HomeMy WebLinkAbout0117 HICKORY HILL CIRCLE - Health 117 Hickory Hill Circle
Osterville
A= 121 — 040
D AT E : 7Z29103
PROPERTY ADDRESS: 717_11.ickoay-K.i.Pe-Ci.zc2e RECEIVED
02655 AUG 2 3 2003
--- -- TOWN OF BARNSTABLE
HEALTH DEPT.
On the above date, I inspected the septic system at the above address.
Tnis system consists of the following: lzi
1. 1- 1000 ga22on ze/?t.ic tank. PARCEL �...® ®............
2. 1-D-iatai&ut.ion 1?ox. 'y,
3. 1- 1000 ga.�•Eon /2/Leca4t .2each.ing i t. LOT -- - - -
Based on my Inspection, I certify the following conditions:
4. 7h.iz .i.a a t.it.2e �eive .se/2t.ic zystem. (78 Code)
5. The 6e/2t ie .6y.etem i.s .in /2ao/2e/t woak.ing oade2 at the +
/zne'sent time.
6. Ua,3te watea is 37" &e.2ow the jnveTt /2.i/2e o/ the
2each.ing 12.it.
SIGNATUR
Name - - J__ P__Macomber_Jr _
Corripany : jqjtph _p, M�ggLn gp d_ Son, Inc ,
MOdre5S : @4 _tz�------------
CUS2CYLLLe-_ ja . AZ-6 3 2-00 6 6
�none : __508- 775 - ) 338 ________
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
LB
P. MACOMBER & SON, INC.
anks-Cesspools•Leachtlelds
Pumped & Installed
Town Sewer Connections
66 Centecviile. MA 02632.0066
775.3338 775.6412
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
Y
• 3
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 117 /Licko zy K i-gi C i2cie
/J e2Ui i te, 0 Q4h. .
Owner's Name: T2ank FU.Q.Qe2
Owner's Address: 7/Z9103
Date of Inspection:
Name of Inspector: (please print)ao,seRh P. Macom9ea ;,z.
Company Name: �. /. Nacomgelt 9 Son Inc.
Mailing Address: Rox 66
renfo7 7o� lylrAA- 02632
Telephone Number: 5 C)
CERTIFICATION STATEMENT
1 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:
> 1 Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: KX Date:
The system inspector shall s mit 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
�µ -•-,•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
1
Paige 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 7 77 K.ickoay K.i H C.iac.Pe
0,31te/zu-ii-ee, Nazz.
Owner: wank 7u.e.2ea
Date of Inspection: 7129103
Inspection Summary: Check A,B,C,D or E/ LA WAYS-complete all of Section D
A. System Passes:
Al() 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:
The o6p.aLic AuAlnm 1A in nnnnvn innaking nnr/on of
.the paezen.t time.
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.
,6 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:
XJO 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
N``D�� explain:
,vLI 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
s
Page 3 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 117 K.icko�zy 11ii P C i zc Pe
,6 teaV e,
Owner: Tank Tu.P.ee2
Date of Inspection: 7129103
C. Further Evaluation is Required by the Board of Health:
VV 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:
-V0 Cesspool or privy is within 50 feet of a surface water
.(FD 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.
46 The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
V b 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
buu nt 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: 117 Kicko zy C-.2cie-
Oh.teltv...22e,
Owner: ;2artk Fu.e.ee2
Date of Inspection: 7/2 9/0 3
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes ;;Dis
tage
p of sewage into facility or system component due to overloaded or clogged SAS or cesspool
— char or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
iclogged SAS or cesspool
—
�/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
�esspool r--Rlp lobo (Ory
iquid depth in,cesspol is less than 6"below invert or available volume is less than 'h day flow
equired pumping ore than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
> of times pumped .
y 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
ater supply.
_ 7:��.ny portion of a cesspool or privy is within a Zone 1 of a public well.
y 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.]
(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 1/the
system is within 400 feet of a surface drinking water supply
l/ a 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.
4
Page 5 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 117 Rickoay Riii Ciacie
eau.c e, a-6 .
Owner: ;raarzk FtLiielt
Date of Inspection: 7129103
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)
v — Was the facility or dwelling inspected for signs of sewage back up?
/ Was the site inspected for signs of break out?
v _ Were all system components;.Kluding 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
maintenance of subsurface sewage disposal systems ? proper
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes n/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)j
5
Page 6 of 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY 'ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 117 fl.icko zy 11-ii2 C i zc-ee
e2v.c 7 1 e, 117 ETT
Owner. ;rnank Tuiie z
Date of Inspection: 1729103
FLOW CONDITIONS
RESIDENTIAL ,
Number of bedrooms(design):j Number of bedrooms(actual):
DESIGN flow based on 3 10 CMR 15.203 (for example: 110 gpd x it of bedrooms): Xv -
Number of current residenu: t
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system(ves or no): (if yes separate inspection required)
Laundry system inspected(yes or no);
Seasonal use: (yes or no):
Water meter readings, if available (last 2 years usage(gpd))Z001_4 5, 000 ga.P.t?on s= 123. 29 gPD
Sump pump(yes or no): 2UUZ=4 T,70T_gaeeo_ n s=17 7. 81 gP D
Last date of occupancy:
�
COMM ERCIALANDUSTRIAL
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):AM
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title S system(yes or no): `i )
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION k
Pumping Records
Source of information:AeB ,9zow_,�
Was system pumped as pan of the inspection(yes or no):
If yes, volume pumped:a gallons•- How was quantity pumped determined? .Ply '
Reason for pumping: q/y9
TYV OF SYSTEM
Septic tank,distribution box, soil absorption system
Single cesspool
Overflow cesspool r
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 conttact.(to be
obtained from system owner)
/0Q Tight tank Ah Attacb a copy of the DEP approval
4 Other(describe):
Approximate age f all components,date installed (if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):
6
Page 7 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 717 Hickoay Kiii C.acie
Owner: ;tank 7u Fz
Date of Inspection:
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction:,�CLcast iron Z40 PVC mother(explain): lle)4
Distance from private water supply well or suction line: 2 t
Comments(on condition of joints, venting,evidence of leakage,etc.):
goint.,i {Ll2,?yrza 11 ghf Nn o»ir/onno n,� Ponkrigo _ 7ho AllAfo,,, i,s
vented thorough .the houze 2001 1)ent'6. a
SEPTIC TANK: locate on site plan)
Depth below grade:
Material of construction ncrete.lW-meta lsfiberglass,l2i) olyethylene
.f 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:
Sludge depth-'
Distance from top off sludge to bottom of outlet tee or baffle:/ .,-,C
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom gf outlet tee qr baffle:
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.):
Pump .6ept.ic tank eves 2-3 Ugn/zA I .Pel R nii.t.Pot i,,PA nno
'1n n.Pnrp .t Zho drink is fnuirLinn00y Annnrl nnrl Ahn)jA r,n o,,:�loaro
o f Ieeakage. L-.qu.id tve2 at the out—et inveltt -i-6 5 7"
GREASE TRA94i�locate on site plan,)
Depth below grade: 164
Material of cons truction;.J�concrete4/ metal J�9 fiberglass.,ehpolyethylenc4,/ other
(explain): /9
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: a
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 1 1
4e-
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C t
SYSTEM INFORMATION(continued)
Property Address: 117 Hickolty fz'-..ei Ci zc ee
Owner: 7aank Tuiig.,z
Date of Inspection: 7/Z 9/0 3
TIGHT or HOLDING TANKL e1e-(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction:0concrete;I,metal4?,4 fiberglass Al.Q Dolyethylene A other(explain):
A
Dimensions: _
Capacity: gallons
Design Flow: allons/day
Alarm present(yes or no):
Alarm level: JA Alarm in working order(yes or no): 4),4
Date of last pumping: AJA
Comments(condition of alarm and float switches, etc.):
7.iaht o2 hoidcng tankz ate not R2e.een .
DISTRIBUTION BOX: ZC1f present must be opened)(locate on site plan) ``-
Depth of liquid level above outlet invert: /1,d
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.):
Dizta-igution Sox hays one iate2d-e No evidence oZ zotidz ca22y
�� Nn vu.irlvnry o.P e i ige. .into o2 out of the 'gox
PUMP CHAMBER-t�/e(locate on site plan) R
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.):
Pumo nhamPpn .iA no#- 22pAant.
j.
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: 117 K.ickoa.y C.i2c.ee
0,6tQ2U
owner: Tnrink Tri.�lPpn
Date of Inspection: 7/J 9/n 3
SOIL ABSORPTION SYSTEM (SAS): zo (locate on site plan,excavation not required)
1- 1000 ya2.eon /22ecazt .eeach.ia R.i.t.
If SAS not located explain why:
/nrnfor]- Coo Dogp 10
Type '
IF.
pits,number:
leaching chambers,number: Q
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
verflow cesspool,number: Q 1
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.):
Loam,y .sand to. none .nand to �.ine .sand. No zign.s off, hyd2au.eic
4aiivae oaPoad.ing So.i.es ate dzy Vegetation .is noama
CESSPOOL Vicesspool must be pumped as part of inspect ion)(locate on site plan)
Number and configuration: Q
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.):
Ce.6.aRoo.e.6 ate not /?2e.6ent.
PRIVYj/4(&(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.):
pa.ivy iz not R2ezent.
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: 177 Hickozy Hiii Ciacie
eavc e, aze.
Owner: ;r/zank 7u Uejz
Date of Inspection: 7129103
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.
/ en
10
Page I 1 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSE6SSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 117 K icko zy h iii C.i2c.Pe
Ozteay.ii2e. l'lazz. `
Owner:Taank Fu—P-eea J
Date of Inspection: 7/,?9/o 3
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water �y�l feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked,date of design plan reviewed: NA
qF.S Observed site(abutting property/observation hole w+thin 150 feet of SAS) I
N(L Checked with local Board of Health-explain: N
14
�/�„�Checked with local excavators, installers-(attach documentation)
RS Accessed USGSdatabase-explain:hi-i—Ili-own. ma, uz. .{•
You must describe how you established the high ground water elevation: `
zed: Cahe•¢ty & M-ii2e¢ bode-2. 12116194 G2ound watez e.fevat.ion'6 agove zea 2evei.
zed: IZSgS: Ogzezvat.ioa weii data. 7LLhe 1992
zed: LLS;s •7n^1�_ c�a �„ aa4B 442 o nnQ/ .1)9a ;a `
I �innilnr�
�.�-#lrarasc�sg aanya� r�te2
=-e4egain
e
Leaching
9 e:
Pit ;eet '
Groundwater Feet Below Bottom of Pit . High Groundwater Ad u stment 1,8 ft per Frimpter Method
Therefore, the vertical separation distance between the bottom
of the leachin it and the adjusted 8 P � groundwater table is
feet.
11 ..
•r.wnP+.—nT►�.•+1—a.nrlrw•wlnfllT.Ts�.Trs+#rfq•+a+�.►f�.R�n1�a g1A1Iti!'w��tl�'In .. •.
Win•-���r�'....,�...
TOWN OF L3a/zn sta&ie BOARD OF HEALTH
4^� SUBSURFACE SEHAGF DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I
� vnrrr•rr.r. —..A
-TYPE OR PRINT CI•EARLY-
PROPERTY INSPECTED
STREET ADDRESS 117 Hickoay 11iii Ci/zc_Re ------------
0ate2v�Q2e, l7a.s�s. '
ASSESSORS MAP, BLOCK AND PARCEL # 121-040
OWNER' s NAME 7aank Fuiiea
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber .Jr.
COMPANY NAME J P Macomber & SoR Ind''.`
COMPANY ADDRESS Box 66 Centerville Mass, 02632
Street Tovn or City Stat• IIP
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 -1 578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system nt
this address and that t)le information reported is true , accurate , and
omplete as of .the time of -inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems ,
' n > Ili• I
Chec one :
System PASSED ,
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
healLh or the environment as defined in 310 CMR 16 - 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have con cted has found that the system fails to
Protect the jiublic health and the environment in accordance with Title
5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
e '
Inspector Signature - Date
( Nheropy of this certification must be provided to the OWNER, the BUYER
applicable ) and the 130ARD OF H$AL71I4
* If the inspection FAILED, the owner ors`operator shall upgrade the system
within one year of the date of the inspection, unless allowed or required
otherwise as provided in 3.10 ChiR 15 . 305 .
partd .doc
4 1b-D)
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF,, ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION.
}
TITLE 5
OFFICIAL'INSPECTION.FORM-NOT-FOR VOLUNTARYASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM FORM
PART A. j
riCERTIFICATION r
Property Address: `117 Hickory Hill Circle1,0
1 ' '
Osterville,MA 02655
Owner's Name:_ . . Ldrry&Janet Renoe -
, .
Owner's Address:. -
1l
'March ]Z'2008 Date of Inspection:.' _ c
Name of Inspector:.(Please Print) Janies M.'For d" �� r�
Company Name: JamesM.:Ford.
Mailing Address: P.O.=Box 49
Osterville,MA_02655-0049 ,
Telephone Number: (508)862-9400
CERTIFICATION STATEMENT
I certify that Lhave 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 ani a DEP
approved system inspector pursuant to Section 15.340.of.Title_5(MO CMR 15.000). The system:
✓_ Passes
Conditionally Passes '
eds.FurtherEvaluation by the Local Approving Authority'
F _ ai s
g
Inspector's, Signature:.-,. -Date: March I8 2008
The system dspector shall sub 'i 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 an.d'.the system owner shall submit,the report to the'appropriate regional office of the
DEP. The ortginal•should"be' sent to the"system owner and"copies sent to the buyerjf applicable,..and the approving
authority.f
Notes and Comments
****This report only.describes conditions at,the time of inspection and under the.conditions of use at.that
U9
time. This.inspection doe;not the-system will perform in the future under the same or different
conditions of use.
Title 5.Inspection,Form 6/15/2000 page:l
Page 2 of 11
OFFICIAL INSPECTIONTORM.-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 117 Hickory Hill Circle
Osterville, MA
Owner's.Name: Larry&Janet Renoe
Date of Inspection: March 12, 2008
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 31.0 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 :.F .
*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 breakout 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: 11 THickory Hill Circle
Osterville, MA
Owner's Name: Larry&Janet Renoe
Date of Inspection: March 12, 2008
C. Further Evaluation is Required by,the Board.of Health:
Conditions exist which }s hich're'require further evaluation b. the Bo
ard of Health m order.to dete q Y nnme if the system
is failing to protect public health;safety or the environment.
1. System will pass unless Board of.Health determines in accoidance.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 r
. z,
2. System will fail unless the Board.of Health(and Public Water Supplier;if any)determines thafthe
system is functioning in a manner that protects the..publichealth,safety and environment: 4
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.
s
The system has a septic tank and SAS and the SAS is less than 100'feet but 50 feet or more from a
P Pp
rivate water su 1 well**. Method used to determine distance
y
**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 ppin,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form. -
3. Other:
4 ..
`r.
Page 4 of i 1
OFFICIAL INSPECTION`FORM-NOT FOR VOLUNTARY ASSESSMENTS'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART A
CERTIFICATION. (continued).
Property Address: H7 Hickory Hill Circle
Osterville, MA
Owner's Name: Larry&Janet Renoe
Date of Inspection: March 12, 2008
D. System.Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following:forall inspections:,
Yes No
✓ Backup of sewage into facility or system.component due to overloaded or clogged.SAS or cesspool
` ✓ Discharge or ponding of effluent to the surface of the.ground or.surface waters due to.an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution;box above outlet invert due to an overloaded or clogged SAS or-
cesspool
_ ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow
✓ 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 privatewater
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 otherfailure criteria
are triggered. A copy of the analysis must be attached to this form:]
No (Yes/No)The system fails. I have'determined that one or more of the above failure:criteria exist as
described in 310 CMR 15,303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System:
To be considered:a largesystem 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 tributaryto a surface drinking water supply
the system is located in nitrogen sensitive area(Interun Wellhead Protection Area-IWPA)or a mapped
Zone lI 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.accordaticewith 310 CMR
15.304. The system owner should contact the appropriate regional office.of the Department. .
4 _
f Page 5.of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST .'A
Property Address: 117 Hickory Hill Circle "
Osterville. MA
Owner's Name: Larry&Janet Renoe
Date of Inspection: March.12, 2008
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,fo the system recently or.as.part of this inspection? .
✓' _ Were as built.plans of the system obtained and"examined 2(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 com systemP onents excludin the SAS located on site?.
g
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 anddocation 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:
✓ _ Determineddri the field(if any of the failure criteria related to.Part Cis at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)]. e
=5
Page 6 of 11
F
OFFICIAL INSPECTION FORM-NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE•DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 117 Hickory Hill Circle
• Y v P
Osterville, MA
Owner's Name: Larry&Janet Renoe
Date of Inspection: March 12.2008
FLOW"CONDITIONS
RESIDENTIAL"
Number of bedrooms(design): 3 Number of bedrooms(actual):. 3
DESIGN flow based on310 CMR 15.203 (for example: 110 gpd x#.of bedrooms): 330
Number of current residents: 0 .
Does residence have a garbage grinder(yes or,no): No
Is laundry on a separate sewage system(yes or,no): n/a jif"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): Wo.•`.
Last date of occupancy: Unknown
COMMERCIAL/INDUSTRIAL
Type of establishment: -
Design flow(based on 310.CMR 15.203): _ spd
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/user
OTHER(describe.):
GENERAL'INFORMATION
Pumping Records.
Source of information: Unavailable
Was system pumped as_part of the inspection(yes or no): . No
If yes,volume pumped: gallons--How was.quantitypumped 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/Altemn tive.technology. Attach_a copy of the current:operation;and maintenance contract.(to be
obtained-from system owner)
Tight Tank Attach a copy of the DE:P approval .
Other(describe):"
Approximate age'.of all components,date installed(if known)and source of information:
Date of installation.-'unknown
Were sewage odors detected when arriving at the site(yes or"no): No
t
6
f Page 7 of 11
OFFICIAL INSPECTION FORMA-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 117 Hickory Hill Circle.
Osterville MA
Owner's Name: Larry&Janet Renoe '
Date of Inspection: March 12, 2008
BUILDING.SEWER(locate on site plan)
Depth below grade:
p
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: 18"
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 Qal.
Sludge depth: 2
Distance from top of sludge to bottom of outlet tee or baffle:' 30"
Scum thickness: 4" r x
Distance'from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlettee'or baffle: 10:'
How were dimensions.detennined: Measuring stick 'IV '
Continents(on pumping reconuneiidations,inlet and outlet tee'or baffle condition'structural integrity;liquid levels;
as related to outlet invert, evidence of leakage,etc.): x
Tees were present. The liquid level Was"even with the outlet invert.- There did not appear to be any signs'of leakage.
Note, The tank is under the deck.The covers were'too grade and there are access doors in the deck
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 scumYto 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 w.
t^
Page 8 of 11
r1
OFFICIAL INSPECTIONYORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C`
SYSTEM INFORMATION(continued)
Property Address: 117 Hickory Hill Circle
Osterville. MA
Owner's Name: Larry&Janet Renoe
Date of Inspection: March 12:2008
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: . 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 _ III
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 y evidence of
leakage into or out of box,etc.): k
The D-box was clean. No solids were present.'
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or`no):
Alannsi in order(yes or no) t
Comnientss(note condition of pump chamber,•condition of pumps and appurtenances,etc.):
8 - e
+ Page 9 of I 1
/! OFFICIAL INSPECTIONS FORM NOT FOR VOLUNTARY ASSESSMENTS ..
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C.
SYSTEM INFORMATION(continued). -
Property Address: H7 Hickory Hill Circle
Osterville. MA
Owner's Name: Larry&Janet Renoe
Date of Inspection.: March 12, 2008
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type _
✓ leaching pits,number: . 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: "
Comments(note condition of soil, igns of hydraulic failure, level.of ponding,damp soil,condition of vegetation,
etc.):
The Leach Pit was dry. There did not appear to be any Signs of failure A Camera was used for the inspection
CESSPOOLS: ' None .(cesspool must be pumped as part of inspection)(locate on site plan)
Number.and configuration:
Depth-top of.liquid to inlet invert: a"
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.):
Page'10 of 11
OFFICIAL INSPECTION`FORNOT FOR VOLUNTARY ASSESSMENTS VI-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
7HickoryHill ircle
'Pro'Property Address. I1 C
P Y -
Osterville.MA
Owners Name:. Larry&Janet Reno e
Date of Inspection: March 12, W&
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.
0 0
i
3` B
j qq 3�: '
3 Yo y3
;o
.. j Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .
PART C
SYSTEM INFORMATION(continued)
Property Address: 117 Hickory Hill Circle
Ostetwilk MA
Owner's Name: Larry&Janet Renoe '
Date of Inspection: March 12, 2008
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water_ . 35 +/. 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:.TopoQraphic 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:
Using Barnstable topographic and water contours maps, the maps were showing approximate1y.35'+/ to groundwater`at this
site.
This report has been prepared only for the septic system and components'described herein.'This septic systein has been
inspected and passed as of the date of inspection. This report.is not a warranty or guarantee'that the systenz will
function properly in the future. There have been no warranties or guarantees,either expressed, written or implied,
relating to the septic system,�the inspection, this report and/or any components of the septic system which have not
been located and inspected. _
11
TOWN OF BARNSTABLE
pLOC ,TION N(CkQr\/ 4111 Cl SEWAGE#
VILLAGE ASSESSOR'S MAP&PARCEL /,1 I— OYO
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY UU�
LEACHING FACILITY:(type) Pi r (size) 0V
NO.OF BEDROOMS 3
OWNER Rtf\O ..
PERMIT DATE: 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 leaching facility) Feet
I' FURNISHED BY Ti1S GGT -1 r� 3Aa D
I�
_Y 0 0 _
3 I3
I yy 30
y a 33 3(o
3 yo 113
y y8 yS
SEWAGE INSPECTIONS
LOCA7P,0N ,667 #/C hoot Y C CPS{ DATE 7129103
VILLAGE Oz'-g"zv-""� , ('a6,6- ASSESSOR'S MAP & LOTI Z1-040
-INSPECTOR �o-5eph %. I�acomge'z
SEPTIC TANK CAPACITY 1000 f. Z30x
LEACHING FACILrY: (type)/-LP- l000 12ji (size) 1500 .c ion�3
NO. OF BEDROOMS 3
BUILDER OR OWNER ;r2anlc fuQQe2
OWNER MAILING ADDRESS
Same
0 �
��tt ��
4"
`�°` //`
�t � /���,� �,. �
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., n1 '` �� cry /
� � � ro
4 .
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u �,
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�_ . � N � �
. � � �� ® II
t,T 17 TOWN OF BARNSTABLE
LOCATION ( "" tl�-SEWAGE #
VILLAGE WASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE N0 htf
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size) ; T
NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER
BUILDER O OVI►NER /`—, '
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
]A -.y
. .: 1p
o
Ai ,,
pri
LOCATION SEWAGE PERMIT NO.
VILLAGE
INSTA LLER'S NAME 8 ADDRESS
R U I L D E R OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED / r''
u�C;o19
ol
. j
THE COMMONWEALTH OFtLSSACt2S�E7TS
BOARD OF HEALTH
/
.A/............OF.. .5.%/� .5 .._..
Appliration for Mipwial Works Tnntrnrtion thrutit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at:
// 7 /fleerj •y K1// C'�r�l� OST`eFvr11f LdT` l7
....................... ...�..... .^ ------ ..........
.......
....-- ....... -----.----------......... --------t------•- .................
ovation--Address
FR�nr.K._M:. .. lraH�es...A. ' :.�3�x__r�rZ r�sef��ll� (9.a 6
�� ,J�� Address
W . .....
Y�r.,Jt"'.........
Installer Address
UType of Building Size Lot..�s,e. ...Sq. feet VV
., Dwelling&�Ko. of Bedrooms.......��` ................................Expansion Attic ( ) Garbage Grinder (
'4 Other—Type T e of Building No, of persons............................ Showers
Ay YP g --------•----•------•------- P ( ) — Cafeteria ( )
a' Other fix ur
W Design Flow............ ..�--7...................gallons per person per da,y. Total daaill f1c. ........ ................gallons.
a
R: Al
Septic Tank—Liquid city .___ .gallons Length//�C... Widt> ......... Diameter________________ Depth.,S....$.__.
W Disposal Trench—No. ................... Width.................... Total Length.............t,.... Total leaching area....................sq. ft.
x / Diameter...... lDepth below inlet.............. Total leaching are sq. ft.a e Pit No...Z Other Distribution box (L,,K Dosin ank ( )
Percolation Test Results Performed by�/ �1!1�� Date.../ ......__.
Test Pit No. 1...-...z....minutes per inch Depth .of Test Pit......1. ..r..... Depth to ground water Udt�
(i Test Pit No. 2....-.Z...minutes per inch Depth of Test Pit.....L?......... Depth to ground water..A/t-..FQ.0* 1
....................--..............
....................................................••-•-•-•------------•-- -- -
xDescription of Soil....— ..., ..�!�ff.�"��� ?.l --....._.2..-/�.— '1�.
V •---•-••-•--------••-•-•-•-••••••••••--•--•--•--•----•----•-••.....................••----•--...._.............----•---•----••-••......•-----•......��
W ----•-----------------------•------••-••-••••-••-•••-----•-------•••--•••-----•••-••-•------........---•---•---•••---•---•-•......•----•----•-••/, t.....---• ..... .
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 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 issued by the board;of health.
Signed...... . ���.
G
Application Approved BY == ......................... .� O at a .....
Date
Application Disapprov f the following reasons:...............................................................................................................
....- -----•----...--••-•---•-•---•---•-•-•--•-••-•--•.................••----•---------........--•---.........................................................••• -.---------- -------------
Date
PermitNo....................................................... Issued..................... ...............: V
FiLB..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Z .............
Appliration for Dhipasal Works Tomitrurtion rantit
Application is hereby made for a Permit to Construct (X) or Repair an Individual Sewage Disposal
System at:
117 Hlck6k..v H,111
... ................. .. ................
......................................................... ......................
................................ ......Lo_c_atio__n .Address cr Lot No.
J......... 6
............... ...............................
Owner Address
Instal I er Address
Type of Building Size Lot_. � Sq. feet
U
Dwellingf'�o. of Bedrooms........ ...............................Expansion Attic Garbage Grinder ( lam)''
aOther—Type of Building ............................ No. of persons.................._.._...__. Showers ( ) — Cafeteria ( )
04 Other fixjurp ........................................................................................................................................................
Design Flow............ ................gallons per person per day- Total dail flow........ .................gajlons.
1:4 Septic Tank—Liquid capacityZ' gallons Length//2/�*..•' Width_�57F/__ Diameter---------------- Depth.5./..e...
Disposal Trench—No..................... Width......._....._._.... Total Length.................... Total leaching area....................sq. ft.
> .../---------- Diameter...... Depth below inlet.....:��.. -
,> Seepage Pit No_ ........ Total leaching area Z .....sq. f t.
Z Other Distribution box (L-)"' Dosing 4ank
Percolation Test Results Performed by.. Date... ......
Test Pit No. I... ._..minutes per inch Depth of Test Pit......1Z.......... Depth to ground water.JA14�1'
11 . ........... ..
Test Pit No. 2.... ....minutes per inch Depth of Test Pit......L2......... Depth to ground water../�/`�` ....5:h'...��.6-7 C,
..................................... ............................................................................................. ............
0 Description of Soil..... ............
�4 ' 7.......
.................................................................................................................................................................... ......
U ......
----------------------------------------------------------------------------------------------------------------------------------------.........//. .......
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 T I T IE 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.
Signe ... .... .. ...... ................ ........................................ 8
Dat
ApplicationApproved By- ............................................................................... ...
eo Date
Application Disapprove f the following reasons:...............................................................................................................
........................................................................................................................................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
-THE COMMONWEALTH-OF MASSACHUSETTS.
BOARD OF HEALTH
..........................................OF.....................................................................................
Tatifiratr of Tompliaurr
PhYS I RTIFY T at the Individual Sewage Disposal System constructed or Repaired
..........
.�7
by... .... .. . ........................ .......... ............. ...... . . .................................................................................................
ler
... .......at................. ........../7........4 ---- ------- -- ... .. ........................................................................... ...... ................
has been installed in accordance with e provisions of Tj L, 5 of The State Sanitary Code a d in the
,T- R
application for Disposal Works Co ruction Permit No..?Xn-�' .19e............... dated..........: .................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No97 11fr ..........................................OF.....................................................................................
FEE........................
io fly
Tongtrudion famit
`'
Permission i e y granted..�.ITA:;.'20......
---------------------------------------------------------------------------
r Re i d*,'.ual Se a 0 ystem
paiX..-(to Constr an Inij�i
at ........................?......... ...... ......Z4..V. ....... ... .......................................................... ....... ..............
Permission i - .. ....Constr a o y
............ ....... . . .. ......
Street
as shown on the appli do or Disposal ve erks Construction Per mit-Wo- - ------------ Dated .... .......... .... ............
t�0/�
... ........ .........................................................................
DATE-----...- .......................................... E-oard of Health
FORM 1255 A. M. SULKIN, INC., E30STON
Commonwealth of Massachusetts .
_ itle 5 Official Inspection Form
A ......
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
117 Hickory Hill Circle
GM
.... Property Address.:.
..
Robert Zepf
Owner
Owner's Name "
information is required for every Osteryille Ma. 02655 1/7/13
_
page: City/Town- State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
_. way. Please see completeness.checklist at,the end.of the form.
Important:When A. General Information -
.filling out forms
on the computer;
use only the tab
1. Inspector: -..... __ _-
key to move your
s cursor-do not.. Ricky Wright
_.
use the return: Name of Inspector
key.
B & B Excavation;Inc.
mp Company Name
14 Teaberry Lane
Company Address.
Forestdale MA::. 02644
City/Town State Zip Code
508-477-0653 S14595
Telephone Number License Number
B. Certification
_ .
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:D.EP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15000). The system:
® Passes, ❑ Conditionally Passes ❑ .Fails •
Q.Needs Further Evaluation by the Local Approving Authority
1/7/13
Inspector's Signature Date ..
The system inspector shall submit.a.copy of this inspection report.to the Approving Authority(Board
of Health or:DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design.flow of 10,000 gpd or greater, the inspector and the.system owner shall submit the...
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving:authority. .
This report only describes conditions at the time of inspection and under the conditions of use
at that time..This inspection does.not address how.the system.will perform in the future under
the same or different conditions:of use. -
.... t5ins•11/10. , -
Title 5 Official Inspect. F Subsurface Sewage Disposal System•Page 1 of 17
t Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
117 Hickory Hill Circle
Property Address
Robert Zepf
Owner Owner's Name
information is required for every Osterville Ma. 02655 1/7/13
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
T
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
' Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 117 Hickory Hill Circle
Property Address
Robert Zepf
Owner Owner's Name
information is required for every Osterville Ma. 02655 1/7/13
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
1
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y- ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts)
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 117 Hickory Hill Circle
Property Address
Robert Zepf
Owner Owner's Name
information is required for every Osterville Ma. 02655 1/7/13
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2-. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections: .
Yes No.
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El ® 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 Y2 day flow
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 117 Hickory Hill Circle
Property Address
Robert Zepf
Owner Owner's Name
information is Osterville Ma. 02655 1/7/13
required for every
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd. ,
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10;000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts .
_ W Title 5 Official Inspection Form --
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
M °p 117 Hickory Hill Circle
Property Address:.
Robert Zepf j
Owner Owner's Name
information is required for every Osterville Ma. 02655 1/7/13
..
page.: City/Town State Zip Code. = Date oflnspection,-
C. Checklist
Check if Ahe 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
❑ N 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 ystem:obtained arid.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?
l
® ❑. . 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 Ihas-
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)l
D. System.Information
Residential.Flow Conditions:
Number of bedrooms(design):: Number of bedrooms (actual)::
DESIGN flow based.on 310 CMR 15.203.(for example: 110 gpd x#of bedrooms),-
330
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System:-Page 6 of 17
II �,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
117 Hickory Hill Circle
Property Address
Robert Zepf
Owner Owner's Name
information is required for every Osterville Ma. 02655 1/7/13
page. City/Town State Zip Code Date of Inspection
D. System Information -
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required]. ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d n/a
9 ( Y 9 (gp ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): /
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
W Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 117 Hickory Hill Circle
Property Address
Robert Zepf
Owner Owner's Name
information is required for every Osterville Ma. 02655 1/7/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ❑ 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)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):
t
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 117 Hickory Hill Circle
Property Address
Robert Zepf
Owner Owner's Name
information is required for every Osterville Ma. 02655 1/7/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
1984
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
3'
Depth below grade: feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >20feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
At time of inspection building sewer appeared to be in working order no sign of leakage or blockage.
Septic Tank(locate on site plan):
2'
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ® No
Dimensions: 1000 gal
6-1
Sludge depth:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
i
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
" Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 117 Hickory Hill Circle
Property Address
Robert Zepf
Owner Owner's Name
information is required for every Osterville Ma. 02655 1/7/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
31"
2" .
Scum thickness
Distance from top of scum to top of outlet tee or baffle
4"
Distance from bottom of scum to bottom of outlet tee or baffle
16"
How were dimensions determined? scour 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.):
At time of inspection septic tank appears to be structurally sound. No sign of back-up.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 117 Hickory Hill Circle
Property Address
Robert Zepf
Owner Owner's Name
information is Osterville Ma. 02655 1/7/13
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
r
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 117 Hickory Hill Circle
Property Address
Robert Zepf
Owner Owner's Name
information is required for every Osterville Ma. 02655 1/7/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 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.):
At time of inspection d-box appears to be in working order.
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.):
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
117 Hickory Hill Circle
Property Address
Robert Zepf
Owner Owner's Name
information is required for every Osterville Ma. 02655 1/7/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
At time of inspection leaching appears to be in working condition.Water level is 4' below invert at time
of inspection.
Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth.of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 117 Hickory Hill Circle
Property Address
Robert Zepf
Owner Owner's Name
information is required for every Osterville Ma. 02655 1/7/13
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
J
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
I
it
r
Commonwealth of Massachusetts
Title 5 Official Inspection form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
117 Hickory MiII Circle
Property Address
Robert Zepf
Owner Owner's Name,.
information is O"sterVille Ma.. 02655 1/7/13
required for every
page. City/Town State Zip Gode . Date of Inspection
D. System Information. (cont.)'
Sketch:Of Sewage Disposal System:'Provide a view of the sewage disposal sysfem, including ties to
at least two permanenfireference 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
Al 3T
A2'
2= 'La-'
A3 ` � S `
3
t5ins-11/10 Title 5 Official Inspection Form:.Subsurface Sewage'Disposal System-:Page`15 of-.17.
I
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
117 Hickory Hill Circle
Property Address
Robert Zepf
Owner Owner's Name
information is required for every Osterville Ma. 02655 1/7/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: >12
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
r
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
I
4
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
117 Hickory Hill Circle
Property Address
Robert Zepf
Owner Owner's Name
information is required for every Osterville Ma. 02655 1/7/13
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
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