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HomeMy WebLinkAbout0138 GUNSTOCK ROAD - Health 138 Gunstock Road Osterville F/R A = 121 106 n a m a oa a 6 a ° ° a m e °TOWN aF BASTABI.fi LOCATION.' ASSESSOR`S Rr1AP $.OT;; IIVSTALLE t'S ld &I'i{)NE N SBF nC T`ANK CAP'CM- lQ LEAC1:iFNG;FACI�:I`i'�' tom} sue} l�b 0 cf rto. � i'�oois 3: �(�pEit;OR OWi�ER RERit2€£DATE: CO €PLIANCE llAT Segarat�on I?stance Between Eire MexianumAdjusteclCroun�iwaterUl A- t�eBottom'afLrachcngFacility i~eee Private�►ater Supgly well aid I�acb,ng F�ctitty �asay+xnlls exisi . Olt sits or:.uttun €eet bf lese iFiag€actcy} Feet Edge Of WttW end Leafing *aality(�€f Any cveRiands exist witiug 3Q0 fe t of teachincity} f Feet ForWrhed by c r=�1 T ,a 3 ' r 3' TOWN OF BARNSTABLE . LOCATION Ir-3) SEWAGE # 4W3' /23 s VILLAGE �ak ,//e ASSESSOR'S MAP & LOT I,1'10(0 INSTALLER'S NAME&PHONE NO. yae-7 2,C SEPTIC TANK CAPACITY I,Oc� GAG �� � �/i✓ �7'De�t LEACHING FACILITY: (type) Ri;",- (size) NO.OF BEDROOMS 3 BUILDER OP<5 WNER gA- PERMTTDATE: 3�7) d 7 COMPLIANCE DATE: -� j 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 'f within 300 feet of leaching facility) Feet Furnished by '� �>3S � ��' _, �y' 3%� sr' ,8' z�' yj� 36` so' Z E a l rj T 4 No. Fee THE COMMONWEALTH OF MAS SACHUSETTS Entered in computer: �K7 Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pplitation for Migool *potent Con!aruction Permit Application for a Permit to Construct( )Repair(✓)Upgrade( )Abandon( ) ❑Complete System 10 Individual Components Location Address or Lot No. Owner's Name,Iddress and T 1.No. /�Cp/`i� Assessor's Map/Parcel Installer's Name,A dress,and Tel.No. /v cf Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /BOO . Zl jz/�°9 Type of S.A.S. ®� Description of Soil Nature of Repairs oyy Alterations(Answer w en applicable). ,�2i 'S�Q� C G�QI�9 ®/ g9 `&gg4 a0) ,2 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by thistBo do ealft Signe _ Date -Y/ . Application Approved by Date Application Disapproved for the following reas s Permit No. Date Issued No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: C" Yes 1 PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS application for 30i5pozar *proem Construction Permit Application for a Permit to Construct( )Repair(V/)Upgrade( )Abandon( ) E)Complete System 19 Individual Components Location Address or Lot No. Owner's Name,Address and T 1.No. Assessor's Map/Parcel Ile Installer's Name,Address,and Tel.No. / Designer's Name,Address and Tel.No. 77i-93�� Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures ,m--- Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title _ Size of Septic Tank /®00 9 Q / , ,� /�� /�'9 Type of S.A.S. 14A!, 91_1 Description of Soil Nature of Repairs o}},,'Alterations(Answer when ap licable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board o ealth. Signe 1 Date .3Al Application Approved by // ,�i.�+ 9 /1�/, 4 Date i Application Disapproved for the following reas Permit No. Date Issued --------------------- ---------- ----- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS �. ✓e--sue� , s� Certificate of Compliance THIS IS TO;CERrf, that thepn-siteSewa..e Disposal System Constructed( )Repaired( ✓)UpgradedAbandoned( )by � � S iat 8rl.1rl , `One A' - 0-51 ' has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit NAM .2&dated Installer Designer The issuance of this p mu shall not be construed as a guarantee that the system f s s' ne Date" Inspector NO. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migpozal *pgtem Construction permit Permission is hereby granted to Construct( )Repair( ✓)Upgrade( )Abandon( ) // System located at t and as described in the above Application for Disposal System Construction Permit.The applicant.recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constructi n must a completed within three years of the date of thi prmit. 9�h , ,E5 Date: / A roved b - �l PP Y f TOWN OF BARNSTABLE LOCATION /Yr e7ws-/,E,4 /o SEWAGE A /23 VILLAGE �s,4.rii ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS 3 BUILDER O WNER PERMTTDATE: >> d 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 J within 300 feet of leaching facility) Feet I l Furnished by 36� I r0 I i i i r f COMMONWEALTH OF MASSACHUSETTS d EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION FAILED INSPECTION RECEIVED 0 1. )n03 TITLE 5 4PFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A RECEIVE® CERTIFICATION MAR 0 4 2003 Property Address: 139 Gunstock Road Osterville MA 02665 TOWN OF BARN�TALBLE Owner's Name: Andrew Park HEALTH DEPT. Owner's Address: Same Date of Inspection: February 9,2003 MAP a �� Name of Inspector: PATRICK M.O'CONNELL PARCEL I ®...._.. ......... Company Name: SEPTIC INSPECTION SERVICES CO. LoT Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: (508)428-1779 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 hAning 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 X Fails Inspector's Signature; (�" Date; The system inspector shall submit a copy of this inspection report to the Approving Authority(Hoard 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 Tank Is leaking.Standing water mark in distribution box Is 2"above outlet pipe. ""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 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 138 Gunstock Road,Osterville Owner: Andrew Park Date of Inspection: February 9,2003 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: • Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 138 Gunstock Road,Osterville Owner: Andrew Park Date of Inspection: February 9,2003 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: i Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 138 Gunstock Road,Osterville Owner: Andrew Park Date of Inspection: February 9,2003 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X_ _ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone l of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] _Yes_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) ,i 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 Il 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. Page 5ofII OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 138 Gunstock Road,Osterville Owner: Andrew Park Date of Inspection: February 9,2003 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _ _X Pumping information was provided.by the owner,occupant,or Board of Health- - X_ Were any of the system components pumped out in the previous two weeks? _ _X_ Has the system received normal flows in the previous two week period? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection? X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ — Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS, located on site? _X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no _X_ _ Existing information. For example,a plan at the Board of Health. _X_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 138 Gunstock Road,Osterville Owner: Andrew Park Date of Inspection: February 9,2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):330 Number of current residents:2 Does residence have a garbage grinder(yes or no):No Is laundry on a separate sewage system(yes or no):No [if yes separate inspection required) . Laundry system inspected(yes or no):_ Seasonal use:(yes or no):No Water meter readings, if available(last 2 years usage(gpd)):2001-336,000 gal. 2002-235,000 gal._782 gpd: Sump pump(yes or no): No Last date of occupancy: February 1,2003 COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records None ' Source of information: Was system pumped as part of the inspection(yes or no): If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF 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 1982 per As-Built card. Were sewage odors detected when arriving at the site(yes or no): No r Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 138 Gunstock Road,Osterville Owner: Andrew Park Date of Inspection: February 9,2003 BUILDING SEWER X (locate on site plan) Depth below grade: 1' Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: 30' Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: X (locate on site plan) Depth below grade: 1' Material of construction:—X—concrete metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: 8'long x 5.2'wide (1000 Gal.) Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 26" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): House was vacant for nine or ten days prior to inspection.Liquid level in tank was 4 inches below outlet invert.Tank is leaking.Outlet baffle is split and close to falling off.Small layer of grease in outlet pipe. GREASE TRAP: No (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.): Page 8 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 138 Gunstock Road,Osterville Owner: Andrew Park Date of Inspection: February 9,2003 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: ;gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 2" 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.): High standing water mark is 2"over outlet invert. Evidence of solids and grease in box. PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 138 Gunstock Road,Osterville Owner: Andrew Park Date of Inspection: February 9,2003 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type _X_leaching pits,number: 1-6x6(1000 gal.) 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.): No ponding but soil is damp over pit. CESSPOOLS: No (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: No (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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued)_ Property Address: 138 Gunstock Road,Osterville Owner: Andrew Park Date of Inspection: February 9,2003 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. . C"Z0 138 �y z I � q3 AP f Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 138 Gunstock Road,Osterville Owner: Andrew Park Date of Inspection: February 9,2003 SITE EXAM Slope Slight Surface water None Check cellar Dry Shallow wells None Estimated depth to groundwater: More than 30 feet. Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) _X_Accessed USGS database-explain: Checked town groundwater contour map and USGS topo map. You must describe how you established the high ground water elevation: Groundwater at EL.15 and property at EL.50 I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION V0 13 I TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION RECEIVED Property Address: 138 Gunstock Road MAR 2 5 2003 Osterville MA 02665 Owner's Name:. Andrew Park Owner's Address: Same TOWN OF BARNSTABLE HEALTH DEPT. Date of Inspection: February 9,2003 ' Name of Inspector: PATRICK M.O'CONNELL �" PAN Q Company Name: SEPTIC INSPECTION SERVICES CO. ' {- Mailing Address: 189 CAMMETT ROADiH1�, C w MARSTONS MILLS MA 02648 Telephone Number: (508)428-1779 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 X Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails . Inspector's Signatur Date: 3z0/0 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments Tank is leaking. Standing water mark in distribution box is 2"above outlet pipe. Leaching pit has 3 %:' of effluent with a high water stain 1 above. ****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: 138 Gunstock Road,Osterville Owner: Andrew Park Date of Inspection: February 9,2003 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: _X_ 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. _Y_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: Tank is leaking and outlet baffle is cracked. _Y_ 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: Pipe from distribution box to pit is pitched back towards box and needs to be replaced. 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: Page 3ofII OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 138 Gunstock Road,Osterville Owner: Andrew Park Date of Inspection: February 9,2003 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. w 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: Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 138 Gunstock Road,Osterville Owner: Andrew Park Date of Inspection: February 9,2003 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this forma No_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply _ — the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone I1 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. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 138 Gunstock Road,Osterville Owner: Andrew Park Date of Inspection: February 9,2003 Check if the following have been done.You must indicate"yes"'or"no"as to each of the following: Yes No _X_ Pumping information was provided by the owner,occupant,or Board of Health _X_ Were any of the system components pumped out in the previous two weeks? _X_ Has the system received normal flows in the previous two week period? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection? X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out? _X_ — Were all system components,excluding the SAS, located on site? _X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _X_ _ Existing information. For example,a plan at the Board of Health. _X_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CVIR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 138 Gunstock Road,Osterville Owner: Andrew Park Date of Inspection: February 9,2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):330 Number of current residents:2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no):No [if yes separate inspection required] Laundry system inspected(yes or no):_ Seasonal use:(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): 2001 336,000 gal. 2002-235,000 gal.=782 gpd. Sump pump(yes or no): No Last date of occupancy: February 1,2003 COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd 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 None Source of information: Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X_Septic tank, distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous,inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components, date installed(if known)and source of information: Installed 1982 per As-Built card. Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 138 Gunstock Road,Osterville Owner: Andrew Park Date of Inspection: February 9,2003 , BUILDING SEWER X (locate on site plan) Depth below grade: 1' Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: 30' Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: X (locate on site plan) Depth below grade: 1' Material of construction:—X—concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 8' long x 5.2'wide (1000 Gal.) Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 26" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: .14" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): House was vacant for nine or ten days prior to inspection.Liquid level in tank was 4 inches below outlet invert.Tank is leaking.Outlet baffle is split and close to falling off.Small layer of grease in outlet pipe. GREASE TRAP: No (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.): Page 8 of 11 f. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 138 Gunstock Road,Osterville Owner: Andrew Park Date of Inspection: February 9,2003 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete ,metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 2" 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.): High standing water mark is 2" over outlet invert. Evidence of solids and grease in box. PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 138 Gunstock Road,Osterville Owner: Andrew Park Date of Inspection: February 9,2003 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits,number: 1-6x6(1000 gal.) 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.): Pit has 3 '/2'of effluent has high water stain 1'above current level. CESSPOOLS: No (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: No (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.): n . Page 10 of l l OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 138 Gunstock Road,Osterville Owner: Andrew Park Date of Inspection: February 9,2003 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. AD iy Z �3 lip 50 Page l 1 of 1 l it I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 138 Gunstock Road,Osterville Owner: Andrew Park Date of Inspection: February 9,2003 SITE EXAM Slope Slight Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 30 feet. Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) _X_Accessed USGS database-explain: Checked town groundwater contour map and USGS topo map. You must describe how you established the high ground water elevation: Groundwater at EL15 and property at EL.50 Commonwealth of Massachusetts �jA Title 5 Official I nspection Toft' ' r4 Subsurface Sewage Disposal System Form ='Not forsVoluntary.Assessments J 138 Gunstock Rd Property Address ,. Steven Scott ,;r?•ry r ,� T- Owner Owner's Name information is ✓ , required for every Osterville,- i, ��..^ ;,,, MA 02655 6-8-2'1 t, page. City/Town t,w .. l State Zip Code Date of Inspection _. ����� *IAA* �'�,f ' • ' r .� Inspection results must be submitted on this form. Inspection forms ma"y not be altered in any way. Please see completeness checklist at the end of the form. t f I,, 'x tr .I.'.:'a9• ,. ,d �,� .fI1'�+tic. f.J,.11 A. Inspector Information tip,, M o_u_, Shawn Mcelroy , - i r' { ? [: !ar N.:It..,rSll'1; .."i' ![ ti1"A?i:.{,t +i Y!'4 4If!!•1!:-d •t „ 1.9• .3 y •�• Name of Inspector' Upper Cape Septic Services Company Name '"•` ": P.O. Box 73 Company Address East Falmouth n;rr-:+rt I -u n. ".t 04' t:J;[MA i:,.Im—'iao..,r nits �fi ,.02536 i.:af, n4 I^ri'City/Tgwn�•Ft7Ffio;`. .xt , :!, r#,,'c'iw', t�v Z rStater a '9 't:J+ :fw' ci 1 ,; aZip Code 508-495-0905 ..stJ pnyImq SI3971, t5{ Telephone Number License Number B. Certification I certify that:l am a DEP approved system inspector in,fulltcompliance with Section 15.340 of Title 5 (310 CMR 15.000);I have personally inspected the sewa a dis osal's stem at the" ro` ert' address listed P Y� P 9 p Y p P Y above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based'on'rnytraining arid,expenen`ce in the'proper function and •maintenance of on-site sewage disposal systems.After conducting this inspectional have determined that the system: i:•r Passes' "r c r[t t ..� ,' .`fy..t:{t,+•3- , flit. + T71 ^ ln! :. ' ! .�,ti.Y: r'.�..' 2.,,❑-,Conditionally Passes yfit f "i:.n . .. nt.'"Til in tf..rtr,r ' i°!. S ?I{;tjXs7 .�lflid3 t•i r 3.1 ❑ Needs Further•Evaluation,by jhe,Local Approving Authority,a e�flrtl 11gl,W. ,-1 4. ❑ Fails ftfrt..t `'';, 13 :t ; ,`.',. t I ' �ritil`�illlf�i¢; `' t;ljr{',.�•�lli�''_r'; ttfil;ttt^i �!{r>�;t^{�iv:f,P, +c}��+•L �'.�, �',f{'i " ''.x*.?� t�ti.`t vri{a:aif !�, lfs t1:1'.;r "1'1lrif*?9i1C� . .. ¢..6-8-21 s ector's Signature ' "'' "''"' ""'. Date " The system inspector shall submit a-copyof this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system-owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/2 612 01 8 `.; Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page.1 of 18 a S_ Commonwealth of Massachusetts Title 5 Official!, Inspection Form.t p Subsurface"Sewage Disposal:System Form -Not for Voluntary Assessments + =Yw•1 138 Gunstock Rd ►= ' "+zi'trt•- 3� Property Address Steven Scott Owner Owner's Name information is required for every Osterville. MA- 02655 6-8-21- page. City/Town ° _ State Zip Code Date of Inspection , C. Inspection Summary f,f ... ;,• { .-J. :ill it+- Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Pa'sses: ;r, . :t i i ; ' Y I ..� ® 1 have not found any information which indicates that any of the,failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any+failure criteria not evaluated are indicated below. Comments: a -.System is in good working order with no sign of failure. System was operating at about 90% of its capacity at inspection with water level at 8"below inlet invert. Recommend pumping septic tank and leach pit annually for maintenance and to prolong life. Syste, Y'+' ..,... •;,. Y" ' r •Y.. Y,; !! 11`:: + 'rn .•, ! I.3' ; :i? 2) m,Conditionally Passes: �4 f ❑ One or repaor more system.components as described in the "ConditionalPass"section need to be Yr, replaceired.The system,.upori completion,of the replacement or repair, as approved by t the Board of Health,will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank'(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent..System will pass inspection if the existing tank isTeplaced with a'66m' plying septic tank•as�approved by 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): i {i: i1 , r + ' +Ci VL'1 f ii t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System+Page 2 of 18 ' A Commonwealth of Massachusetts �_ .,. . s - 3� : ' �`•��.; ;�;*:. ,r ,�,,' Title 5 Official .- Inspection- Fd-r w s. hi Subsurface Sewage Disposal System,Form.-Not,for Voluntary Assessments :,V(J 138 Gunstock Rd Property Address Steven Scott Owner ' Owner's Name information is required for every Osterville MA 02655 6-8-21 page. City/Town P. State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes.(coat.): Hr ❑ Pump Chamber pumps/alarms not operational. System will pass-with Board of Health approval if .pumps/alarms are'repairedt° #o,, r.a-tsf4„ ,.l+:,`:.11 "} "'�J: a :r..$ •. 'i�7�'.A i:seq?t-,,fv16' is i i i.- ❑ 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)' n- • � -r,Y •� •ri a t,i 'i"# �t,�47sa i 1 i:,,. u:.7`#«:G - •>7 F, ;,# -. }.t broken-pipe(sj are replaced' ND (Explain below): • der: ri;, .i '' fit' ' nobstruction is removed ' rf' ''�'"�`""❑`Y-''❑NE' ❑ ND (Explain below): fo t'z"'}ce figs{ t'?C "distribution box is leveled or replaced'`'''❑Y`' �t❑ N ' ❑r ND (Explain below): `A'! J." :t n. .site i,�•?C�:7#]i,.1; '� i. ' � r ;rr' .3i.t ,t+ ?J�' �ifw:8t-.,+�'•ililw�' sttlr'+•:f'tt:(i �'.i}:P '3'`-i ?{�,� . ,}�rt+-�� i-r .ti° ❑ 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:, id-i:) anefne, #{L ❑ conditions exist which require further evaluation by,the,Board of Health in order to determine if .the system�is'failing to$rotect public health, nm safety or enviroent fr : - 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 - - e Commonwealth of Massachusetts i ` . .i` 1� Title 5 official Inspection Form 'AI Subsurface Sewage Disposal System Form -Not forrVoluntary Assessments +, :V 1 138 Gunstock Rd Property Address - Steven Scott _ .Y Owner Owner's Name information is Osterville MA 02655 6-8-21�' A required for every � ""� • page. City/Town l 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 I supply. " ❑The system has a septic tank and SAS and the SAS S 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. / - -6. Other: 4) System Failure Criteria Applicable to'AII Systems:,.' You must indicate "Yes"or"No'to each of the f6ilowi6g for all inspections: as Yes NoEl ® 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 -a. ± "�U 14 Title 5 Official Inspectidn. form . I ..d f Subsurface Sewage Dis osal S stem Form.-Not for Voluntary Asses e ' 1r. ., .r► g p y ry _ sm nts t t � +� �. > 138 Gunstock Rdl ,_ Property Address Steven Scott a '?t. r1',)V-,X Owner Owner's Name information is r, .,• _ orl required for every Ostervllle.-t7-f c .�J n'.- MA 02655 6-8-213`+' + C page. Cityfrown ct,L *.- State Zip Code Date of Inspection ! C. Inspection Summary (cost.) / ;� ,►° ;,� •:,�»t ., •, , 4) ;System Failure Criteria Applicable to All Systems: (cont.) a1: Y'I'ri r, t e It "t-'1 a' t '!. �•f�ts''�'i1`-I "� �=�'6" �� .r ?.' s 3, .� Yes.. Itf,No, to : ,,:�►o,,f, t,r ,,,Irl:c,^ e:t9 f� r x, 4t3 s ° � ', �' ,,�... 1• , -_ ma's Jr. c'} � ' i'1 "}'" ,.. +.. .. -n ,r n:.- •-�'r.., 3 .. ® Static liquid level in the`distnbution box above outlet invert due to an overloaded l.... , � ` ..iC. d a`I ilk .. .�-.. 'or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less -than''/2 day flow El ® Required pumping more than 4 times in the last year NOTdue to clogged or obstructed pipe(s). Number of times pumped: ' )'T 1r.fe El jp, ,� v Any portion of the-SAS,,cesspool,or.privy is below high.-ground water elevation. { Any portion of cesspool orfprivy is within 100 feet of a surface water supply or '` '`i1ti` F<'?":°_ ❑rr� `�` ® ',ds tributary to a surface water supply' Any portion of a cesspool or privy is within a Zone 1 of a public water supply ti�k:f`rf{ lt'iV ,0: r+' :�q 3rtj r, tt: ode,t.•t x ini+•. 1 «?a rf r well. rA14 .' n �tl.�':.f'41 t .'fin" -,L. 'e- i .r : •+ , Y.r^a tax ® Any portion of a cesspool or envy it within 50 feet of a private water supply well., It f ,n F-..r '.iG'9' l�Ch �... ,:fl. .a.1,: °� tT it,,Ll.as• *I.--tt- t ❑ ® Any portion of a cesspool or privy isless than 1^00 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(systerrt faiis. I have deierm_ined,that one or more of the above failure r" ❑ f4' ' ® critena exist as described'in 310 CMR 15.303,therefore the system fails. The £.,,. ,, ,s ,,, , 1 ,;1'' system;owner,should contact-the.Board of Health to determine what will be 4 :;• ,, aa:..`, .�t;:� l�. ra i, necessary;to correct the,failure:3ttt,;,,I,r,; r, - I. '`--i ((41 4. j'i= F-3s.`tvywti r+UM"I firs, tf.is r. :t� ¢ 1',) r',r I';.,, rUnc rift j - 5) - Large Systems:To be considereda large system the system must serve-a facility with a design `flow of 10,000 gpd to 15,000 gpd•, I. # r' ,f ,tS :,-r►,_.{,,;. ;; a --t 3*For large systems, you must,indicate either"yes or.P"no74o each of the,following, in addition to the i.E,questions,in Section CA ;jMf wi =.;n.� ..;` rl .t�=�;.-11,3Xicr. 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 a Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts + ' Title 5 official inspection Form = i ,•ri Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 138 Gunstock Rd r' Property Address Steven Scott Owner Owner's Name information is MA 02655 6-8-21 required for every Osterville =u page. City/Town + ,• State Zip Code Date of Inspection C. Inspection Summary (cont.) ; : '_ - ' If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of.the Department. r. 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.in_troduced 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? + ®. U.❑ Was the'site'inspected for signs of break out? ® ❑' Were all system components, excluding the SAS, located on site? I' ® ❑ 'Were the sreptic 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? i'. Wasthe facility owner(and occupants if different from owner) provided with Information on the proper maintenance of subsurface sewage disposal systems. The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑` Existing information. For example, a plan at the Board of Health. ® ❑ 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 ;,t + a xfl Fly t• z; .:.` Title Official I ns.p:ec$io Foy : - ! t Subsurface Sewage Disposal System Form a=Not for;•Voluntary Assessments. 138 Gunstock Rd r, Property Address ,.. IL Steven Scott Owner Owner's Name information is required for every Osterville'. .-. 7 FS' + MA 02655 6-8-21,.• page. City/Town - -, State Zip Code Date of Inspection _y - D. System Information 1. Residential Flow Conditions: =^,�`Ci+irs,� � •�e�," ta..t�Y: ,:Fw',; a :' rs Number of bedrooms (design): 3 - Number•of bedrooms-.(actual): 3 DESIGN flowbased on 310 CMR 15.203 (foriexample: 110 gpd•x#,of bedrooms): 330 Description: ..:,0 r;14 .,,61A,r 11 ,q1 I7 Number of current residents: S t Jr+' �+ x, 6i r +4'a .�t�ti:: . .s} �+ 3 Does residence have a garbage grinder?, .y;t,01 L�„jr8rj:4.,, ❑ Yes ® No Does residence have a water treatment unit? ,'E; ,.,,• Ittetirf•ar.,.n ❑ Yes ® No If yes, discharges to: .%(Vt Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) - ,rf .,,,< �.E, , ,' ❑ Yes ® No Laundry system inspected? - - El Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: . _ �'flC�`�S L}�'Cj�T•.Ft.("`RY{.f e1j,'w_ Sump pump? h t.T ..# c'� . ti ❑ Yes ® No Last date of occupancy: 4;t;�:itF r t� , ;;f=ft #V,!loss. _vt ;t, 6-2021 Date t5insp.doc•rev.7/28/2018• . . Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18, 1 Commonwealth of Massachusetts _; v tr.= rf' •. !r ,':; Tetle 5 ® fici:al inspection �or�n- �Cl Subsurface Sewage Disposal System Form --Not for Voluntary,Assessments 'u 138 Gunstock Rd Property Address Steven Scott =l' Owner Owner's Name " information is required for every Osterville MA 02655 6-8-21: page. City/Town State Zip Code Date of Inspection -a D. System Information (coat.) 2. Commercial/Industrial Flow Conditions: `,►.r %� .,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? t t'r' F s ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? + ❑ Yes ❑ No Y Water meter readings, if available: ' Last date of occupancy/use: '"' Date . Other(describe below): r y 3. Pumping Records: Source of information: Owner---pumped 2yrs ago Was system pumped as part of the inspection? ❑ Yes. ® No .`I If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 18 Commonwealth of Massachusetts Title 5 Official, Inspection F& I 1A Subsurface Sewage Disposal System Form Not-for Voluntary,,Assessments,: .r + 138 Gunstock Rd t,r, ;, t� Property Address Steven Scott r,,,�•;, , 4.tr Owner Owner's Name information is required for every Osterville,.i_;a e:;. 9+n �,' MA 02655 6-8-21 page. City/Town ,; -; State Zip Code Date of Inspection D. System information (cont.) 4. Type of System: jfF3nty v,4 f!ir ,'s ;►) . .'s' u .7r ® Septic tank, distribution box, soil absorption system~ Ir1}e r ❑ Single cesspool n,1.�� . :) t,, ,: I{.;"t y`, a, . l'i ❑:�- ,, .3� Ov`erflow cesspool,, �. •r . ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) I ❑ - Innovative/Alternative technology.Attach a co of the current operation and PY p maintenance contract (to be obtained from system owner) and a copy of latest - - - inspection of the I/A system by system operator,-,under contract,t; ► ❑ ►t,,.,.;n;r Jight tank.-Attach a-copylof,the,DER. approval.-4 i, ❑ Other(describe): a-n 9 r-tx,fill"; a Approximate`age of all components;-date installed (if,known).and source of.information: 1983 ; nh Were sewage'odors detected when,arriving at the;site?,1L..- y t;J ,�,;,, y , :,,❑ Yes ® No 5. Building Sewer(locate on site,plan):. ,apad o+rII,')u;r, r+otro,t mt%t ".rs ', t 18„ Depth below grade: ,�,,,,,� ^'. tr #�feet " Material of construction-"`t ,r: l,.ln, . 's.st3 1✓+ 'crf;,ar;:at tz�{ rn. i r� 1:� rU e� c: f f t .�r'H3i;11` a r; =.�r,t :- {:,�.s ut�� - �t 3-I f .,;t bill fV, t+t{; ••+1: Irr zcast i x+ron C ,other(explain):tFc.i , ie, ti.e{`s `c, ai ' ®`40PV ❑ 9 Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. t5insp.doc•rev.7/26/2018. y Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts ,'. Title 5 Official Inspection- Form� { : ; 0 Mi Subsurface Sewage Disposal System'Form' 'Not for Voluntary Assessments, 138 Gunstock Rd " 'iI" •'�1ii \ Property Address Steven Scott Owner Owner's Name r L�! Information is required for every Osterville, .1, -0 ` 1" MA 02655 6-8-2111 page. City/Town State Zip Code Date of Inspection L, wl D. System Information (cont.) J . 6. Septic Tank(locate on site plan): oct I Depth below grade:= y ,<- ,, _,. ,_.. , .., ,., 12„ feet Material of construction: is t ® concrete ❑ metal ❑ fiberglass w , ❑ polyethylene.-; ❑ other(explain) If tank is metal, list age: - _ �' "<, `-'' t �`'t fig t3 - '\ v years Is age confirmed by ajCertificate,of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions t ,. 1000 gal 6„ Sludge depth: Distance from top of sludge to bottom,of outlet tee or baffler s `26f''` " lotScum thickness 'I a'• 6" Distance from top of scum to top of outlet tee or baffle' .• � Distance from bottom of scum to bottom of outlet tee or baffle', How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outletltee=or baffle condition; structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with.bafffles installed and no sign of leakage.=,Recommend pumping annually for maintenance and to prolong life. y t5insp.doc-rev.712612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 i Commonwealth of Massachusetts Title 5 Official.- Inspection.. Fo*tm, t.,,, ?'I h Subsurface Sewage Disposal System�Form�Not.for Voluntary,Assessments,;°:tt{,. ,_— 138 Gunstock Rd Property Address , Steven Scott ,+:� �• ,,. Owner Owner's Name w+ 3r= information is , required for every Ostefyille'_ _�� +^: ,4 MA 02655 6-8-21 Ft;=K{i ''' ---- a page. City/Town ,, .t ,,F �,� State Zip Code Date of Inspection r D. System Information (cont.) ; �; ; r �, At•,, , a , . :� : , 7. Grease Trap (locate on site plan): ;';c':��. �l€, r€► It,. io d Depth below grade: .,Y :" feet' v Material of;construction:-,,,, ->,-t • , ❑ concrete ❑ metal ❑ fiberglass Ey❑ polyethylene,; 3 ❑ other(explain): n . Dimensions: Scum thickness - T - •- Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum.to bottom of outlet tee or baffle i ' r Date of last-pumping: ., ea .�:`rt f?tiY tf Lg*mf%'I,' ` ,:= f'roq 1,Uou,^, Comments (on pumping recommendations, inlet-and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,"etc:): rto'•°' ` '"sh: ` 1' t1;1•„all"•'J a.«w •, .+�.'y aqr - r .�. ...•.,,6 -111c)% ail f1 41 c.9 - C, ,�C': -i ' .���.las r;.,,`l.('Si,lt�a.�� r:'` ('?{aa.Is-0 11 i'N'(:n 4`1.f-,r1-"P k ti-t tT,*i.'Ftv-''eC to ortia t'fi +r 's-et ;:.tL-. r dii".`r;'tflfto 0 . 8. Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: - Material of construction: ❑ concrete.- - ❑ metal - ❑ fiberglass ❑ polyethylene ❑ other(explain):. Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 f"� Commonwealth of Massachusetts y Title 5 Official Inspection Forte "i ,> <al Subsurface Sewage Disposal System,Form -'Not for Voluntary Assessments 138 Gunstock Rd ��� ''• •' Property Address Steven Scott Owner Owner's Name information is ille L ' ' ' required for every Ostery MA 02655 6-8-21 page. City/Town State Zip Code Date of Inspection , D. System Information (cont.) 8. Tight or Holding Tank (cont.) ''. Ar, Alarm present: ❑ Yes 0% No Alarm level: Alarm in working'order.°•' "❑ Yes ❑ No Date of last pumping: i' Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached?-' _❑ Yes ❑ No .M . - f..Sli 5 f.!)e1t..;• i,e; ftt�` 1 .t . n- ' ,'' 9. ' Distribution Box,(if present must be opened)(locate on site„plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from pit. r a, tf.•. ...11 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts :, •r,' s-;� t �� r , �Jt � ;f;Ff. , :' Title 5 Officiel1 I rispecti6ft, Foeffi "I ibl Subsurface Sewage Disposal System Form--Not for Voluntary Assessments J 138 Gunstock Rd ihP s'^Itit _ts* K:a Property Addressr- Steven Scott Owner Owner's Name r,, ,t.•< ,, .; a.t s�� information isr tz�9qi Ostefville.r_ :, �... required for every �• -1 MA 02655 6-8-21 __- page. City/Town ,,, 1, :a -t J ,,, ,„ 1, State Zip Code Date of Inspection - D. System Information (cont.) 10. Pump Chamber(locate on site plan): _ F,f,. umps�in�worlkingorder: "*- �� �;Ott�, tr ;[� lsa no�'i#+ t,w � 0 Yes" ❑ No" P ,r • r r- - 'I r rs tJ'J7�`3F'�:t � fi`"Ct'+��7: r :•+,aL r,=•`:7- t... f Alarms'in working order:- ❑ Yes: El No* ".i, r ;�. , a ,:•IT4s v 1s. • '77"-E s!�'lOi iftltzL=\.i., k1 , ,l7._� !r :.i:-' __ Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): . ••lj r 1+kri- IL".;\a trrt4,7 .i \E-.''� ,1'f .:.k*1 4:e t•t! }U. .,t s�fY R♦ .iwa ti._ r'Iv -.».i " If pumps or alarms are not in working order, system is a.conditional pass r'; ttatj 11. Soil Absorption System (SAS) (locate on site plan Jeri If SAS not located, explain why: :2'LJi..*.p..." tl• wf!•'tK.l lir9.tY' t�? i Type.' 016 rsr t�c�saft_'tz� 4 leaclifiigrpits't €Iet��Yl1y l �c :x1jj .«� ': i�o'riumber'°r 2frt�Ytf ao 1-1000 gal . - ❑ leaching chambers - number:- ❑ leaching galleries - number: ❑ - leaching trenches number, length: ❑ leaching fields number,-dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 r a w1 ,'_• n ." ,a;; Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c Commonwealth of Massachusetts �f-I ;� �• :3 � i .• t �It�� 5 Official. ��sp�ctI 1��Fo� �a . h► Subsurface Sewage Disposal System Form'-Not for Voluntary Assessments,,by iU, 138 Gunstock Rd Property Address »t , Steven Scott •- Owner Owner's Name ' information is , . required for every Osterville ; ' MA 02655 6-8-21 page. City/Town • ' State Zip Code Date of Inspection D. System Information (cont.) ��_ ,�: ,, ,..• . *; •,:.; 11. Soil Absorption System (SAS) (cont.) �,,• fir '� + G.n •` Comments (note condition of soil, signs of hydraulic failure„level of ponding, damp soil, condition of vegetation, etc.): ' Leach pit was holding water at 8" below inlet invert at inspection with no visible stain lines. h Recommend pumping annually for maintenance and to prolorig life. ,..7?":e - '+I 4 `nt,�,�.at •' "L7°. j'tr t t. r - -• ,�;.,r, � rf •t+lf + ,; 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration=l Ur, . ",r' 4, :no ,.) Depth—top of liquid to inlef invert A I ' ' 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.): rJ t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts f �; �.�, •,; rpg°^r v`tt `t�"'iQ. f Tile 5 Official Inspection Fofth' Mi Subsurface Sewage Disposal.System Form-Not for.Voluntary Assessments<• �r.;�as _ Vy. L;n 138 Gunstock Rd •. .,� 3" w - Property Address Steven Scott Hof- 41"f Owner Owner's Name information is required for every Osterville, '.t c'�A3 ; ;., MA 02655 6-8-21°=� page. City/Town State Zip Code Date of Inspection r; .• D. System Information (cont.) 4 c— r"i 13. Privy (locate on site plan): ' :*- '-' ,, •, :. ! � ��"`°_. .. . .r ' }.. :-� � : n) .'rtt�,?``d;;;i°4 �fiwi*?� I#..a,,,,�r-it .;�fd�'.i:: �''�fit?' :. i..f. .].�:�':7''�'} � fir; �• _7.,. 4.i �.. j .r...,.r t f• -`� ��.. ��� ; '� f� � �..,• .1 Materials of constructlori:' Dimensions Depth of solids .��.�.�#- +;,���� ,��I �-�•s . � i.� Comments (note condition of soil, signs of hydraulic failure,�Ievel of ponding,_condition of vegetation, 9 etc.): ) 4 t, w + t i t ,. 'J s 1 i++�'r.mat _� � 4y4 �'14• � $9�. ...M.t +�. _ ��y WF*�-P� ..v � s:n.+k'.Y.. n.i,F yM•a^..r� .s ^' . • M,�a may.na:l.e.n'_'i'."+yy-i.'�.- - i ^L. 1 !�'•- 'A. •,,, drip - . 1 t5insp.doc•rev.7/26/2018• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 t, Commonwealth of Massachusetts ,w Title 5 Official Inspection 'Form' i�i Subsurface Sewage Disposal System Form -Not.for,Voluntary Assessments 138 Gunstock Rd i "�..•, ., Property Address Steven Scott Owner Owner's Name s information is re Osterville - r required for eve MA 02655 6-8-2`1" q every City/Town/Town State Zip Code Y Date of Inspection page. p p 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 CA, 4. ,6 i r y- 3 6 - � v t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts - .. ,•aw?T. �;. raT- ,�wfT�:z.�� Title 5 Official- Inspection, dorm' !} Km Subsurface Sewage Disposal System Form:-Not for.: oluntary Assessments R: c 138 Gunstock Rd h l =z __ter=3 %4; Property Address Steven Scott Owner Owner's Name information is required for every Osterville ', 3 deb r, ,;�i MA 02655 6-8-21 'wf .0 page. City/Town State Zip Code Date of Inspection D. System Information (cont.�)',)1 � ,; v,;;,%v 15. Site Exam: ;� �. 1.Iar 1� . 7-- rt �4 ❑ Check Slope ❑ Surface water t; u .�.� 4..+ ❑ Check cellar 1� R: _,� Y � •� t ; :j f ❑ Shallow wells Estimated depth to high ground water:r0,3 i" Sri^� i�e0t Please indicate all methods used to determine the high ground,water.elevationa,f ❑ Obtained from,system:design plans on•recordy,+t,1 41lt-1 P If checked0date of design plan reviewed:;.;;, - Date ® .:,Observed site (abutting property/observationrhole.withi,nJ50�feet,of SAS) ® Checked with local Board of Health-explain: ® . Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 20'. 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 TM , i Title 5 official Inspection Form' i;I Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments ? °i 138 Gunstock Rd fir_ •�,; . `. Property Address , Steven Scott Owner Owner's Name information is required for every Cisterville MA 02655 6-8-21" page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 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 1r 4 1 •.1., r 1 it • ., t5insp.doc-rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Fxa.. ..s.................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEA H �.. ..........OF. e. ..:.......................... ..... s Appliratioaa for DiopooFal Vorkg Toutitrurtion ramit Application is hereby made for a Permit to Construct ((`,) or Repair ( ) an Individual Sewage Disposal System at: y Loc.ion-Address i a� l G n ..or Lot �`jj `\ Q�' ......°�.C , ..C? �.lh .... ,L 1 \ Owner Address Install Address �. d Type of Building Size Lot_._�_�f..................Sq. feet Dwelling—No. of Bedrooms............... Expansion Attic ( ) Garbage Grinder ( ) -----•------------- 0 Other—T e of Building a Other—Type g ._�!1Sr............. No. of persons............................ Showers (�) — Cafeteria ( ) dOthers fiZtures ------------------------•-----------------------.-.--- ---- W Design Flow.........�-..J............................gallons per person �r day. Total daily flow___....._.................._...........................ga�llo s. �y b WSeptic Tank—Liquid capacity.QW.gallons Length -.. Width..�'l._k___. Diameter________________ Depth.__.5..�.. x Disposal Trench—No. ..................:. Width_..._............_.. Total Length.........}}......... Total leaching area....................sq. ft. Seepage Pit No.......i------------ Diameter-------ic_1....... Depth below inlet......(2_e........ Total leaching area..U/P.....sq. ft. •z. Other Distribution box ( ) Dosing tank ( ) 1 �� ZG Percolation Test Results Performed by._....�,'LL�1�� _� .1_��4.1r!?. Date................. ................... aTest Pit No. 1....�.2.0minutes per inch Depth of Test Pit....M!.......... Depth to ground water_ __o-� � (i Test Pit No. 2__ .._.minutes per inch Depth of Test Pit---- � ------- Depth to ground water------- i Description of Soil QG�¢''1 {` g O 1. . .................................................................. �wU Nature of Repairs or Alteratior�—Awerh applicable ____.____._...._ :. - r.. - -1V6- �Z1 .......... .........•-------------------------------------------------------------------------•------•--_..... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of SITU 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is ed b the boar of health. Q� Signed -------- .................�!_.._ ---- --•..............:. ... Application Approved BY E `a.'f-........................ Date Application Disapproved for the following reasons-------------------------------------•-------•---------------..........---------•---•-----• ---•-•----...--•-_. --------------------------•-•-------•...•----- ----•-------.............................................................. Date PermitNo......................................................... Issued....................................................... 'w s No..ao�Cell= .... ifs Fu$....3-S-°:....'i......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ". R ,.r ..............oF... s ...............�.. .. Appliration for MipoaaliVorks Tnnitrurtinn Vandt Application is hereby made for a Permit to Construct (')�.-) or Repair ( ) an Individual Sewage Disposal S ptem,at: Li Lr , , c , ..._. oLocation-Address •p �{ t or Lot No l Owner Address ,-1 ----....... .................•-•-....... ......_..... Install r Address Type of Building r Size Lot............................Sq. feet V Dwelling—No. of Bedroo .............Ytie ..._._......._.....Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building °+'�L '` a yp g ............................ No. of persons............................ Showers (`)) — Cafeteria ( ) Othet fixtures -------------------------------------------•-----------•-•-•--•---•---••............••--••......--•- �y---- W Design Flow........ .. .................. ..gallons per person ,er 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.___-.V. .......... Diameter.......6...__..._. Depth below inlet...... Total leaching area-ZG-,.4......sq. ft. Z Other Distribution box ( ) -"" Dosing tank ( ) a Percolation Test Results Performed b ..... !—. .r.` 1��0, .... .. ���.�.lF +?4 Date..... ;1..����*_`_..� ......... ,-a Test Pit No. 1---- per inch Depth of Test Pit..... ............ Depth to ground waterL Xel(—..�� rlk (s, Test Pit No. 2....4.01_....minutes per inch Depth of Test Pit---........... Depth to ground water-------- 1 , ................................................................... Description of Soil............................-----�........: --------.;..._�_,----•-----------�-- r W ................... `{. 1. 7I f�`t'+°= 1+t/Yl4-i�_sd_..,R•c+Y�" :_..:_ sr :'>c ?.. .!_?rr.!.`...�1 ��..:3/C?4 /( v ��j �. UNature 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 TIT r E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed 1. .......................... ......., .... - �....�. - ace... .... Application Approved By...... r` i� '- .............. -----•--•--- Date Application Disapproved for the following reasons------------ -----•----------•-•-----------------........----------•-------------------------------•-----•----•- •------------•-•-•••.....-----••---------••-•-•-•------•--•-....•-•-•.......................••-----•----.-••-•••------------- Date PermitNo......................................................... Issued_...................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......... �` `'�..........OF.... G.f v,,,, ^"'............................ Cwrrtifirtttr of Tuntpliaurr THIS IS TO CERTILY, That the Individual Sewage Disposal System constructed (7%) .or Repaired ( ) (� 1 1c � ( 6t/ly q � 1�staller V-�� .f' t d�1�........................... �4 has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No....&2.. �re.............. dated................................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUES AS A GUARANTEE THAT THE SYSTEM WILL FUNCT N ATISFACTORY. 77 DATE...................... 15.-� ............--.....---------- Inspector--•- d�' THE COMMONWEALTH OF MASSACHUSETTS 136ARD OF HEALTH � � No................. FEE. .. � _ �. Permission is hereby granted.... ..----•-----..._..4 �-'- ---------------------------------------------------------------------------------------------- to Con trust ) r epair ( ) a Individul�l^�ewage Dis osal System atNo. �� "' ...................................` ` , "exte r f..•�I ..--.............................................................. Street as shown on the application for Disposal Works Construction rmit No..................... Dated.......................................... " ---------------------------------- �� �J" DATE -----•-- �.............................v FORM 1255 HOBBS & WARREN. INC., PUBLISHERS T01Ni. tFF E ABLE f, /J Vffi,At;F,_„ 2 ASSFQR'S �flT L�s�►c�lm�'G F�c � � ffi0 OF8&D�t3t3D�S :.. .. a Bt7IX.D�O!R i ER .s�p�eon D�tanco Betad►e�n fie• �i6aximum A istec Ca�uu�wat bie o t e oim'. fL�a hi Fac ty Feet: Rrlva:c 'ei,�ttrppy tali atagt { �►Y yr exsst pnmts crh 3.tl�f�t �ein$f } Feat cte o£11tetd amd IRaehitts��"[f aY vctlauds exist ' � withia 3C�Q;feet it€teactua�faa'rn�} � Feet°_. a � Pb°� 3a �• - �3' ,l3 -3 • y3' f /SFoo3 S i 6�1n ` too 90 N V 1 vou � t16 N I `qq INJ , F r/ lJ Fi LEGEND EXISTING SPOT ELEVATION Oxo CERTIFIED PLOT PLAN EXISTING CONTOUR.--- 0 --- 07- 'reP . FINISHED SPOT ELEVATION FINISHED CONTOUR 0S`T 7c ! �- IN APPROVED = BOARD OF HEALTH J*AAA 8lA,§ ' 9 A + DATE AGENT SCALE, ,� = 3 0 DATE, gS . L DREDGE ENGINEERING CO. IN O sr,i ✓. TIZ . CLIENT I CERTIFY THAT THE PROPOSED EGISTERE REGISTERED JOB NO. 20U BUILDING SHOWN ON THIS PLAN CIVIL LAND CONFORMS TO THE ZONING LAWS ENGINEER URVEYOR DR.BY= OF BARNS B E, MAS . P 712 MAIN ST. CH. 8Y= HYANNiS, MASS. 2.. SHEET_L OF DA E REG. LAND SURVEYOR r"?k. 2vF 20 FT. MIA'. N07"E /P E 7HjffR THE SEPT/C TANK OR ZeACH//vG P/T ARE MORE TNA/V /2"BEL0J 4h: /O F7 MIN GRAOEj A 24"O/AM ETER CO/yCRA7T.= COii 'tlt •¢'PYC P/PE SWALL BE ®/ROuGINT TO GJ�i4 DE.�fiN .EXTr?/ COIVCRL r4a tiE.4Vy CA ST IRON CO{DER Sf/.4 L L SE ZISF.O Nf/N. P/TCN !F/N OR/VEyt/A y •:• �LE1l / v 0,0 coYER.*S .441,PF�Q FT 2% M/N• CO/VCRLFTE A :%o: _ (j ApB COVER C•L -AN .SAND 6AC/CF/LL d�� � J - - • . • . 2 LAYS_R /RGCN P o �.q.o . . o o OF ��8 -'�/B '¢ MIN.P/TCN G/IL. 1 • • . • • • • • s •„ ►•{/ASHFD 57ONE SEPTIC TA/VEC D/sT, • e • • . . . . . • • , e . t. I. BOX o • � e • • • • • • .°° v n ° •� / pr or p 1 • •EFRECT/VL r ` • ° 3 4 ^. • ° r • • DEPTH • • • • • o WASHED STOiYE �. • �e Sr: o •a o • • • • • • . • • v O o ° ei • • • • • • • • • p top PRECA5T"EPAGE /NV,ei!'T CL EVA7YDNS o ►• e e • • • • • • • a o P/7 OR. EQUIV. /NI,&RT AT BUILDING 7•v Jar 6 O/AM. /AILET SEPT/C 7,4NK. 96 •-f FT. C(SEE7AB!/L.4TJOw� 0U74E7'SEPTIC TANK 9��3 F //VL.ET O/57Ri61/7-10N BOX 9d o FT. SECT/O/V OF GROuNo WATER TABLE OIJTLETD/STR/BL/T/ON BAX �r� FT. INLET LEACH/N4 /=1/7' S. FT SELVAGE 01SA"A L SYSTEM TABULATION 4EACH//V6 P/7' DJMEN.S/ON A 3ThT. DES/GN CRITERIA sc.nL E D/M.ENS/o N $ FT. NUMBER OF BEDROOMS .3 R DIAIAWS/ON C FT. GARe.4GED/SPOSAL UNIT_� SO/L LOG TOTAL EST/M�1'TEG FLory 3 3 y G.aL.�DA� SO/L TEST #/ SOIL TEST S SOIL TEST /'UMBER OF LEACNlJVG PITS f"ELEK 97•0 -EtEY, PATE OF SO/L TEST SIDE LEACHIMC, PER P/T 51P PT. O Z RESULTS iV/TNESSED J. �' 60TT0h1 L.G4CN/NG PERT/T 7 W. AT, ���Aq PERCaLAT/ON RATE / M/NVJNCH TOTAL LEACH/NG AT,--A SO -FT. SU/3es - `RCOLAT/®M RATE A2 -`4yZ-�.-,� MJN.�/NGH RESERVE 4E4CNIN6 AREA �'a sa FT. , /Nd. T2 , /"1�'�' ? ✓f� L_u G G�J�/s7U e/c < �'�; `"�`; 'E.= `�; ELOREDGE ENG/N.E�'R/J1�G CC�INO•. 7/2 MA/HST. NC GROUND YYi4TCR ENCOIJNTl�R1�-O HYANN/S (3 GRO U/VL> kV.47,ER AT EL_4 2 , e ✓oB /vo. Fro 04 y sf,rEE7-?o�