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HomeMy WebLinkAbout0020 HOLLINGSWORTH ROAD - Health 20 HOLLINGSWORTH RVOOSTERVILLE o � o , A o o O 1t O f. k �Y a v o I F 0 1 O Commonwealth of Massachusetts Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' .� 20 Hollingsworth Road Property.Address NJ Glenn Tobin " Owner Owner's Name information is Osterville Ma 02655 8/16/2019 0 required for every c page. Cityrrown State Zip Code Date of Inspection t. . Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information u / filling out forms on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not . S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Beldan Lane -Company Address Centerville Ma 02632 City/Town State Zip Code »� 774-248-4850 smjonestitle5@gmail.com, S14522 sean@smjonestitle5.com License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000);1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. _❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails lr 8/16/2019 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. r t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Hollingsworth Road Rroperty.Address Glenn Tobin Owner Owner's Name information is required for every Osterville Ma 02655 8/16/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The property located at 20 Hollingsworth Rd Osterville is served by 2 Title V septic systems. This report represents a system consisting of a 1000 gallon septic tank, distribution box and 2 500 gallon leaching chambers. The system was found to be in proper working condition at the time of inspection. 2) System Conditionally Passes: ❑ One or.more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not -determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Hollingsworth Road Property.Address Glenn Tobin Owner Owner's Name information is required for every Osterville Ma 02655 8/16/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ .ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection-if(with approval of the Board-of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 r Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Hollingsworth Road Property Address Glenn Tobin Owner Owner's Name information is required for every Osterville Ma 02655 8/16/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 400 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**. it Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ 1z Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Hollingsworth Road Rroperty.Address Glenn Tobin Owner Owner's Name information is required for every Osterville Ma 02655 8/16/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow Required pumping more than 4 times in the last year NOT due to clogged or El ® obstructed pipe(s). Number-of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board'of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No El ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 r — Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Hollingsworth Road Property Address Glenn Tobin Owner Owner's Name information is required for every Osterville Ma 02655 8/16/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large.volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 I . Commonwealth of Massachusetts �n lip Title 5 Official Inspection Form �a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Hollingsworth Road Property•Address Glenn Tobin Owner Owner's Name information is required for every Osterville Ma 02655 8/16/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): ** Number of bedrooms (actual): 6 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660 gpd . Description: *' dwelling has 2 septic systems. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes .E No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes .E No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 2017 Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Hollingsworth Road Property Address Glenn Tobin Owner Owner's Name information is required for every Osterville Ma 02655 8/16/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments 20 Hollingsworth Road Property-Address Glenn Tobin Owner Owner's Name information is required for every Osterville Ma 02655 8/16/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: tank date unknown, s.a.s repaired 10/1999 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): sewer line was video inspected and found clean and in good condidtion. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;.� 20 Hollingsworth Road -Property Address Glenn Tobin Owner Owner's Name information is required for every Osterville Ma 02655 8/16/2019 page. Cityrrown State Zip Code Date of Inspectiori D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 2.5 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 gallons Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 4 Scum thickness 211 Distance from top of scum to top of outlet tee or baffle 7" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Opened covers and took measurements 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 does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. Outlet pipe under brick patio is orangeburg in good condition, pipe material changes to PVC. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 118 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Hollingsworth Road Property.Address Glenn Tobin Owner Owner's Name information is required for every Osterville Ma 02655 8/16/2019 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts .a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Hollingsworth Road -Property Address. Glenn Tobin Owner Owner's Name information is required for every Osterville Ma 02655 8/16/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes .❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): Distribution box was video inspected and found level and in good condition with no rot. Water level was even with-outlet'rnvert'with no signs-of past backup. I l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Hollingsworth Road Property Address. Glenn Tobin Owner Owner's Name information is required for every Osterville Ma 02655 8/16/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 2x500 gal ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Hollingsworth Road Property Address, Glenn Tobin Owner Owner's Name information is required for every Osteryille Ma 02655 8/16/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No sign of past overloading, no lush vegetation. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 j Commonwealth of Massachusetts 9 ,4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Hollingsworth Road Property Address: Glenn Tobin Owner Owner's Name information is required for every Osterville Ma 02655 8/16/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.); t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Hollingsworth Road ,PFopertr Address Glenn Tobin Owner Owner's Name information is required for every Osterville Ma 02655 8/16/2019 page. Cityrrown State. Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system,tnciuft ties-to at 4eas1 two permanent-refierence 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 At 13 �I Z3 L f�Z Z3 3 /7 y P� M 37 2 0 6 a Y 7Z'� A5 23'(' CS L-13 ZI c� 39 C 7 1c� t5lnsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Hollingsworth Road PropertyAddress Glenn Tobin Owner Owner's Name information is required for every Osterville Ma 02655 8/16/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells T 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: Groundwater was established by accessing town of Barnstable groundwater contour maps. 4 I Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Hollingsworth Road V Property Address Glenn Tobin Owner Owners Name information is required for every Osterville Ma 02655 8/16/2019 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 1 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t` �. 20 Hollingsworth Road (system 2) .Property•Address Glenn Tobin Owner Owner's Name information is / required for every Osterville/ Ma 02655 8/16/2019 ' page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in`any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information /� filling out forms 110�C on the computer, use only the tab Sean M. Jones. key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use-the return Company Name key. 74 Beldan Lane Company Address Centerville Ma 02632 Cityrrown State Zip Code 774-248-4850 smjonestitle5@gmail.com, S14522 sean@smjonestitle5.com License Number B. Gertifacation- I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (3 -0 CMR -have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 8/16/2019 Inspector'sSignature 'Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V 20 Hollingsworth Road (system 2) -Property Address Glenn Tobin Owner Owner's Name information is required for every Osterville Ma 02655 8/16/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The property located at 20 Hollingsworth Rd Osterville is served by 2 Title V septic systems. This report represents a system consisting of a 1000 gallon septic tank, block overflow pit and precast leach pit. The system was found to be in proper working condition at the time of inspection. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not -determined,"p+ease-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): I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Hollingsworth Road (system 2) PropertyAddress Glenn Tobin Owner Owner's Name information is required for every Osterville Ma 02655 8/16/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass-inspection-if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if. the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Hollingsworth Road (system 2) .Property-Address Glenn Tobin Owner Owner's Name information is required for every Osterville Ma 02655 8/16/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within III 1.00 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 criterila are triggered. A copy of the analysis must be attached to this form. c. Other: II 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts 1 Title 5 official Inspection Form I a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Hollingsworth Road (system 2) Property Address Glenn Tobin Owner Owner's Name information is required for every Osterville Ma 02655 8/16/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed-pipe(s). Number of times pumped: . ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within'50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Hollingsworth Road (system 2) .Property•Address Glenn Tobin Owner Owner's Name information is required for every Osterville Ma 02655 8/16/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for an inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this-inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components; excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . 20 Hollingsworth Road (system 2) ,Property Address Glenn Tobin Owner Owner's Name information is required for every Osterville Ma 02655 8/16/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): �* Number of bedrooms (actual): 6 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660 gpd Description: dwelling has 2 septic systems. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 2017 ,. Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Hollingsworth Road (system 2) RropertyAddress Glenn Tobin Owner Owners Name information is required for every Osterville Ma 02655 8/16/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Hollingsworth Road (system 2) Property Address Glenn Tobin Owner Owner's Name information is required for every Osteryille Ma 02655 8/16/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: tank date unknown, overflow pit dates unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): sewer line was video inspected and found clean and in good condidtion. I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts - e Title 5 Official Inspection Form �o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Hollingsworth Road (system 2) Property Address Glenn Tobin Owner Owner's Name information is required for every Osterville Ma 02655 8/16/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 2.5 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 gallons Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 4' Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 711 Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Opened covers and took measurements 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 does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Hollingsworth Road (system 2) Rroperty Address Glenn Tobin Owner Owner's Name information is required for every Osterville Ma 02655 8/16/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass_ ❑ polyethylene ❑.other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank tank must be pumped at time of inspection) locate on site plan): 9 g ( P P P ) ( P ) Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth o ealth of Massachusetts Title 5 Official Inspection Form l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Hollingsworth Road (system 2) -Property-Address Glenn Tobin Owner Owner's Name information is required for every Osterville Ma 02655 8/16/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level' Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑' Yes y❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert N/A 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts �a Title 5 official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 20 Hollingsworth Road (system 2) ' -Property-Address Glenn Tobin Owner Owner's Name information is required for every Osterville Ma 02655 8/16/2019 page. City/Town State Zip Code .Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: 1 ❑ innovative/alternative system Type/name of technology: l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Hollingsworth Road (system 2) -Property-Address Glenn Tobin Owner Owner's Name information is required for every Osterville Ma 02655 8/16/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): s.a.s. consists of a block overflow pit and precast leach pit in series. The precast pit was located and opened and was found dry with a stain line 2'from bottom. Precast pit has 10' effective leaching with unknown amount of stone surrounding. Block pit was located but not opened. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration' Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M„ 20 Hollingsworth Road (system 2) -Property-Address Glenn Tobin Owner Owner's Name information is required for every Osterville Ma 02655 8/16/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4� 20 Hollingsworth Road ,Property-Address Glenn Tobin Owner Owner's Name information is required for every Osterville Ma 02655 8/16/2019 Cit /Town State Zip Code Date of Inspection Page. Y p P D. System Information (cont.) 14. Sketch Of Sewage Disposal System: p Y Provide a view of the sewage dispose)system,incUding 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 I . 13k Az 12 tb o A5 > G S y3 A16 21 c� 3y A 7 SS 7 c7L 7 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 l Commonwealth of Massachusetts e Title 5 Official Inspection Form �a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Hollingsworth Road (system 2) .Prope4Addxess. Glenn Tobin Owner Owner's Name information is required for every Osterville Ma 02655 8/16/2019 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 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: Groundwater was established by accessing town of Barnstable groundwater contour maps. ` r Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Hollingsworth Road (system 2) -Property..Ad&ess. Glenn Tobin Owner Owner's Name information is required for every Osterville Ma 02655 8/16/2019 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 �.• �c 11 2015 2227 Jim The Inspector Man 5085349919 page 1 lqo--622- Qo2 Ma i � Commonwealth of Massachusetts. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments t 20 Hollingsworth Road.(System 2) Property Address F Barbara Wood Owner Owner's Name - information is required for every ✓Osterville MA 02655 12-10-1&?, 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 filling out Corms A. General Information `�pttutlttrt44 on the computer, J c `��� (H OF 1�1gSi/i��� use only the tab 1. Inspector: _�= •�'y'� key to move your JAMES 'u' cursor-do not James D.Sears = c use the return key. Name of Inspector :H a Capewide Enterprise, LLC *' �• o _�. Company Name %% 'f��??T �•r . 153 Commercial Street Company Address Mashpee MA 02649 Cityrrown State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification i certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails 1 ❑ Needs Further Evaluation by the Local Approving Authority ) 12-10-15 spector'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 un er the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Form:Subsuraoe Sewage Disposal System•Page 1 or 17 f 3 Dec 11 2015 2227 Jim The Inspector Man 50853499119 page 2 Commonwealth of Massachusetts Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 20 Hollingsworth Road (System 2) Property Address Barbara Wood Owner Owner's Name information is required for every Osterville MA 02655 12-1045- 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: System 1 - Newer system. The system is a 1000 Gal. Tank D Box and two.500,Gal, chambers. 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. i ❑ Y ❑, N ❑ ND(Explain below):' �JJ i i y 15ina-3113 Title 5 orriciai inspectlon Form'Subsurface Sewage Disposal System•Page 2 of 17 Dec 11 2015 22:27 Jim The Inspector Man 5085349919 page 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 20 Hollingsworth Road (System 2) Property Address Barbara Wood Owner Owner's Name information is Osterville MA 02655 12-10-15 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health.approval if pumps/alarms are repaired. 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 (Explaln below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed ppe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ NO (Explain below): ❑ obstruction is removed ❑, Y ❑ N . ❑ ND"(Explain below): { j • I 1II 7 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 1 1. System will pass unless Board of Health determines in accordance with 310 CMR j 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 151ns•W13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Dec 11 2015 22:27 Jim The Inspector Man 5085349919 ' page 4 Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y 20 Hollingsworth Road (System 2). Property Address Barbara Wood Owner Owner's Name information is required for every Osterville MA 02655 12-10A 5 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: . a 1 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. ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Ei ® Liquid depth in ampoU is less than 6" below invert or available volume is less than '/2 day flow A Ed(%//,*e t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 ' a • 'I IDec 11 2015 22:27 Jim The Inspector Man .5085349919 page 5 Commonwealth of Massachusetts Title 5' Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Hollingsworth Road (System 2) Property Address Barbara Wood Owner owner's Name information Is required for every Osterville MA 02655 12-10-15 page. Cityfrown 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 it 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 1 ❑ ❑ Area—IWPA) or a mapped Zone 11 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. One.•3113 _ Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 5 of 17 Dec 11 2015 22:27 Jim The Inspector Man 5085349919 page 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Hollingsworth Road (System 2) Property Address Barbara Wood Owner Owner's Name information is required for every Osterville MA 02655 12-10-15 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? ® El available as built plans of the system obtained and examined?(If they were not available note as NIA) ® ❑ 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? I 1 ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) 1310 CM 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 '' Dec, 11 2015 22:28 Jim The Inspector Man 5085349919 page 7 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Hollingsworth Road (System 2) Property Address Barbara Wood Owner Owner's Name information is required for every Osterville MA 02655 12-10-15 page. City/town State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal. Tank D Box and 2 500 Gal. Chambers. Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection 0 Yes ® No information in this report.) p ) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2014-48,000 Gal g y g (gP ))' 2015-28,000Gal's Detail Sump pump? ❑ Yes ® No Present Last date of occupancy: 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 trapY p resent?. ❑ es ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non sanitary waste discharged to the Title 5 system. ❑ Yes .❑ No Water meter readings, if available: 15ins•3113 Title 5Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 i� Dec 11 2015 22:28 Jim The Inspector Man 5085349919 page 8 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System form - Not for Voluntary Assessments 20 Hollingsworth Road (System 2) Property Address Barbara Wood Owner Owner's Name information is required for every Osterville MA 02655 12-10-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: pate Other(describe below): General Information Pumping Records: Source of information: ' 4/19/13 Was system pumped as part of the inspection? ❑ Yes ® No l 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 'l maintenance contract (to be obtained from system owner) and a copy of latest inspection of the 11A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): 151ns-3l19 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 t Dec 11 2015 22:28 Jim The Inspector Man 5085349919 page 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments rp 20 Hollingsworth Road (System 2) Property Address Barbara Wood Owner Owner's Name information is required for every Osterville MA 02655 12-10-15 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: Tank around 1970/ D Box and Leaching 1999 Permit#99 -67 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): • Depth below grade: 33"feet Material of construction: ®cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is cast iron and PVC SCH 40. y Septic Tank (locate on site plan); Depth below grade: 23" 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. Precast H-10 1„ Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 S Y Dec 11 2015 22:29 Jim The Inspector Man 5085349919 page 10 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Hollingsworth Road (System 2) Property Address Barbara Wood Owner Owner's Name information isequired or every very Osteryille MA 02655 12-10-15 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 29° I Scum thickness Ors Distance from top of scum to top of outlet tee or baffle 12 Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-Tape Sludge Judge 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 at working level. Tank at 3 below grade w/out let cover at 3" under brick patio. Inlet tee, outlet baffle. No sign of leakage or over loading a i i _ I 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 tap of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins 3r13 Title 5 official Inspection Form:Subsurface Sewage Disposal System-page 10 of 17 _ I I Dec 11 2015 22:29 Jim The Inspector Man 5085349919 page 11 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments "( 20 Hollingsworth Road (System 2) Property Address Barbara Wood Owner Owner's Name information is Osterville MA 02655 12-10-15 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: P 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 (Sins 3/13 Title 5 Oliclal Ins pection Form:Subsurface Sewage Disposal System•Page 11.0117 Dec 11 2015 22:29 Jim The Inspector Man 5085349919 page 12 Commonwealth of Massachusetts Title 5 Official Inspection Fora 6 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Hollingsworth Road (System 2) Property Address Barbara Wood Owner Owner's Name information is required for every Osterville MA 02665 12-10-15 page. Citylrown State Zip Code Date of Ihspection 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.): D Box is 16"x21"42" Below.grade w/cover at 10". Box is clean and solid wltwo Hines out. No sign of over loading or solid carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No` Alarms in working order. ❑ Yes ❑ No" I Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): — j If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3113 Title s omdal inspection Form:Subaurfao6 Sewage Disposal System-Page 12 of 17 I Dec 11 2015 2229 Jim The Inspector Man 5085349919 page 13 . Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' y 20 Hollingsworth Road (System 2) Property Address Barbara Wood Owner Owner's Name information is required for every Osterville MA' 02655 12-10-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ 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.): Leaching is two 500 Gal. Dry well chambers 12'x25'x2' Chambers are clean and dry like new. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 o117 f i I Dec 11 2015 22:29 Jim The Inspector Man 5085349919 page 14 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Hollingsworth Road (System 2) Property Address Barbara Wood Owner Owner's Name information is required for every Osterville MA 02655 12-10-15 page. City/Town 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: I Dimensions Depth of solids i Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l . f t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syslem-Page 14 of 17 Dec 11 2015 22:29 Jim The Inspector Man 5085349919 page 15 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Hollingsworth Road (System 2) Property Address Barbara Wood Owner Owner's Name Information is reequiredquired for every Osterville MA 02655 12-10-15 page. Cityfrown State Zip Code Date of Inspection D. 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 1 I t5ins•3N 3 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 15 of 17 I Dec 11 2015 22:29 Jim The Inspector Man 5085349919 page 16 OS� . f ORICK a o to PPr, 7 0 3 5 yy��� o i,'D �.R S i5T'£r, NEwC9 5isr£-�n i I Dec 11 2015 22:29 Jim The Inspector Man 5085349919 page 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Hollingsworth Road (System 2) Property Address Barbara Wood Owner Owner's Name ion is every Osteryille required wiredd roreve MA 02655 12-10-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Na Estimated depth to igh ground water: 20'+ 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: No G.W. problem seen. Abutting property drop's off 20'+ Before filing this Inspection Report, please see Report Completeness Checklist on next page. IS ins•3/13 Title 5 Official Inspection Form Subsurfooe Sewage Disposal System•Page 16 o117 I I Dec 11 2015 22:30 Jim The Inspector Man 5085349919 'page 18 Commonwealth of Massachusetts Title 5 Official Inspection . Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments yt 20 Hollingsworth Road (System 2) Property Address Barbara Wood Owner Owners Name information is required For every Osterville MA 02655 12-10-16 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 t i F I t5ins•M3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 I Dec. 11 2015 22:30 Jim The Inspector Man 5085349919 page 19 ' Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Hollingworth Road (System 1) Property Address ; Barbara Wood `= Owner Owner's Name information is Osterville MA 0265b 12-10-15`"required for everyt� page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms.emay not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information ►iuultrur��� on the computer, _/ �p gy ,t"OF*�i����i use only the tab 1. Inspector: key to move your cursor-do not James D.Sears . ? JAMES ,m' use the return Name of Inspector :y key. i*: • * ` Capewide Enterprises,LLC �,. o •� tG—J Company Name ��i� t...:• ' 153 Commercial StreetsPEG01�`�� Company Address , Mashpee MA 02649 City/Town state Zip Code 508477-8877 S 1623 Telephone Number License Number. ; B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails. ❑ Needs Further Evaluation by the Local Approving Authority, 12=10-15 spector'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. I 15ins•3/13 - - Title 5 Official Inspection Form:Subsurfooe Sewage Disposal System•Page 1 of 17 Dec 11 2015 22:30 'Jim The Inspector Man 5085349919 page 20 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 3 - 20 Hollingworth Road (System 1) Property Address Barbara Wood Owner Owner's Name Information is Osterville MA 02655 12-10-15 required for every page. Cfty/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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are, indicated below. Comments: The system is a 1000 Gala Tank Ipool and pit. 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•3/13 Title 5 Vidal Inspection Form Subsurface Sewage Disposal System•Page 2 of 17 ,� Dec 11 2015 22:30 Jim The Inspector Man 5085349919 page 21 Commonwealth of Massachusetts M Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Hollingworth Road (System 1) Property Address Barbara Wood Owner Owners Name information is required for every Osterville MA 02655 12-10-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational.System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cost.): ❑ 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): El distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): i ❑ 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 pipes) are replaced ❑ Y ❑ N ❑ ND(Explain below): i ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): { _ 1 ' 1 i I `I I C) Further Evaluation is Required by the Board of Health: I ❑ Conditions exist which requite further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. j 1. System will pass unless Board of Health determines in accordance with 310 CMR I' 16.303(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•3Y3 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 1 Dec 11 2015 22:31 Jim The Inspector Man 5085349919 page 22 Commonwealth of Massachusetts Title 5 Official Inspection Form, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 20 Hollingworth Road (System 1) Property Address Barbara Wood Owner Owner's Name information is Osterville MA 02655 12-10-15 required for every _ 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 I.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: ;i D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No" to each of the following for all inspections: Yes No t ❑ ® 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 NA ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Ei ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y day flow t5lns-3/13 Title 5 Official ftpection Form:Subsurface Sewage Disposal 5yslem-Page 4 of 17 f • 1 Dec 11 2015 22:31 Jim The Inspector Man 5085349919 page 23 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `~ 20 Hollingworth Road (System 1) Property Address - -- Barbara Wood Owner Owner's Name information is required for every psteryille MA 02655 12-10-15 page. Cityrrcwn State 'Zip Code Date of Inspection B. Certification (cost.) 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. El ® 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 l 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 11 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•W13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 • I y 1 Dec 11 2015 22:32 Jim The Inspector Man 5085349919 page 24 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments '^ 20 Hollingworth Road (System 1) Property Address Barbara Wood Owner Owner's Name information is Osterville MA 02655 12-1045 required for every page. Cityrrown Slate Zip Cade 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 NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 'I D. System Information Residential Flow Conditions: Number of bedrooms(design): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 t5ins•3A 3 Title 5 Official Inspection Form:Subsurfsoe Sewage Disposal System•Page 6 of 17 i a i I 1 Dec 11 2015 22:32 Jim The Inspector Man 5085349919 page 25 Commonwealth of Massachusetts . Title 5 official Inspection Form r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Hollingworth Road (System 1) Property Address Barbara Wood Owner Owner's Name information is Osterville required fore very MA 02655 12-10-15 page. City[Town State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal. Tank c.pool and pit Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available usage last 2 ears 2014-48,000Gals ( y g (9Pd))' 2015-28,000Gal's Detail: Sump pump? El Yes ® No Last date of occupancy: Present Date Commercial/Industrial Flow Conditions: j Type of Establishment: Design flow(based on 310 CM 15.203): canons per day Igpdt 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 D No Water meter readings, if available: t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 I� Dec 11 2015 22:32 Jim The Inspector Man 5085349919 page 26 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 20 Hollingworth Road (System 1) Property Address Barbara Wood - Owner Owner's Name information is required for every Osterville MA 02655 12-10-15 page. Cityrrown 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: NA i Wass stem pumped as art of the inspection?Y P p p p El Yes ® No i If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: j ® Septic tank, , 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. f ❑ Other(describe): t5ins 3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 8 of 17 'I sl .I Dec 11 2015 22:33 Jim The Inspector Man 5085349919 page 27 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y 20 Hollingworth Road (System 1) Property Address Barbara Wood Owner Owner's Name Information is required for every Osteryille =MA 02655 12-10-15 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: Tank and c.pool 1970!Pit 1978 Permit #715-260. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: r 30" feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is cast iron and PVC SCH 40_ Septic Tank(locate on site plan): Depth below grade: 201, feet Material of construction: ® concrete ❑ metal fiberglass ❑ polyethylene ❑ other(explain) 1 1 • I i If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes [❑ No 4•. 3I Dimensions: 1000 Gal. Precast H-10 Sludge depth: 41 i i5ins•3n3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17. � Dec 11 2015 22:33 Jim The Inspector Man 5085349919 page 28 Commonwealth of Massachusetts Tftle 5 Official Inspection Form A Subsurface Sewage Disposal System Form - Not for Voluntary Assessments „ 20 Hollingworth Road (System 1) Property Address Barbara Wood Owner Owner's Name information is Osterville MA 02665 12-10-15 required for every , 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 26' Oil Scum thickness Distance from top of scum to top of outlet tee or baffle 8. Distance from bottom of scum to bottom of outlet tee or baffle 18 How were dimensions determined? Asbuilt Tape Sludge Judge 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 at working level_Tank and out let. Cover at 20"below grade wlinlet cover at 3". Inlet Baffle, outlet tee. No sign of leakage or over loading. I l i 1 Grease Trap (locate on site plan): Depth below grade: teen Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: • i Scum thickness `i Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet the or baffle Date of last pumping: Date t51ns•W 3 Title 5 Ofllc al Insp ection Form:Subsurface Sewage Disposal System-Page 10 0l 17 i t Dec 11 2015 22:33 Jim The Inspector Man 5085349919 page 29 Commonwealth of Massachusetts _ Title 5 official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Hollingworth Road (System 1) Property Address Barbara Wood Owner Owners Name information is required for every Osterville MA .02655 12-10-15 page. Cityfrown 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 s 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Dec 11 2015 22:33 Jim The Inspector Man 5085349919 page 30 i Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Hollingworth Road (System 1) Property Address Barbara Wood Owner Owner's Name information required for every Osterville MA 02655 12-10-15 page. Cityfrown 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 No Box 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.): . - c 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.):- i If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: i , l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 i! Dec 11 2015 22:33 Jim The Inspector Man 5085349919 page 31 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Hollingworth Road (System 1) Property Address Barbara Wood Owner Owner's Name information is required for every Osterville MA 02655 12-10-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: ❑ leaching chambers number: ❑ leaching galleries - number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): Leaching is a 6' block c.pool and 10'precast pit. C.Pool at 2' below grade wlcover at4".Pool level at outlet tee. Pit and cover at 2' below grade dry. No sign of over loading or high stain line. 1 Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): 1 Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool I Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title S Official Inspection Form:Subsurfac a Sewage Disposal System-Page 13 of 17 1 • 1 Dec 11 2015 22:34 Jim The Inspector Man 5085349919 page 32 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 20 Hollingworth Road (System 1) Property Address Barbara Wood Owner Owner's Name information is required for every Cisterville MA 02656 12-10-16 page. Citylfown 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5i^s'9/13 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 1T Ii Dec 11 2015 22:34 Jim The Inspector Man 5085349919" page 33 Commonwealth of Massachusetts Title 5 ®fficial Inspection Form ( y Subsurface Sewage Disposal System Form - Not for Voluntary Assessments " 20 Hollingworth Road (System 1) Property Address Barbara Wood , Owner Owner's Name information is required for every Osterville ' MA '02655 12-10-15 page. City/Town State Zip Code Date of Inspection D. 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 a tsins 3/13 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System Page 15 of 17 Dec 11 2015 22:34 Jim The Inspector Man 5085349919 page 34 • IP b Us Pcti ! 6Ricl< a O U i O � 0 3 G o�D �R s ;sr�M PEW. 9 s 5Ttln iI I f r :3 '7` C ,�,V- 3 �. '1 Dec 11 2015 22:34 Jim The Inspector Man 5085349919 page 35 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 20 Hollingworth Road (System 1) Property Address Barbara Wood Owner Owner's Name information Is required for every Ostervllle MA 02655 12-10-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Nv 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 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: No G.W. Problem Seen. Abutting property drops off 20'+. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•W 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Dec 11 2015 22:35 Jim The Inspector Man 5085349919 page 36 r t Commonwealth of Massachusetts --{ - Title 5 Official Inspection Form- Subsurface Sewage Disposal System Form Not for.Voluntary Assessments 20 Hollingworth Road (System.1) Property Address Barbara Wood Owner Owner's Name information is required for every Osterville MA 02655 . 12-10-15 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist Z. 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 t, tsins•3n3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 � fJ No. Fees THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: " a`t �G�•a�0 Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 'v . pplication for Mi!6pogal *p9tem Congtruction Verrait Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) EJ Complete System El Individual Components Location Address or Lot No. / .# / Owner's Name,Address ddresAs and Tel.No. d5/Prv+7� �!�rr / /Y�c �or�, •� Assessor's Map/Parcel /9©w e 7l,®G Installer's Nam(e/Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tankl= /O®c? Type of S.A.S. Description of Soil Nature of Repairs or Alterations SSAnswer when applicable) v� bP�rv� 41, .f . '/4/d yr Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described'on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b t Bo d of He h. Signed 19 Date Application Approved by Date Application Disapproved for the following reason Permit No. ^ Date Issued f i ,, s1 f owl No. Fee Entered in computer: THE COMMONWEALTH OF MASSACH ITS PUBLIC HEALTH DIVISION - t,'N O BARNSTABLE., MASSACHUSETTS 01pprication for Mig o a paem Cbnotruction ermit C Application for a Permit to-Construct( )Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. r Owner's Name,Address and Tel.No. Assessor's Map/Parcel /y0- 87.2, 001 �,t. ✓': _ Installer's Name,Address,and Tel.No. VZsi0e'r's"+Name tddress a'nd-Tel.No. Type of Building: ' ' l Dwelling No.of Bedrooms 6 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daiiy flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tanks= /OaOy Type of S.A.S. "" Description of Soil Nature of Repairs;.oAlterations�j Answer;'when applicable) J h S fe 2 4 Ile V S '>/� S fu t�GCAr Q h ? /p_ejYv CV A" ��H� t 6 � �c��N i b k Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation imiil a Certifi=, -cate of Compliance has been issued b t Bo d of He - Signed ML Date Application Approved by Date Application Disapproved for the following reasons 9 Permit No. Date Issued J ' -- #--- -- --------------------------- _ .s'. THE COMMONWEALTH OF MASSACHUSETTS t3, <'t BARNSTABLE, MASSACHUSETTS _ (Certificate of Compliance ---—THIS IS TO CERTIFY that the On-site ewage Disposal System Constructed( kRepaired( )Upgraded( ) Abandoned( )by at has been constructed in accordant with the provisions of Title 5 and the for tsposal System Construction Permit No. a dated Installer -Designer. y The issuance of this - t shafll of b �-construed as a guarantee that the sy i 1 n¢'o as d� ne Date f Inspector m ;=--------------------------- No. 9,�ee -4 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS i Mig ogal ztem Conotruction Permit 1 � p Permission is hereby grantqd to.Construct Repair( )U�rade( )Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this I. �y Date: �� r Approved 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only, - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) gel /7i hereby certify that the application for disposal works construction permit signed by me dated concerning the property located at 20 fw 14 afzrl rke meets all of the following criteria: , k • The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. i • The soil is classified as CLASS I and the percolation rate.is less than or equal to 5 minutes per inch. • There are no wetlands within 100 feet of the proposed septic system 1 • There are no private wells within 150 feet of the proposed septic system t � • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor method when applicable] • If the S:A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed _ leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) 'y 2 B) G.W.Elevation �+the M.A.X.High G.W. Adjustment. DIFFERENCE BETWEEN A and B 2 , SIGNED DATE: : f (Sketch pro rsedlan of system on back]. q:health folder.cent v 7Z--- . fi C� 7 0 LOCATION SEWAGE PERMIT NO.- V+ILLAGE IN.STA LLER'S N � ME & ADDRESS BJJ+bV OR OWNER DATE PERMIT ISSUED �. I� �- � DATE COMPLIANCE ISSUED � � �/� � �t 111 1 L Y� TO OF BARNMWAGE LOCATI �ON � # 'VILLAGE ���"t v ASSESSOR'S MAP & LOT I y INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: 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 Furnished by I c AB AC AID BD `� �f TOWN OF BARNSTABLE r� PP'' OCATION� �0 4 D( /l o%C S W o `k. 9�d SEWAGE # JILLAGE 0,5+ _ASSESSOR'S MAP& LOT62--a-d INSTALLER'S NAME&PHONE NO. ZQk j8 Aeav SEPTIC TANK CAPACITY LEACHING FACILITY: ( ) 2/501) 6-L dh-t n"(size) Aa` X 0S'X 01' NO.OF BEDROOMS jj��'' O BUILDER OR OWNER er/ PERMTTDATE: 1 1 COMPLIANCE DATE:_,® Separation Distance Between Ithe- MaximumAdjusted Groundwater Table and 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 Furnished by. I 1'-.0 a "ro E�cis7iw6 No. 31 Fee Zo�— THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftplitation for Disposal 6pstem Construction permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Z 0 , Owner's Name,Address,and Tel.No. SS v 1 Cl,, vzx) O S i G!c.iJ;�i e �E b q.G ylf•ay^ZI -2— Assessor's Map/Parcel /q p c w-,— © © Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Capgw u4t �n <�3�'� L.L c Sv8 '-177 ZZ-27 Type of Building: .4- Dwelling No.of Bedrooms Lot Size o 00 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 11P_2 JQC_e (�X),A , ,� :�4 o T-r> Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued is Board Healt ig a ate Z 0 [S Application Approved by ate Application Disapproved by Date for the following reasons Permit No. Date Issued _..,, •--•- No. C i Fee /Z:v THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftpliration for Disposal 6pstem Construction 3permit Application for a Permit to Construct( ) Repair4V,) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Z i t;"SS Or rn-er_'s Name,Address,and Tel.No. i U �-T &"ZJ 'k V b�4. o- �►a-p� e�� ilati.'rt'ScJc2lZ� ti� Assessor's Map/Parcel J yo Installer's Name,Address,and Tel.No. Designer's Name,Address,`kid Tel.No. T Type of Building: ` Dwelling No.of Bedrooms Lot Size ZO,uoO sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date a - kTitle ":Size of Septic;Tank Type of S.A.S.41 t F •Descript o.,of Soil �# Nature of Repairs or Alterations(Answer when applicable) T�Z a .q o Cis Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in 1 accordance with the provisions of Title 5 of the Environmental Code and not to place the system in opera.ion until a Certificate of ,'',Compliance has been issued jiyjhis Board f Healt Sile Date � a ' � ^ Z01 Application Approved by 6% y Date d Application Disapproved by V Date for the following reasons Permit No. Date Issued / -- -------`----------------------------------- - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS o e C Certificate of Compliance It 17S TO C�E+RTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired` Upgraded( ) Abandoned( )by `-'Q / at ZO 1.lA tl��g w��� (Z7 has been cons cted in acc rZ �, with the provisions of Title 5 and the for Disposal System Construction Permit No-. bd Installer s (L' e:t.� ✓ y-e s (. .k Designer ,{.-) #bedrooms All I Approved design flow gpd i The issuance of this permi hal n asj,not be construed as a guarantee that the system will. ct' designed. 1, Date /o��l f/ Inspector I1/ V --=------------------- -------�-------------------------------------------------==------- -------------- No _ �`/ �O Fee- . THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal *pstem Construrtion 3dermit Permission is hereby granted to Construct( ) Repair K) Upgrade( ) Abandon( ) System located at -'� �`W`� c S Loa ,2!' Sn- i Z-1D L re rL ri �. -e and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construct io u t Pe completed within three years of the date of this permit. 9�) Date Approved by_ / & 1 1 )A- No.......... - 4r_-.. Fxs.............. ......... THE COMMONWEALTH OF MASSACHUSETTS P60 BOAR® PF [IEALTH ..........OF........V..Q/}/Jrl'.......-.. Appliratilau for Uhyaaa1 Works Towi$rurtinu Orrutit Application is hereby made for a Permit to Construct ( ) or Repair (�) an Individual Sewage Disposal System a : ..sz< .. -L-.I.-•=�:°---•................. ..•--•-----'.-°�• ''Y '-•----- ---•-----------•--•---.............------- ... ... ......_ < < - Locatio -Add or Lot No. - ---- er r dress --------------------•------------_... J.. ..._ ------ Installer Address d Type of Building Size ...Sq. feet aDwelling�No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) p-, Other—Type of Building ____________________________ No. of persons__----•----••---------- Showers ( ) — Cafeteria ( ) a' Other fixtures ------------------------- ------ - - W Design Flow............................................gallons per person per,day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No_____________________ Width-__xx___�........ Total Length............. ..... Total leaching area....................sq. ft.' Seepage Pit No--------------------- Diameter____�1�._. Depth below inlet______........... Total leeching area...11, 1'9...sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------------------------•----------------------------------------------- Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit____________________ Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------_................. ODescription of Soil--- 4/ --- � ------------------------------------ ---------------••-------------- ----------------- x V .....-----•----------------------------••--••--------•--...-----•----------------...-----••-------------------------•-------•--•-------------•----------•-----•••--------•-----••--...--•------••-------. W -------------------------------------- -----------------------------------------------------------=•----------- ---------- ---- -----------------------------------................................. U Nature of Repairs o Alterations Answer whe applicable . . � 1_4____________________________ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iIT E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued b the board health: Signed_ .•---- f/" ................................ S_ ................................ Date Application Approved BY .!�d G .__._ D a•t.e_ . Application Disapproved for the following reasons:................................................................................................................ ---------------------•---•••-•-•--••---•-----------••---•-----------•-•••------•--------------------._....-----•---------------------------•------------------------------•-----•--•------------......... Date Permit No. Issued. ................ ......................... Date No............T ............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD /5)F HEALTH --------------- ...OF....... ....................................................... Appliratiou for Disposal Works Tomitrurtion Vamit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal Ste In, . .. . t: ............. ........... .....r • .............................................................. ... .......... ..... . ........... ocati&A or Lot No. ............................ .....................................................•............................................ er n dress ...... ......... - ­­------------- .............. - ------- ...... Yustai'ler .... Address Type of Buildin Size ...Sq. feet DwellinPNo. of Bedrooms............................................Expansio Attic Garbage Grinder ( ) pa, Other —T e of Building No. of persori .......................... Showers Cafeteria ( ) Type g ............................ V. P-4 Other fixtures ...................................................................................................................................................... Design Flow............................................gallons per person per day. Total daily flc.w............................................gallons. 1:4 Septic Tank—Liquid capacity............gallons Length................ Width__...__._._.._.. Diameter._........_..... Depth........._..._-_ Di4p76i§al_.Tren h—No..................... Width. Total Length..... . Total leaching area....................sq. f t. Seepage Pit No--------------------• Diameter... below inlet. ..... Total leaching area...,7.?;.2....sq. f t. Z Other Distribution box Dosing tank Percolation Test Results Performed by......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit....._._...._...__.. Depth to ground water------------------------- Test Pit No. 2................minutes per inch Depth of Test Pit___--___---_____.--- Depth to ground water_-__._.__._._.......__.. ............................. ............*"*"'*"*---------------*-----------------*---------------------------------------- 0 Description of Soil._ - - ---- -- ----------------------------------------------------------------------------------------—--------- U .....................;Y................................................................................................................................................................................. .................. ------------------------------------------------------------------------------------------------------ 14..................................................................... U Nature of Re airs ov Alterations Answer-*heji applicable... ............... ............................. ................................................i............................ ... .... ..... Agreement: Thq,undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT= 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 4y the board gf health. 51 Signed. Date Application Approved By...... _7. . . -4-4-0111.1---- ---------­---- . ........C­44,...?!.f...... Date Application Disapproved for,the following reasons:................................................................................................................. .......................................................................................................................................................................................---------------- Date Issued------- ...... 7 ........... Permit No.:..................................................... . ..... .......... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............... ...OF....... .............................................. Trrtffiratr of Tompliana .111) or Repaired THeI I ITO TtL,-�hat the Individual Sewage Disposal System constructed ....... .... ------ by......... ....4...... ............................ Installer .......... e1,.?,;? 4&A-Z;� ..................... ........... .. ... at....!nn...Ax 4Z*L,... ......C .....................2 has been ins4led in accordance with the provisions of T 5 of The Late Sanitary Code as described in the application for Disposal Works Construction Permit No_&I ------2---Llp..a........ dated-- --- ............. 'THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. 'OL DATE......- .7,f.................................. Inspector...,w........................ ................................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . .. .OF.......i. .. . ......................................................... ��4 .. %,­,1�1 IFE)t........... ........... .. ...........r.& ..... Permission 's ereby.granted_�'!�......... ....... ........ . .... . ..................................................... y to Construct-,$ ..'72ReDapil Individual Sewage D al-System S 'stern ------t............................................... a ....... ....2 U.- - i f or as shown on the applicati n for Disposal Works Construction Pppnit,N ..7.... ..... Dated__, .........1............. e/. --------_-----------------_— oa d of He ItV DATE.h`— .................................. FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS e_ TOWN OF BARNSTABLE LOCATION c 4 r D 111 n g-s W y (4, IU SEWAGE # ��!!; VILLAGE D S-�- ASSESSOR'S MAP & LOT 'L(,tJl INSTALLER'S NAME&PHONE NO. Z06 A SEPTIC TANK CAPACITY LEACHING FACILITY: ( ) AA500 6R1- LThc,,loon(size) /A/ of X d' NO.OF BEDROOMS p BUILDER OR OWNER / PERMTTDATE: COMPLIANCE DATE: l.1 Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 Furnished by ro'JanaJ ' 9ry1J.1X3 oJ %�1 , Lh COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Graci DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108:(617).292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE `.Secretary u ARGEO PAUL CELLUCCI DAVID B.STRUHS Govemor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A , CERTIFICATION a Property Address: 20 HOLLINGSWORTH RD. OSTERVILLE SYSTEM TWO 62-- Name of Owner PHIL MCCARTIN W Address of Owner: n/a Date of Inspection: 9/16/99 iVrO Name of Inspector:(Please Print)JOHN GRACI I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) S EP Company Name: n/a r0ftOF 4 1995 Mailing Address: n/a � / 401, Telephone Number: n/a ' CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The inpection Is based on criteria defined In Title V _ Conditionally Passes code 310 CMR 15.303.My findings are of how the system is _ Needs Further Evaluation By the Local Approving Authority performing at the time of the Inspection.My inspection does _ Fails not imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. Inspector's Signature: Date:9/22/99 ,f The System Inspector shal submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS ' THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS: E - x- E revised 9/2/98 Page 1 of.11 ; s • • SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) s Property Address: 20 HOLLINGSWORTH RD.OSTERVILLE SYSTEM TWO Owner: PHIL MCCARTIN Date of Inspection:9/16/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: _ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist:Any failure criteria not evaluated are indicated below. COMMENTS: ,e. System passes Title V inspection w. B. SYSTEM CONDITIONALLY PASSES: nLa 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. ,• n Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. Wit The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. s nLa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _ broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced ` nta The system required pumping more than four times a year due to broken or obstructed p pe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced _ obstruction is removed revised 9/2/98 Page 2 of 11 ,,. , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 20 HOLLINGSWORTH RD.OSTERVILLE SYSTEM TWO Owner: PHIL MCCARTIN Date of Inspection:9/16/99 - 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 the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. w- 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, . The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis 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,Method used to determine distance nLa_(approximation not valid). 3) OTHER nLa 4 a revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 20 HOLLINGSWORTH RD.OSTERVILLE SYSTEM TWO Owner: PHIL MCCARTIN , Date of Inspection:9/16/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: t' I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted.to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to"clogged or obstructed pipe(s). Number of times pumped n1a. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water:,supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydrau_lic,Failure. E. LARGE SYSTEM FAILS: 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: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No r X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 " " Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' PART B r « h^¢ CHECKLIST'- Property Address: 20 HOLLINGSWORTH rRD.OSTERVILLE SYSTEM TWO 4 Owner: PHIL MCCARTIN +, Date of Inspection:9/16/99 } 4 wry Check if the following have been done:You must indicate either"Yes"or No"as to each of the following: Yes No h X Pumping information was provided by the owner,occupant or Board of Health X None of the system components have been pumped for at least two weeks and the system has been.receiving normal flow rates during that period.Large volumes of water have not been introduced into the system,recently or as part of this inspection. , 4 tw. . X As built plans have been obtained and examined.Note ifthey are not available with N/A ' X The facility or dwelling was inspected for signs of sewage back-up X The system does not receive non sanitary or industrial waste flow;: X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been`located'on the site. t X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected'for conditionof baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge;depth of scum.The size and location of the Soil Absorption System on the site has been determined based on X Existing information,For example,Plan at B4O,H * s _ ' X Determined in the field(if any of.the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [t 5.302(3)(b)) X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 * Page 5 of 1'1 k SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM f PART C SYSTEM INFORMATION ` Property Address: 20 HOLLINGSWORTH RD.OSTERVILLE SYSTEM TWO Owner: PHIL MCCARTIN Date of Inspection:9/16199 FLOW CONDITIONS RESIDENTIAL: Design flow:-&U g.p.d./bedroom Number of bedrooms(design): 6 Number of bedrooms(actual): , Total DESIGN flow: 09 Number of current residents:2 Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NQ If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no):M Water meter readings,if available(last two year's usage(gpd): nta Sump Pump(yes or no): NQ Last date of occupancy: nLa 2 . COMMERCIAL/INDUSTRIAL Type of establishment: nLa Design flow: n&gpd(Based on 15.203) Basis of design flow: nta Grease trap present:(yes or no):JLQ Industrial Waste Holding Tank present:(yes or no): r1Q Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings.if available:Wa Last date of occupancy: nta OTHER: (Describe) D& „ Last date of occupancy: n1a GENERAL INFORMATION PUMPING RECORDS and source of information: nLd ` System pumped as part of inspection:(yes or no):NO v If yes,volume pumped nLiL gallons a Reason for pumping: nLa TYPE OF SYSTEM r X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: nLa APPROXIMATE AGE of all components,date installed(if known)and source of information: THE SYSTEM IS 30 YEARS OLD. Sewage odors.detected when arriving at the'site:(yes or no): NQ E, revised 9/2/,98 N. Page 6 of 11 ; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.C SYSTEM INFORMATION(continued) Property Address: 20 HOLLINGSWORTH RD.OSTERVILLE SYSTEM TWO Owner: PHIL MCCARTIN Date of Inspection:9/16/99 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n1a ` Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) t Wa Dimensions: n1a Capacity: Wa gallons Design flow: nLa gallons/day Alarm present: MO Alarm level:l]La_ Alarm in working order:Yes—No—: MO Date of previous pumping: Wa Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Wa ; } s DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert:nLa Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) nLa ' PUMP CHAMBER: NO (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): MS2 Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) n1a revised 9/2/98 Page 8 of 11 Z n • Y ` � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ` SYSTEM INFORMATION(continued) Property Address: 20 HOLLINGSWORTH RD.OSTERVILLE SYSTEM TWO, 9 ' Owner: PHIL MCCARTIN Date of Inspection:9116/99 BUILDING SEWER: y $, 4 xi � 4 F • (Locate on site plan) a� ' Depth below grade: 2Er ' Material of construction: cast iron _40 PVC X, other'(explain) . a r Distance from private water supply well or suction line: TOWN Diameter: { .e � r. nL " rc Comments: (condition of joints,venting;evidence of leakage etc) s SEPTIC TANK: X (locate on site plan) b' v Depth below grade: T -� Material of construction:X concrete_ metal_'Fiberglassk Polyethylene _'other(explain) ; ,, u If tank is metal,list age Is age confirmed by.Certificate of Compliance(Yes/No)nta A, a.; Dimensions: L S'6"H 6'7"W 4'10 Sludge depth: 2 Distance from top of sludge to bottom of outlet tee or baffle: 1 Scum thickness: ' Distance from top of scum to top of outlet tee or baffle. re Distance from bottom of scum to bottom of outlet tee or baffle , M_ASUREr] } , How dimensions were determined:-.__F___ Comments: {.•, 'k ya . (recommendation for pumping,condition of inlet and outlet tees orba_ffles,-depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING SYSTEM NOW AND THEN MAINTAINED EVERY TWO YEARS. ' L" s• �4 GREASE TRAP: (locate on site plan) Depth below grade: y _ k Material of construction._concrete_ metal_ Fiberglass .'Polyethylene_other(explam IILa .- Dimensions: n& �h Scum thickness: Wa Distance from top of scum to top of outlet tee or baffle:_tVA 1n Distance from bottom of scum to bottom of outlet tee or.baffle nlS t, f' Date of last pumping: nLa n Comments (recommendation forpumping,condition of inlet and outlet tees'or baffles,depth of liquid level in relation to outlet Invert,structural integrity,evidence of Leakage; etc.) ,�� v f �f.. 1 � ��1'�a .w x .,fir + c+, $s�•3••� 14 J* �� t .y'„ 7 _ '`+� *,_ � ° +•.#� Z ° ri s revised 9/2/98 ,, �� Page 7 of 11 ,, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 HOLLINGSWORTH RD.OSTERVILLE SYSTEM TWO Owner: PHIL MCCARTIN Date of Inspection:9116/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nta Type: leaching pits,number: 1000 GALLON LEACH PIT W/A'SLEEVE leaching chambers,number: jVa leaching galleries,number: .3La leaching trenches,number,length: Wa _ leaching fields,number,dimensions: nLa overflow cesspool,number: 6'X6'BLOCK CESSPOOL Alternative system: n1a Name of Technology: _nLd Comments: , (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PITS ARE STRUCTURALL SOUND AND FUNTIONING PROPERLY THE NEW PIT HAS NOT HAD MORE THAN 2'OF WATER IN IT CESSPOOLS: _ (locate on site plan) Number and configuration: nLa Depth-top of liquid to inlet invert: n(a Depth of solids layer: Wit Depth of scum layer. Wa Dimensions of cesspool: nLa Materials of construction: IILd Indication of groundwater: n& inflow(cesspool mustbe pumped as part of inspection)nLa y. { Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nLa PRIVY: _ (locate on site plan) Materials of construction:n& Dimensions:n1a ` Depth of solids: nLa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a n y ry revised 9/2/98' Page 9 of 11 Orr— SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM,,,-, PART C , SYSTEM INFORMATION(continued) Property Address: 20 HOLLINGSWORTH RD.OSTERVILLE SYSTEM ONE _ Owner: PHIL MCCARTIN Date of Inspection:9/16/99 trJ. SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks.,,,,,. locate all wells within 100'(Locate where public water supply comes into house) o n/a d. • 7. Aw " C' I 3-7 e „ r 7It S _ 1.• a to- 't Page 10 revised 9/2/98 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM g PART C SYSTEM INFORMATION(continued) w t f Property Address: 20 HOLLINGSWORTH RD.OSTERVILLE SYSTEM TWO "" t"- Owner: PHIL MCCARTIN ` Date of Inspection:9/16/99 tV 4114 NRCS Report name: n1a k t Soil Type: nta Typical depth to groundwater: nta USGS Date website visited: nLa Observation Wells checked: NQ "` * Groundwater depth:Shallow _ Moderate _ Deep. '`•,,, ta a SITE EXAM _ Slope t � 4: �'� * ` * �� �`�•''� � � 5 _ Surface water k yJ' p _ Check Cellar _ Shallow wells - Estimated Depth to Groundwater 10 `Feet Please indicate all the methods used to determine High Groundwater Elevation i J f t � _ Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) Y x Determined from local conditions Checked with local Board of health _ Checked FEMA Maps ° x y _ Checked pumping records `� �• F - _ F _ Checked local excavators,installers XUsed USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS-10+FEET R L 4 } r. - - - t w „• ��}t ,Y z revised 9098 Page 11 Of=11, o 4 , r y.