HomeMy WebLinkAbout0278 HICKORY HILL CIRCLE - Health 278 Hickory Hill Circle
Osterville
A = 120 014
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F
Commonwealth of Massachusetts +.- �&�
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 278 Hickory Hill Cir f _`
Property Address
Bank Owned (Contact David'Holt(6 Today Real Estate-1-800-966-2448) "
Owner Owner's Name
information is Osteryille.- , MA 02655 8-9-12-
required for every
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.
A. General Information
1. Inspector:
•
Shawn Mcelroy -
Name of Inspector" -
Upper Cape Septic Services
Company Name k
29 Atwater Dr
Company Address
E. Falmouth MA 02536
CitylTown T State Zip Code
1-508-495-0905 S13971
Telephone Number License Number "
B. Certification
4 _ e
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: -`� -' wl' ` {
® .Passes Conditionally Passes , . ❑ Fails
• El Needs Further Evaluation by the Local Approving Authority '
f •
Inspector's Signat re w Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health orDEP)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.
nil
t5ins•11110 Ti a icial Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 `
t
Commonwealth of Massachusetts '
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 278 Hickory Hill Cir
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Osteryille MA 02655 8-9-12
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System is in good working order with no sign of failure.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass"section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
I •
Commonwealth of Massachusetts
F Title 5 Official,,I rispection Form `
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
278 Hickory Hill Cir r
Property Address ;
Bank Owned (Contact.David Holt @ Today Real Estate 1-800-966-2448)'. t
Owner Owner's Name ,
information is
required for every Osterville MA 02655 8-9-1 2-
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.) r
:r
B) System Conditionally Passes (cont.):
4.
❑ 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):
❑ .r obstructionJs'removed ❑ Y ❑ N ❑ ND'(Explain below):
❑ -distribution'`boz is leveled or replaced El. ❑ N." ❑ ND,(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
broken pipe(s) are.replaced ❑ Y' ❑ !N ❑' ND(Explain below):
❑ obstruction is removed. ❑ Y ❑ N ❑ ND (Explain below):
C)-,Further Evaluation is Required,by:the Board of Health:
a ❑ `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 ina"manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface'water
r
`❑ ``` 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 k
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form =Not for Voluntary Assessments
278 Hickory Hill Cir
Property Address
Bank Owned (Contact David Holt @ Today Real!Estate 1-800-966-2448)
Owner Owner's Name
information is
required for every Osterville MA 02655 8-9-12
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 aseptic 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.
❑ .7he 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
ponding of effluent to the surface of the ground or surface waters
❑ ® Discharge or
due to an overloaded or clogged S/4S'or cesspool
El ® Static liquid level.in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 'h day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
r
Commonwealth of Massachusetts .
F Title 5 Official Iftspection' Forte
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments-o . .• •
278 Hickory Hill Cir - 4
Property Address �s 4
Bank Owned (Contact-David Holt @-Today keal.Estate 1-800-966-2448) f
Owner Owner's Name
information is ,
required for every Osterville•A MA 02655 8-9-12 ,
page. City/Town_ State Zip Code Date of Inspection
B. Certification -(cont.)
' .Yes x• 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.
i - t Any,portion of cesspool or privy is within 100 feet of a surface watersupply or
® tributary to a surface water supply.
®° 14 - 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.
El '®,' 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.]
El
® The•system is a cesspool,serving a facility with a design flow of 2000gpd-
i 10,000gpd.''t
The system'faiIs.•1-have determined that one or more of the above failure
E] ® + „ 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:; • r
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
❑` r❑ 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
El, n the•system is located in a nitrogen sensitive area (Interim Wellhead-Protection
Area—IWPA)or a mapped Zone II of a public water•supplywell
' 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 M 1 _ Title 5 Official Inspedon Form:Subsurface Sewage Disposal System-Page 5 of 17
•
Commonwealth of Massachusetts
Title 5 Official Inspection Form'
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments'
278 Hickory Hill Cir '
Property Address
Bank.Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Osterville - MA 02655 8-9-12
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"-as to each of the following:
Yes No -
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
Have large.volumes of water been introduced to the system recently or as part of
❑ ® this inspection?
® ❑ Were as built plans of the system obtained and examined? (if they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ •Was the site inspected for signs of break out?
® ❑, Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
a ® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on: '
® ❑ Existing information. For example, a plan at the Board of Health.
a ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design):'* 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR,16.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 OfficialInspection Form{
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 278 Hickory Hill Cir
Property Address
Bank Owned (ContactDavid;Holt @'Today Real Estate 1-800-966-2448)`'
Owner Owner's Name r
information is Osterville MA 02655 8-9-12
required for every •-' •
page. City/Town r„ State Zip Code Date of Inspection
D. System Information
Description: R
Number of current residents: • 0
t
Does residence have a garbage grinder? ❑ Yes Z No
Is laundry on a separate Sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes' No
•;f S -
Seasonal use? _ f°° ❑ Yes No
Water meter readings, if available (last 2 years usage(god)):
Detail: Y
Sump pump? f , " , ;,; _ k' ¢ . ❑ Yes Z No
Last date of occupancy: 6-2012
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:,.' j
'Design flow(based.on 310 CMR 15:203): w ''Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc:,): s ,• .,
Grease trap present? R El Yes
❑ No
E
Industrial waste holding tank•presedt? a -'r El Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-11710 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System a Page 7 of 17
Commonwealth of Massachusetts r
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
278 Hickory Hill Cir
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name ..
information is required for every Osterville MA 02655 8-9-12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
f
General Information
Pumping Records:
Source of information: N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ - Tight tank.Attach a copy of the DEP approval. -
❑ Other(describe):
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 17
Commonwealth of Massachusetts � •�� � � ' :z�, �•
_ Title 5 Official Inspection "Form
Subsurface Sewage Disposal System,For h-Not for Voluntary Assessmentsr.
278 Hickory Hill Cir
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) '-
Owner Owner's Name
information is r •�
required for every Osteiville MA 02655 8-9-12 r
page. .City[Town 3 State Zip Code Date of Inspection
D-System Information (cons)
Approximate'age of all components, date,installed (if�known) and source of information:
1990
Were sewage odors detected when arriving at the site? ' ❑ Yes ® No
Building Sewer(locate on site plan):'
Depth below grade: 14','
"e
` feet,
Material of construction:
t `cast-iron ® 40 PVC '
other(explain]
Distance from private water supply well or suction line' feet
Y. c
Comments(on condition of joints,venting, evidence of leakage;,kc.):
Good condition.
Septic Tank.(locate on site plan):,,,..,, }
Depth below grade: �x, , stt
i.' feet
Material of construction: ,_*
® concrete Elmetal 'El 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: f 1000 gal _ ^
12�t.
„ ,
Sludge depth: x
t5ins•11/10 + Title 5 Official Inspection Form-Subsurface Sewage Disposal System•Page 9 of 17
.. - -.
Commonwealth of Massachusetts _
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments -
M r 278 Hickory Hill Cir
Property Address
Bank Owned (Contact-David.Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is Osterville MA 02655 8-9-12
required for every -
page. City/Town State Zip Code Date of Inspection
D. System Information (cost,)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
20"
lot
Scum thickness .
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
15"
How were dimensions determined? Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.): `
Tank is in good condition with baffles installed and no sign of leakage.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction: ,
❑ concrete ❑ metal ❑ fiberglass Y- ❑ 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
- t
Date of last pumping: Date
t5ins-11110 1 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
I •
Commonwealth of Massachusetts
Title 5 Official. Inspection Form ` 1
I a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments.. .
9 p Y rY
278 Hickory Hill Cir 'f t
Property Address °
Bank Owned (Contact David Holt @ Today;Real Estate 1-800-966-2448),:
Owner Owner's Name
information is
t Oserville MA 02655 8-9-12•,
required for every µ •-
page. City/Town '`•, State Zip Code Date of Inspection` f
D. System Information (cost.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,'evidence of leakage, etc.):
g
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on.site plan):
Depth below grade::
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
$ gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
Date -
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract (required): Is copy attached? ❑ Yes ❑ No
t5ins•11/10 s Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
s 278 Hickory Hill Cir
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Osterville MA 02655 8-9-12
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.):
Good condition with water at working level and no sign of back-up.
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-11/10 Title 5Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
�/ /TOWN OF BARNS�TABLE
OCATION 7 /Y• Lk vey �7 l� C .'T SEWAGE #
I, E QS¢4ej- O d'l'e ASSESSOR'S i &LOT
INSTALLER'S NAME&PHONE NO .
SEF IC TANK CAPACITY _ A )uO
LEACFIING FACHAW: (type) 3
-/0 00
NO.OF;BEDROGPhS___ .3_.._..
BUILDER OR OWNER
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 wclls exist
on site or within 200 feet of leaching facility) Feet
Edge of Weiland and Leaching Facility(If any wetlands exist
within 300 feet Ieachting fa 'city) Feet
.'Furnished by
6� All,
F- jq6
t'
Commonwealth of Massachusetts `
Title 5 Official Inspection Form
x
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Hickory Hill Cir ,L
Property Address
Bank Owned (Contact David;Holt @.Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Osterville MA 02655' 8-9-12
page. City/Town . . State Zip Code Date of Inspection
D. System Information (cont.)
Type: ?, t'
® teaching pits number: 3-1000 gal
❑ leaching chambers _ number:
❑ leaching galleries number-,
❑ leaching trenches - number, length:
❑ leaching fields .number;dimensions:
❑ overflow cesspool _number: •'
El 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.):
Leach pits empty at inspection with stain line in pit"H"at 36" below inlet invert.
M
Cesspools (cesspool must be pumped as part of inspection) (locate on site planj:, -
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
r
t5ins•11110 ," + Y Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
.4 - -
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 278 Hickory Hill Cir -
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for eve Osterville MA 02655 8-9-12
page. every City/Town State Zip Code Date of Inspection
i P
D. System Information (cont.)
Comments note condition of soil signs of hydraulic failure level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure,"Ievel of ponding, condition of vegetation,
etc.):
t5ens•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
it
- s
C.
Commonwealth of Massachusetts
Title 5 Official Inspection Forr�i
Subsurface Sewage Disposal System'Form -Not for Voluntary.Assessments
M 278 Hickory Hill Cir f' • .
Property Address
r Bank Owned (Contact David:Holf(0 Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Osterville MA.- . 02655: 8-9-12
page. City/Town State, Zip Code Date of Inspection '
U. System Information (cont.)" .
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal,system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately ° "� " •-'
46
y Vo
&) f7
q .
•r '
t5ins•11110 _ e Title 5 Official Inspection Form:Subsurface Sewage Disposal System"Page 15 of 17
Commonwealth of Massachusetts '
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form =Not for Voluntary Assessments
278 Hickory Hill Cir t
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Osterville MA 02655 8-9-12
page. City/Town : State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam;
❑ Check Slope
❑ Surface water s
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20
feet
Please indicate all methods used to determine the,high ground water elevation:
❑ Obtained from system design plans on record
t 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:
USGS and town maps show groundwater at greater than 20'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-11l10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
278 Hickory Hill Cir, Y .
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-'2448) -
Owner Owner's Name
information is required for every Osterville MA 02655 8-9-12
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 a
t
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
TOWN'OF BARNSTABLE
LOCATION ���' l}(C�tJt�Jt' P /yL SEWAGE # 0
VILLAGE 0S'Tf P_,)i ASSESSOR'S MAP Cz LOT
INSTALLER'S NAME & PHONE NO. U S fir..
SEPTIC TANK CAPACITY
f
LEACHING FACILITY:(type) / (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER ?Ug L-
BUILDER OR OWNER2 �I
DATE PERMIT ISSUED: /CO 'J�" �®
DATE COMPLIANCE ISSUED: Iq'
el
VARIANCE GRANTED: Yes No
C' _ ,
A/o
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No...... ... L..
THE COMMONWEALTH OF MASSACHUSETTS'
/off v O BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Disposal Works Tonstrudion Frrutit .
Application is hereby made for a Permit to Construct ( ) or Repair (�), an Individual Sewage Disposal
System at
;;17 ..... � � ... f.f. ......_...1.L C..lULt U�"iL'6L4�tit.t;� SS
-------------------•-•----•-•-•-•-•--•------•------••-•-----------.............-••............----
Location-Address or Lot No.
tL0�a D-�9 !+ Gc.o� ,,a_ti O SICWa.u.a
.--•-••. ---. .............. ..................................... --._.........------------------................_..•-••-----------.................................
O er Add" s
Installer" Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms------.-2..............................Expansion Attic ( ) Garbage Grinder ( )
P4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
P4Other fixtures -----------------------------------------------------.------------------.
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length....... ...__..._ Total leaching area-----_...............sq. ft.
Seepage Pit No.......1------------ Diameter.__....°......... Depth below inlet.....
)=........... Total leaching area..a .(......sq. ft.
Z Other Distribution box ( ) -Dosing tank ( )
a
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit..................... Depth to ground water........................
GTq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
--------------------------------------------------------------------------------------------•-...---...........................................................
0 Description of Soil........................................................................................................................................................................
U --------------------------------------------------------------------------------------------------?--....--------------------------------------------------------------------------------.............
U Natu e of R fpairs or Alterations—Answer when applicable.....UJ ��L�-:-......_�7._x._
. ........�......--0F...5_q. e-------t,^>-------- 1r._. 4-L, --------------------------------------------------------------------------
Ag Bement:
The.,undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance h been 'ssu �boardlth.
Signed -----1�.J. ... V 6^Q 0
a Date
Application Approved B . .................... ---- -----1 - ✓ r'�L -r'.... �
Dale
Application Disapproved for the following reasons: .-------- - ------------ ------------------------------- ------------
--------------------------------------------------- -- ------ ------------------------------------------------------------------ ..
----------------------------------------
�j ,rP `
Permit No. ----��a� !'" a.Y Issued �' `� -.. "" e
Dare
No.............. D Fics, —.
THE COMMONWEALTH OF 'MASSACHUSETTS
rt �/ BOARD OF HEALTH
TOWN OF BARNSTABLE
3 Appliratilan for Disposal Works Tonstrnrtinn 11nmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
4�» stem at:977
AICKUQy I+1 LL CteCt� O5 6I.Utt.t,c S
................___._—` - ._........ ..... - - ---------•------.....------------....................------......___-------•-
`, Location-Address or Lot No. r //
• LAaOAT �^# 8 141C-16 �}1LL 8S�tLv1,� `f
wnez Addres O s
W yl�lOc�DS T7C73)AR-V a- L() c.1WLSf«I1J fZ So. I?EN�✓� f,+�fR
- -------- ------- --•---�-- - --------..----- -.-----..-•-..----- ---------------------------------------------------
Installer t 1 i Address
Type of Building :" Size Lot.................... .....Sq. feet
.a Dwelling—No. of Bedrooms................... ......... ........Expansion Attic ( ) Garbage Grinder ( )
=P 1 Other—Type of Building .........................'-: No. of�persons............................ Showers ( ) — Cafeteria-
Other ( )
`ar
fixturesJ. , ------------------------------------------ ------------..._....------
r Design Flow_............................................gallons per person per day.-Total daily flow............................................gallons.
Septic Tank—Liquid capacity............gallons Length--------------- Width...............:Diameter---------------- Depth................
Disposal Trench—No--------------- - Width.................... Total Length Total leaching area--------------------sq. ft.
Seepage Pit No.......I........... Diameter.................... Depth below inlet.......... Total leaching area...P 5 j.._..sq. ft.
<r Z Other Distribution box ( ) Dosing tank (, )
a Percolation Test Results Performed by-_------------------------
---------••-----------------•---•------------- Date.---------------......---------•--.f:-
Test Pit No. 1................minutes per inch Depth of Test Pit..................... Depth _o ground water....................
• fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water------_............#_..
Ix ••---••••-----------------..................................................................................................................................
ODescription of Soil.................................................................................................----•-•-----•-----••---•-----•-•-------•----•----•-----••••-...
v •--•--•--•-••----•-•----•-••...................•-•--•-•-•---......--•-•-•--•-•••...._...--•••------••-----•-•---•-•---•-•----•-•-•-----••--------•--•...._........._................---------••-......
W •-----••-•-•---------------------•---------------•-------------------•----•------------•--•••-••--------•--•-----------------------------. -- --- •--••----------------------.--•-- f
`V Nature of Rgpairs or Alterations—Answer when applicable...__ N3.tr-._.__..�?..X__....._... � _-P_/-_�_._........
w/ �...:--S- "'-'-E••-•••.^.........._Sys�2�....A--- ----- --------
---- -
-------- --------------------- ------
F' Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
i
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
systemlin operation until a Certificate of Compliance ha been issued b f the board of health.
"aa Y'^..I.� ♦ (( ........................................
Signed 6- --------------
Date _
Application Approved By ,- ....-----4i � i,,�------------------ !% � F►��< �
Dare-------------------
Application Disapproved for the following reasons: ----...... -----------------------------------------------------------------------------
--- - - - ---------- ----------------------------------------------------------------- -..............................................._ = .........------------------------------
Permit No. Issued -------/40
- -
Da -`�
te
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
1
(gelr#tft>Late of C outpltaxue
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (
a
by-----------................. _ fi ....... -� V-- -- 1............................
.r '♦,\ Instal;1
`r at .T .:./ 4.. .........f�t'�r .. �. a'.. ................................."J/i � ------------------------------
y has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal'Works Construction Permit No. ........-f7.. g.... dated .ZV4f .l��"�'�
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUEVAS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. l
DATE...... `..�:L...,.. ----. ----------------------------------------------------- Inspector...._ -----...........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE ,JCS
No.;..................... FEE.......................
.
Disposal nrkg� Tuni#rnlllan ramie
Permission is hereby granted.............. ..•`•----- 1 _ ..................................................................
to Construct ( or tRR--pair (, ) an Individuuall Sewage Dis osal System J
at No......s:. � -.P'" •f' ?r ' . .`-�� ...... .A- !� 1` F�! - /Arw''` `���t'f-..........- .....
Street 4 / 14
as shown on the application for Disposal Works Construction Permit o.. �� ._.......(..�.................
...--•------.r,....------ t,. .................. .--•---------
Board of Health
DATE---..... p :. ....................... j
FORM 36508 H0884 h WARREN.INC.,PUBLISHERS