TING CONTOUR --- 0 --- f z-OT /, / �.c/. /s'�� �2 :.
FINISHED SPOT ELEVATION "f C : '— cl�t .�:_C
FINISHED CONTOUR 0
INy ,
AMOVED s BOARD OF HEALTH aa
GATE AGENT ' , o; 'SCALE=' / '=33 9- , DATE, Vz- ?
` C®RE06E ENG/NEER/NG CO. IN cis 7: /"Vv;
>' CLIENT I CERTIFY THAT .THE P001)09.801
EOISTERE r.., REGISTERED JOB'N0. F-G v4 BUILDING SHOWN ON THIS , PLAN;,. x
�• CIVIL LAND CONFORMS TO THE ZONIN® :LAMB ,,�
N ErR URV YOR DR.BY-' --,>1'. OF , BARN OLE, MA08. : v / a
s ; 712 MAIN ST. CH. BY= 9 �sl t
dt l ;a !
NYANN.IS, MASS. SHEETL OF DATE REG,: LANQ 3tiR .
Y t,
240 FT. M/N. °IYOTF /F E/TfIER 7',W e SEPT/C TANlC OR
LEACH/ivG P/T,ARE MORE TNA lV '/2"EEL'ON/ �
/O FT M/N f GRAA!If ,A 2 OM E 4' /ATE T,S R CO/VCR.F COP&&
�.. SNAL[ B.F BAVV&4S 7" TO 4)TAOE.�-4JV ASrTRA '• !a
CO/yCmerg 4IV. P/TCN O/Pr /ie,4Vy CAST IRON CO//ER SHALL BE 41SE•d
L j v p COVE M/�{/ /F/N ORI VEJoVA r
t�J�J(( MiN. CO/VCoe&
A C�RAOE CO NER �.
CLEAN SANG
45ACAe,
I UQ!//N LEYEL
CAST Z*LAYER
IRON P/PE !.. p o v o e OF
P/TGN f GAL. a +f eL
yyASHEO 57i�NE
TANfC D/ST, o s e e . . e • e e• • • ee • .►° .• e •
0 e •EFPECTrvC ' ` . , 3 a 0-
1 • ° ' e • DEPTH• • e • 0 0 1V.4SHED STGiYE
. i' O • e • • • • •• 1 �O 0
j p too C • e • • • • . e • p p PRECAST SEE-I�IGE
INVERT 4e'LEf/A7'140H5 , • ►o • • • •, • Off . e o P/7 OR EQU/V,
/NV,ERT AT DU/LD/NG 9 ?- f FT, 6 FT D/AM.
INLET SEPT/C Ti4NK 9 i.e,-' AFT, e . —LV FT. DVAM. C SEE 7)-WVLA r)0Al)
OlJTLET SEPT/C TANK 'FT
'INLET D/STR/D!?/ON BOX `C 12 !FT. SECT/ON OF GROUND WA7ZX TABLE
OtITLETD/STIR/®f/T/ON BQX 9U.� �F7; T. `
INLET ZEs►C///NG /aV T 0.o �T .SELVAGE 0/SA05A A. .SYST<'FM TABULATION n
4 LEACHING P/T
dCALE �4" a /=O~ D/MEN-TION
D.ESl6N CR/TER/A '0/MEWS/ON 8 6 FT.
N[/AJQER OF BEDROOMS �. O/HENS/ON C �' Fr /1! F
Gi4R&AGEO/SP05AL UNIT - SOIL` LOG.
TOTAL EST//►�V�TED F'LOH/ ? O . `.. SO/L TEST
GAL.1D.AT.` SOIL TEST AI SO/L TFST40,2
AlUMBER OF LErACNlNTi PITS / - fELEY. ZU ELFY - pATE OP SO/L TEST
S_LOE-.LrAGH/NG PE/?P/T L Ss
BOTTOM LE�ICN/NG PGR P/T :r ram' RLVSUATS AW-rV&SSED BY
PT Lu A PfERCaLAT/ON RATE#! L SS' M//V�I/NCH
7'07ri94 LE4C/!/NG AREA 4 s,� ,fT.. y ;/i L J VICCOLAT/ON RA7"E A-2 "T"r:s��ei M/N�/NCH
ARSBRVELB4CNIMOS AREA �� St. FT. a. _ 2,0
5 's
RBERT ,T
C/ >
t3UfdiKl
o�p fVa.22162�0 aF'
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Fss`ONAL� '... Et - �� ; r t.
M. AIN Sr.. W. .
®"/N0 8/�ONND Wi4r&,V AWCDI/IVTJ+"RED, NYANN/S�. MA SO
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