HomeMy WebLinkAbout0171 HOLLINGSWORTH ROAD - Health (2) 171 HOLLINGSWORTH RD., OSTERVILL
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THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
0(ppricotiou for Mi!gpomt *pttem Cow5tructiou Permit L
Application is hereby made for a Permit to Construct( )or Repair an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
1 t7 1 . tA 0LA—X A S Woi—:!Tt-4 Q-- 1ZC vx
W,�\)Ak
Installer's Name Address,andse�o. Designer's Name,Address and Tel.No.
�S VMs�-�w° /'�i e lc 7
ti 4,Wn
Type of Building:
Dwelling No.of Bedrooms 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
Description of Soil P�
Nature of Repairs or Alterations(Answer when applicable)
tA+_-Jj o N t 0 rL SST,
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-
cateof Compliance has been issued by this Bo d f Health.
Signed �1 Date
Application Approved by
Application Disapproved for the following reasons
Permit No. Date Issued
No. _ - — FeC3 O
THE COMMONWEALTH OF MASSACHUSETTS �
' PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE} MASSACHUSETTS
,( 0[pplicotion for Mi5pogof *p.5tem Cori$truction permit it
Application is hereby made for a Permit to Construct( )or Repair an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No,
Installer's Name,Address,and Tel. o. Designer's Name,Address and Tel.No.
CIOrj s /-h e rc,L y
4A-9V NI
Type of Building: -
Dwelling "No.of Bedrooms Garbage Grinder(
Other Type of Building No.of Persons Showers( ' ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons. 1
Plan Date Number of sheets Revision Date
Title a
Description of Soils• Z Si)�,� '"�_ -- /+*�-'��
a
Nature of Repairs or Alterations(Answer when applicable) PQt-`P w EK t g►lKC oe S5.%ao �-
tA� 0 w 5c t N�A S�rsT�ai Cos i_s� R 0 IZ
t` 1 -'T1? yo e t�Aa"' Z C Y
Date last inspected: p t•'
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-hie sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and"not to place the system in.operation until a Certifi-
cate of Compliance has been issued by this Bo d f Health.
f Signed a-- ` Date
I
App cation Approved b
Application Disapproved for the following reasons
-Permit No. l' S Y Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Certificate of Compliance _
THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or re paired%replaced(r-)on
by rtk-�t454 C6N.S. for Q-A
tlo�u.w1-9 C Z' , k has been constructed► accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. c15 B1 dated
Use of this system is conditioned on compliance with the provisions set f elow: i
No. Feed�J
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
3ji5pogar 6peum Cots.5truction i3ermit
Permission is hereby granted to t-4 tc
to construct )repair( Vran On-site Sewage System located at t7l
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
i
comply with t Title 5 and the following local provisions or special conditions.
' All construction ust be completed within two years of the date below.
�.I�
Date: �� Approved by`' P✓�'
� , �; . v
TOWN OF BARNSTABLE
LOCATION i r..P - SEWAGE "
_ VILLAGE - i 1 ASSESSOR'S MAP &LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY U
LEACHING FACILITY: (size)
NO.OF BEDROOMS
BLIII.Ml OR OWNER
PERMITDATE: --L� COMPLIANCE DATE:
Separation D sytance 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
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TOWN OF BARNSTABLE
LOCATIONl�`f'/ /T4iC,�flJ,/ Sp 14�. .SEWAGE #
VILLAGE �� ASSESSOR'S MAP & LOT.
INSTALLER'S NAME & PHONE.NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size).
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
hereby certify that the application for disposal works
r
construction permit signed by me dated 3 4 6— concerning the
property located at 1 meets all of the
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed. .
SIGNED : DATE:
LICENSED SEPTIC SYSTEM INSTALLER IN.U M TOWN Or aARNSTABLE NL':t'IBER
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
C
No................_--- Fps..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...................-. ....................OF.......................................----------------------•.................._..._._..
Appliration for Disposal Works Tontrurtion ' rrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
. � .... .............. .............. ---------------.......... ._.. ---------------
Location-A sT A
or Lot No.
...................................
}�
Installer /Address
Type of Building Size Lot...........................Sq. feet
Dwelling—No. of Bedrooms........•_.._.__A/
...... Attic ( ) Garbage Grinder ( )
Other—T e of Building No, of persons............................ Showers — Cafeteria
Pa Other fixtures •----•--•-------------------------------------------..
W Design Flow................... ...........gallons per person per day. Total daily flow.............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date..............
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fro Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a --------------------
------------------------------------
-......................
-.........
_.......
..........................................................
ODescription of Soil.......................................................................................................................................................................
x
V
W •••••---•••-..-....•-•-•••-•-----•--••-•---•----•------•-•••---••-•••-••••--•••••--••-•...............•••-......---....--•---
�^s V.
V Nature of Repairs or Alterations—Answer when applicable..-- . . _.... ST__/1-..�___.._....®____'...
...........•.....
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal-System in accordance with
the provisions of L I T IS 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed..--•- ........
------------------------------------------...................i Date
Application Approved By.......... • ... __ -• • v_ ---- ....
?_4..
�• Date
Application Disapproved for the following reasons-....................................---•--------------------•----...---•---••------------------._.............
......................................................-------------------•---••---------.......-----------.._.._.........-•-----•••------•=----...•----••-•-••-•-••••--•---•-------•••......--••••---•-
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS \I
BOARD O HEALTH
............ . ...OF..........Ba'11-o-q..............................................
Tntifiratr of Tontulianrr
THIS IS C RTIFY at the Individual Sewage Disposal System constructed ( ) or Repaired
by..... ......... ---- ........................._. ..............
Insta
has been installed in accordance with the provisions of T 5 of he State Sanitary Code as described in the
application for Disposal Works Construction Permit No..
__ __________?? ._;t�_1......... da.ted_...- :___Z_7."__ ;:..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
.......... ...... OF........ ,................................................. .mac
Disposal Ifion lion �erntit
Perrrlission is hereby granted. •GG.
to Constru or aire( an Individual Sewa osal System
at No
reet
as shown on the application for Disposal Works Construction Pe �No_____ ___ ______ ted.._. :. ==.. .........
-•-•- -•- J ------•••----
Board of ealth
DATE--•.............................................................................
-.
FORM •1.255 HOBBS & WARREN. INC.. PUBLISHERS /J
Nooll .....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Allp iration for Bispos al ]Vor'6 Tousfrfrtion "truth
Application is hereby made fora Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
y��qq .. cation-A s /
.gg.. Ss ... ........... Ad
or Lot No ....../Owner....._.. .................................. .....4' -i ... _
a Installer r�Address
.Sq. feet
U Type of DwellindingNo. of Bedr Size Lot...........................
a g— ooms............... t._._...._.._...Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons......................_..... Showers ( ) — Cafeteria ( )
Otherfixtures ------------------------------------------------------......-------------------------------------------------------------....--------•--........-----
W Design Flow.................. ............gallons per person per day. Total daily flow......................._...........,........gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by..------•---•••-••--..........••-•-----------------------------•--••----- Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-------------_..........
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................._. Depth to ground water........................
a ..............................................................-•-•----------- "----------------------------------------------------------- ------------
ODescription of Soil------------------------------------------------------------------•----------------------------------------------------------------------------------------------..-----
x
W -••--------------------------•••-------•-------•-•------•-----------•---••••••-••-•----....•-•--•••--••------•-------•---•••• = ..............
�
,r
U Nature of Repairs or Alterations—Answer when applicable... n-__C2'fz ......r:.. ......... ..,a7...�i.-.._... " .____'__.
--------------------------------------••-----•••-----•----•-••---•---------.._..........._...................-----------•---- ............ ------------------------------------------••---------
Agreement:
The undersigned :agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
of L.the provisions
of the State Sanitary Code—The undersigned further agrees not,to place the system in
operation.until a Certificate of Compliance has been issued by the board of health.
SignedT......... ......•-------------.......--•--.....-----.........------...•. ................................
Application Approved B /: Date
`
Date
Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------------------•----
..........................•--...-•----.............----------.........------------....-•----------------.---...--------•-•••------•-------•-•--•-----------------•••---••-----------•---------•--•-•.---
Date
PermitNo......................................................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ® HEALTH
: .., Yam.. .OF....... 1 a—A -`?.....:...... .............................
._
(It
of Tnutpliaurr
THI IS _ ' CERTIFY hat the,Individual Sewage Disposal System constructed ( ) or Repaired ( )
by...... ----- ... .. ._....._ ..
--
/ Instal
r
has been installed in accordance with the provisions of T j of hhee State Sanitary Code as described in the
application for Disposal Works Construction Permit No.re ......... dated__..//n.. .i ."._ --_--------
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE:THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..........................................................-•--•--••-----.-----• Inspector...................................................................................
` THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9F HEALTH
FEE ......................
Diaposalf IV $ won #r to amit
-'Permission is hereby granted----�" - ----- - ----- r�"'�----------•--------------------------------------------------------------
to Constru or pairl( an Individual Sew e Deposal System J
at No....- . ,... `"' 1 !�. '! c _sa•!4? ro4.S reet ,
as shown on the application for Disposal Works Construction Pern'G.. No _ Med.... �
m
PP P - �-----
.�
DATE......... ................••---...--•--------- .....
Board of Health
FORM 1255 HOBBS.& WARREN. INC.. PUBLISHERS -
TOWN OF BARNSTABLE
LOCATION /7/ 1-f1d 11/I 5SGcrdr2t 2a• SEWAGE # .L.c✓f�ECTi�S/
VM'LAGE OS nr ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. G oz a to b v ena v, b—S6 Al o
I SEPTIC TANK CAPACITY 15-0 t5 A 4
LEACHING FACILITY: (type) h5QCV���v (size) �r�Xv��X 410
NO. OF BEDROOMS
BUILDER OR OWNER J)Te.'U9.1 ( Prt.ce-
PERMTTDATE: 9/9d' 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 CG 2p c -W%G I l k
f 1
f c
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ to Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
171 Hollingsworth Rd
Property Address
Jeremiah Hegarty
Owner Owner's Name
information is d r
required for every
Osterville Ma 02655 11/1/19
page. City/Town State Zip Code Date of Inspection F
Inspection results must be submitted on this form. Inspection forms may not be altered1h any
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector Information
filling out forms
on the computer„
use only the tab Michael DiBuono
key to move your Name of Inspector
cursor-do not DiBuono Sewer And Drain
use the return Company Name
key.
35 Content Lane
Q Company Address
Cotuit Ma 02635
City/Town State Zip Code
RAW 508-364-9587 S113522
Telephone Number 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
11/4/19
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.
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 s.
I� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
171 Hollingsworth Rd
Property Address
Jeremiah Hegarty
Owner Owner's Name
information is required for every Osterville Ma 02655 11/1/19
page. Cityrrown 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:
System contains a 1500 Gallon septic tank as well as a concrete distribution box and a field of pipe in
stone
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
Commonwealth of Massachusetts
-, Title 5 official Inspection Form
� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
171 Hollingsworth Rd
Property Address
Jeremiah Hegarty
Owner Owner's Name
information is required for every Osterville Ma 02655 11/1/19
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 El
(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
1 Title 5 Official Inspection Form
.. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
0 171 Hollingsworth Rd
Property Address
Jeremiah Hegarty
Owner Owner's Name
information is required for every Osterville Ma 02655 11/1/19
page.e. 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 an
Y ( pp � Y)
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.
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
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surfacer 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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a
171 Hollingsworth Rd
Property Address
Jeremiah Hegarty
Owner Owner's Name
information is required for every Osterville Ma 02655 11/1/19
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 '/z 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.
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 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
❑ r supply
❑ the system is within 400 feet of a surface drinking water s pp y
❑ ❑ 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
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
ip Title 5 Official Inspection Form t=
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
171 Hollingsworth Rd
Property Address
Jeremiah Hegarty
Owner Owner's Name
information is required for every Osterville Ma 02655 11/1/19
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 El ® in p g information
o mation 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?
facility® Was the❑ 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.
® El Determined an
Determined in the field of the failure criteria related to Part C is at issue
( Y
approximation of distance is unacceptable) [310 CMR 15.302(5)]
l5insp.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
_ Ira Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
171 Hollingsworth Rd
Property Address
Jeremiah Hegarty
Owner Owner's Name
information is required for every Osterville Ma 02655 11/1/19
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 }
Description:
Number of current residents: 2
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 ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usa a 168 Gpd
9 ( Y 9 (gPd)):
Detail:
Sump pump? ❑ Yes ❑ No
Last date of occupancy: 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 - s
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
171 Hollingsworth Rd
Property Address
Jeremiah Hegarty
Owner Owner's Name
information is required for every Osterville Ma 02655 11/1/19
page. Citylrown 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:
Not provided.
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for
o pumping.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
,0 Title 5 Official Inspection Form
FI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
171 Hollingsworth Rd
u Property Address
Jeremiah Hegarty
Owner Owner's Name
information is required for every Osterville - Ma 02655 11/1/19
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:
Installed 1998
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 1.5
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.):
System is vented at the roof line
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u � 171 Hollingsworth Rd
Property Address
Jeremiah Hegarty
Owner Owner's Name
inormation is Ostill
requiredforevery erye Ma 02655 11/1/19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 1
feet
Material of construction:
conc
rete Crete metal
❑ fiber lass
❑ g El polyethylene El other(explain)
1500
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500
Sludge depth: 3
Distance from top of sludge to bottom of outlet tee or baffle
24"
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle 411
Distance from bottom of scum to bottom of outlet tee or baffle
30"
dimensions determined? Tap e
How were d im � Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is at normal level. Tee's are in place
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
171 Hollingsworth Rd
Property Address
Jeremiah Hegarty
Owner Owner's Name
information is required for every Osteryille Ma 02655 11/1/19
page. Cityrrown 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
I�
c Commonwealth of Massachusetts
Title 5 Official Inspection Form r
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
171 Hollingsworth Rd
Property Address
Jeremiah Hegarty
Owner Owner's Name
information is required for every Osteryille Ma 02655 11/1/19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
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 Level is normal with no sign of carry over or
overloading
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
Title 5 Official Inspection Form
e
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
171 Hollingsworth Rd
Property Address
Jeremiah Hegarty
Owner Owner's Name
information is required for every Osterville Ma 02655 11/1/19
page. CityrFown 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:
Clean and dry
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions: 1 4' x 40' Pipe in
stone
❑ 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
u 171 Hollingsworth Rd
Property Address
Jeremiah Hegarty
Owner Owner's Name
information is Osterville Ma 02655 11/1/19
required for every
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.):
Sent camera down perferated pipe. Pipe was clear with no ponding or back up
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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
C Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
171 Hollingsworth Rd
Property Address
Jeremiah Hegarty
Owner Owner's Name
information is required for every Osterville Ma 02655 11/1/19
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.):
i
l5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
I`
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�= Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
171 Hollingsworth Rd
u-
Property Address
Jeremiah Hegarty
Owner Owner's Name
information is required for every Osterville Ma 02655 11/1/19
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, 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 18
11/4/2019 Assessing As-Built Cards
/ TOWN OF/BARNSTAHLE
LOCATION �7I H �/�_ /L •C��csc✓d�� SEWAGE N %[18ECTio�s/
VILLAGE S l Fr'lri I�C ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO. G O U o i t _E. *E A3AM a - 4*%S-56!jc
SEPTIC TANK CAPACITY�/SoOGA�
LEACHING FACILrrY:(type) .(size) y9aat,4.gp
NO.OF BEDROOMS
BUILDER OR OWNER 1R.W.1 'l r,c e
PERMrrDATE:,A6V — I!�/rS 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 �y f(
t
I �
A yo`
0
'3S'.
ea
j
i
https://www.townofbarnstable.us/Departments/Assessing/Property_Values/HMdisplay.asp?mappar=140041&seq=2 1/2
Commonwealth of Massachusetts
y Title 5 Official Inspection Form
Y
I� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
171 Hollingsworth Rd
Property Address
Jeremiah Hegarty
Owner Owner's Name
information is required for every Osterville Ma 02655 11/1/19
page. Cityrrown 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: 10 +
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: 1998
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:
Test hole data at B.O.H.
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 r -
r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
171 Hollingsworth Rd
Property Address
Jeremiah Hegarty
Owner Owner's Name
information is required for every Osterville Ma 02655 11/1/19
page. Cityrrown 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:
i
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
< Commonwealth of Massachusetts
Title 5 Official Inspection Form
70
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
171 Hollingsworth Road
,� aV
Property Address r+�
Ruth & Michael Deeley Trust
Owner
Owners Name ��
information is
required for every Osterville MA 02655 7/11/2017
page. CitylTown State Zip Code Date of Inspection "
Inspection results must be submitted on this form. Inspection forms,may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information S�#
filling out forms oZ�g
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not James Ford
use the return Name.of Inspector
key.
Ford Septic Services, LLC
Company Name
P.O. Box 49
Company Address
Osterville MA 02655
City/Town State Zip Code
508-862-9400 S12482
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 Furthe valuation by the Local Approving Authority
7/11/17
Inspect 's Signature Date
The s st m inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Heal or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
. W'd VIS
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
A, 171 Hollingsworth Road
Property Address
Ruth & Michael Deeley Trust
Owner Owners Name
information is
required for every Osterville MA 02655 7/11/2017
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section.D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B �I
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 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary'Assessments
�.. 171 Hollingsworth Road
Property Address
Ruth & Michael Deeley Trust
Owner Owner's Name
information is
required for every . Osterville MA 02655 7/11/2017
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 (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b).that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or.privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-3/13
Title 5 Official Inspe Lion form:Subsurface Sewage Disposal System-Page 3 of 17
. t
y t Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments,
171 Hollingsworth Road
Property Address
Ruth & Michael Deeley Trust
Owner Owner's Name
information is
required for every Osterville MA 02655' 7/11/2017
page. Cityrrown
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
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
Ej ® 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 1Y2 day flow
t5ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
171 Hollingsworth Road
Property Address
Ruth & Michael Deeley Trust
Owner information is' Owner's Name
required for every Osterville MA 02655 7/11/2017
page. City/Town
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 suppiy.
❑ Z Any portion of a cesspool or privy is within a Zone 1 of a.public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone ll 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.
,Sins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary As
171 Hollingsworth Road
Property Address
Owner
Ruth & Michael Deele Trust information is Owner's Name
required for every Osterville MA
0265&page. City/Town State Zip Code 7/11/2017
C. Checklist ( p Date of Inspection
Check if the following have been done. You must indicate "yes"or"no"as to each of the following:
9
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were anyjof the system components pumped out in the previous two weeks?
i
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have larg 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 Tote as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage backup?
® ❑ Was the site inspected for signs of breakout?.
® ❑ Were all s stem 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 a location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ElExisting inf
ormation. 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)]
D. System Information
Residential Flow Conditions:
i
Number of bedrooms (design): 3 Number of bedrooms (actual): 3-----=—
DESIGN flow based on 310 CM� 15.203 (for example: 110 gpd x#of bedrooms): 330
l5ins-3/13
Title 5 Ofricial Inspection Form:Subsurface Sewage Disposal system-Page 6 of 17
i
Commonwealth of Massachusetts r
W Title 5 Official Inspection Form
R Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
171 Hollingsworth Road
Property Address
Ruth & Michael Deeley Trust
Owner Owner's Name
information is
required for every Osterville MA 02655 7/11/2017
page. City/Town State Zi Code
P Dateof Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection
information in this report.) ❑ Yes ® No
Laundry system inspected? El Yes ® No
Seasonal use?
❑ Yes ® No
Water meter readings, if available'(last 2 years usage (gpd)):
Detail:
unavailable
Sump pump?
❑ Yes ® No
Last date of occupancy: currently
Date-
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? El Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
15ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
' 171 Hollingsworth Road
Property Address
Ruth & Michael Deeley Trust
Owner Owners Name
information is
required for every Osterville MA 02655 7/11/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Date
Other(describe below):
General Information
Pumping Records:
Source of information: unavailable
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping: maintenance
Type of System:
® Septic tank, distribution box, soil absorption system
El 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 VA system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
171 Hollingsworth Road
Property Address
Ruth & Michael Deeley Trust
Owner Owner's Name
information is
required for every Osterville MA 02655 7/11/2017
page. Cityrrown State Zi Code
P Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
system installed - 1995
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade:
feet
Material of construction:
❑ cast iron ® 40 PVC
El-other(explain):
Distance from private.water supply well or suction line:
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade: 22"
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: 1500 - H-10
Sludge depth: 2
t5ins•3113
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
171 Hollingsworth Road
Property Address
Ruth & Michael Deeley Trust
Owner information is Owner's Name
required for every Osterville MA 02655 7/11/2017
page. CityfTown
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 24
Scum thickness 4
Distance from top of scum to top of outlet tee or baffle 5
Distance from bottom of scum to bottom of outlet tee or baffle 12
How were dimensions determined? measure stick
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tees were present. A riser was installed on the outlet The tank was pumped after the inspection
Grease Trap (locate on site plan):
Depth below grade: n/a
feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ pot eth lene
Y Y El other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 10 of 17
Commonwealth of Massachusetts '
u _ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
171 Hollingsworth Road
Property Address
Ruth & Michael Deeley Trust.
Owner Owner's Name
information is
required for every Osterville MA 02655 7/11/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene
❑ other(explain):
N/a
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
15ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a 171 Hollingsworth Road
Property Address
Ruth & Michael Deeley Trust
Owner Owner's Name
information is
required for every Osterville MA 02655 7/11/2017 .
page. Cityrrown State ZipCode
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 even
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
The D-box normal. A camera was used.
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.
Soil Absorption System (SAS)(locate on site plan, excavation not required):
1f SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
'`� e •`'• 171 Hollingsworth Road
Property Address
Ruth & Michael bee ley Trust
Owner '
information is Owners Name ,
required for every Cisterville MA 02655
page. City/Town 7/11/2017
State Zip Code Date of inspection
D. System Information. (Cont.)
Type.
❑ leaching pits number:
❑ leaching chambers
number:
❑ leaching galleries
number:.
® leaching trenches 4'x2'x40'
number,length:
El 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.):
There was no sign of failure in the leach field. A camera was used to•ins ect.
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 El Yes
❑ No"
t5iris•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System.•Page 13 of 17
Commonwealth of Massachusetts
N Title 5 Official Inspection Form-
} e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
171 Hollingsworth Road
Property Address
Ruth & Michael Deeley Trust
Owner Owner's Name
information is
required for every Ostervllle MA 02655 7/11/2017
page. Cityrrown State ZipCode 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.):
N/a
ti
l5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
` Commonwealth of Massachusetts
Title 5 Official Inspection Form
orm
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
`� e,•'r 171 Hollingsworth Road
Property Address
Ruth & Michael Dooley Trust
Owner Owner's Name
information is
required for every Ostervllle MA 02655 7/11/2017
page. Cityrrowh State ZipCode
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
FrOAT
(3 a
ag 3
3
yo ai`°
t5ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
• Commonwealth of Massachusetts
P-�
• _ Title .5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
• " 171 Hollingsworth Road
Property Address
Ruth & Michael Deeley Trust
Owner Owner's Name
information is
required for every Osterville MA 02655 7/11/2017
page. CitylTown State ZipCode
Date of Inspection
D. System Information (cont..)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 25'
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:
Topo and water contours map.
❑ Checked with local excavators, installers -(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
see above
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments
c� A,••`'�r 171 Hollingsworth Road
Property Address
Ruth & Michael Deeley Trust
Owner '
information is Owners Name
required for every Osterville
— MA 02655 7/11/2017
page. CityfTown
State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on,page 15 or attached in separate file
t5ins•3113
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET,BOSTON MA 02108 (617)292-5500
WILLIAM F.WELD TRUDY COXE
Governor Sectetary
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
ARGEO PAUL CELLUCCI PART A DAVID B.STRUHS
Lt.Governor CERTIFICATION Commissioner
Property Address: 171 Hollingsworth Road Osterville, MA Address of Owner: P.O. Box 299
Date of Inspection: March 16, 1998 (If different) 2.55 Crystal Lake Rodd
Name of Inspector: Gonion E. BuMus Ostendlle, MA 02655
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: Gordon E. BuMus
Mailing Address: 215 Osterville West Barnstable Road, Osterville. MA 02655 -
Telephone Number: UN) 428-5640 5 "
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this addres"s 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 aeexpe ' tceioper function and
maintenance of on-site sewage disposal systems. The system: y�ci?
v� Passes RtcEiVE9Conditionally Passes Needs Further Evaluation By the Local Approving Authority rytT 2 4 1998Fails iOWNpFBHFgITM p�T�IE
Inspector's Signature: Date-.-', March 17 1998
The System Inspector shall submit a copy of this inspection report to the Approving Authority within 1of mpleting this
inspection. If the system is a shared system or has a design flow.of 10,000 gpd or greater, the inspector and h 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.'
INSPECTION SUMMARY: Check A, B, C, or Dc
A] SYSTEM PASSES: ,
✓ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS: r
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.
Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If"not determined",explain why not.
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;
f 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 conforming septic
tank as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web: http:/hvww.magnet.state.ma.us/dep
i� Printed on Recycled Paper
� 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 171 Hollingsworth. Road, Osterville, MA
Owner: VK11 Price
Date of Inspection: March 16, 1998
continued
B] SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
g P g
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). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
11
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) SYSTEWWILLrPASS SUNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT
IO FUNCTNING IN Ay MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND
,THE.ENVIRONMENT
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WELL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,
IF APPROPRIATE) 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 to 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 1 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 (approximation not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
i T
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A +*
CERTIFICATION (continued)
Property YAddress: 171 Hollingsworth Road, Ostevlle, MA
Owner: VK11 Price
Date of Inspection: March 16, 1998
D] SYSTEM FAILS: `
You must indicate either "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined 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.
' t I
Yes No
Backup of sewage into facility or system component due to an 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. w
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.1/2 day flow.
Required pumping more than 4 times in the'last year N T due to clogged or obstructed pipe(s). .
Number of times pumped
Any portion•of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
,t
Any portion of a 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds,.ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as 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 ;
the system is within 460 feet of a surface drinking water supply 4
the system is within 200:feet of a tributary,to a surface drinking water supply g ;
the system is located m 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 bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 171 Hollingsworth. Road, Osterville, MA
Owner: Will Price
Date of Inspection: March 16, 1998
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
✓ _ Pumping information was provided by the owner, occupant, and Board of Health.
✓ 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.
✓ As built plans have been obtained and examined. Note if they are not available with N/A.
✓ The facility or dwelling was inspected for signs of sewage back-up.
✓ The system does not receive non-sanitary or industrial waste flow.
✓ _ The site was inspected for signs of breakout.
✓ _ All system components, excluding the Soil Absorption System, have been located on the site.
✓ _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of 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:
✓ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance
of Sub-Surface Disposal System.
✓ Existing information. Ex. Plan at B.O.H.
✓ Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
[15.302(3)(b)].
(revised 04/25/97) Page 4 of 10
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 171 Hollingsworth Road, Osterville, MA ,
Owner: Will Price
Date of Inspection: March 16, 1.998
FLOW CONDITIONS _
RESIDENTIAL:
1
Design flow: 330 g.p.d./bedroom for S.A.S.
Number of bedrooms: 3 k
Number of current residents: 3 '
Garbage grinder (yes or no): No
Laundry connected to system(yes or no): Yes _
Seasonal use (yes or no): No
Water meter readings, if available (last two (2) year usage (gpd): Not available.
Sump Pump (yes or no): No
Last date of occupancy: Presently occ►.pied
,
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: gallons/day
Grease trap present (yes or no):
Industrial Waste Holding Tank present (yes or no): -
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL.INFORMATION
PUMPING RECORDS and source of information:
Not RuMed -per owner.
System pumped as part of inspection (yes or no): No d
If yes, volume pumped: gallons
Reason for pumping:
r
TYPE OF SYSTEM
✓ Septic tank/distribution box/soil absorption system.. _
Single cesspool
Overflow cesspool x
Privy ;
Shared system(yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract? h.
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: Nova 1595 -per as built cant.
Sewage odors detected when arriving at the site (yes or no): No
(revised 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 171 Hollingsworth Road, Osterville, MA
Owner: Will Price
Date of Inspection: March 16, 1998
BUILDING SEWER: None
(Locate on site plan)
Depth below grade:
Material of construction: cast iron 40 PVC _other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK: Yes
(locate on site plan)
Depth below grade: 18"
Material of construction: ✓ concrete _metal _Fiberglass _Polyethylene _other (explain)
if tank is metal, list age Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions: 10'6"L X 5'8"W X 5'8"D - 1500 Gal.
Sludge depth: 1"-2"
Distance from top of sludge to bottom of outlet tee or baffle: 3'1"
Scum thickness: 1"-2"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 13"
How dimensions were determined: Measuring stick
Comments: -
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) Liquid level wns even with outlet invert No sign d leakage.
GREASE TRAP: None
(locate on site plan)
Depth below grade:
Material of construction: concrete _metal _Fiberglass _Polyethylene _other (explain)
Dimensions:
Scum thickness:
Distance from top of scum to top.,of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 04/25/97) Page 6 of 10
i
t y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION ]FORM
PART C y
SYSTEM INFORMATION (continued)
Property Address: 171 Hollingsworth Road, OsteMlle, MA
Owner: Will Price
Date of Inspection: March 16, 1998
TIGHT OR HOLDING TANK: None (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other (explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level: Alarm in working order_Yes; No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.).
DISTRIBUTION BOX: Yes
(locate on site plan)
Depth of liquid level above outlet invert: on
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence.of leakage into or out of box, 'etc.) _.
Box was level No signs cf solids carryover.
PUMP CHAMBER: None
(locate on site plan)
Pumps in working order (Yes or No):
Alarms in working order (Yes or-No):
Comments:
(note condition of pump chamber, condition of pumps and'appurtenances, etc.)
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
i'roperty Address: 171 Hollingsworth Road, OsteMlle, MA
Owner: VKH Price
Date of Inspection: March 16, 1998
SOIL ABSORPTION SYSTEM (SAS): Yes
`locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
if not determined to be present, explain:
Type:
leaching pits, number:
leaching chambers, number:
leaching galleries, number:
leaching trenches, number, length: 1 (40'X 4'X 2')
leaching fields, number, dimensions:
- overflow cesspool, number:
Alternative system:
Name of Technology:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
No signs d hydmulichilure-
CESSPOOLS: None
(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 (cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: None
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04125/97) Page 8'of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION" FORM,
PART C
N .
SYSTEM INFORMATION (continued)
Property Address: 171 Hollingsworth Road, Osterville, MA
Owner: WYII Price
Date of Inspection: March 16, 1998
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to at least two permanent references, landmarks or benchmarks.
Locate all wells within 100' (Locate where public water supply comes into house). .
—Lq 1
:a-
'lT'i�- ��I I � i • LSO
3 •
e m O
At
OU
Wo
(revised 04/25/97) Page 9 of 10
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 171 Hollingsworth Road, Osterville, MA
Owner: Will Price
Date of Inspection: March 16, 1998
Depth to Groundwater: 22.7' feet
Please indicate all the methods used to determine High Groundwater Elevation:
✓ Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
✓ Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators, installers
✓ Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. (Must be completed)
Using USGS mops and Cope Cod Water Tables Contour map.
Maps are showing 22.7' to groundwater.
(revised 04/25/97) Page 10 of 10
ti
� t
.r
to 0ir DATE:_9_/27/95 .
PROPERTY ADDRESS:_1.71 Rolling-vorth . Road.
Osterville ,Mass .
02655
On the above date, I Inspected the septic system at the above .address.
This system consists of the following:
1 . 1-6' x8l. block cesspool.
Based on my Ins ectlon, I certify the following conditions:
1 . This is not a title five septic sytez-
2. Thio-is ' a sewage system that is filled to its capacity..
Water- is above the inlet invert. -
3. Tie sewage system is in fai4iure and must be_upgrad'ea to a title
five septic system. . `
51GNATUR�':
Name: J. P .Macomber Jr.. i
Company:_J. P_Macoi�ber_ & Son-_Inc
Address:_-13e�c-bb-----= -- -- p� CfIO/fo
r
__Centerville LMass__0.2632 199,5
Phone:---S 7�-3338__.___-- • 1 �,
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
r
.l'OSEPN P. MACORRBER & SON, INC.
Tanks-Ces pools-Leachfleld:
. Pumped & Installed
Town Sewer Connections
P.O. Box 66' Centerville, MA 02632-0066
773-3338 77"412 - :.
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
William F.Weld
Governor
Trudy Coxe
Secretary,EOEA
David IB. Struhs
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION `
Property Address; 171 Hollings Worth Road 0 s t e r Address of Owner:
Date of Inspection: 9/27/95 ville (If different)
Name of Inspector: Joseph P.Maeomber Jr.
Company Name, Address and Telephone Number:
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 oa my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
_ Passes
Conditionally Passes
Needs Further Evaluation By the local Approving Authority
-I•�/Fails
Inspector's Signatu Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority 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.
INSPECTION SUMMARY:
Check A, B, C, or D:
A] SYSTEM PASSES:
_ 1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
4,
lyd One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not)
�/�— The septic tank is metal, 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 conforming septic tank as
approved by the Board of Health.
(revised 8/15/95)
One Winter Street 0 Boston, Massachusetts 02108 0 FAX(617)556-1049 9 Telephone (617)292-5500
r
SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 171 Hollings Worth Road Osterville ,Mass
.
Owner: Robert Depasqua
Date of Inspection: 9/27/95.
B] SYSTEM CONDITIONALLY PASSES (continued)
A() 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
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
/yd 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 THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
&Q Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES_ THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The SV51em nas a sepuL lank anu SUii dbbOrption systen', and is within 100 fee, to a surface % atcr supply c. t :Mica'j to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
,d The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and 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.
D] SYSTEM FAILS: -
I have determined that the system violates one or more of the following failure criteria as defined 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.
/A.9) Backup of sewage into facility or system component due to an 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,
(revised 8/15/95) 2
•
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 171 Hollings Worth Road 0sterville ,Mass. '
Owner: Robert Depasqua
Date of Inspection: 9/2 7/9 5
D) SYSTEM FAILS (continued):
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
I Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day 5flow.
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 Soil AbsorptionSystem, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 I of.a public well.
Any portion of a cesspool or privy is within 50-feet of a privatey water supply well.
/1Q 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 compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flow of system is 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:
the system is within 400 feet of a surface drinking water supply
y
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in 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 bring.the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 8/15/9s) $.
t I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 171 Hollings Worth Road Osterville ,Mass . "
Owner: Robert Depasqua •
Date of Inspection: 9/2 7/9 5
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
A$As built plans have been obtained and examined. Note if they are not available with N/A.
t/The facility or dwelling was inspected for signs of sewage back-up.
ZThe system does not receive non-sanitary or industrial waste flow
4/-The site was inspected for signs of breakout.
_I/AII system components, ituding the Soil Absorption System, have been located on the site.
9&he septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of 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 existing information or
approximated by non-intrusive methods.
The facility oa.ne: (and occupants, if different from owner) were provided with information on the proper maintenance of Sufi-
Surface Disposal System.
Recommendations
1 . System has failed.
2. Should be upgraded to a title five septic system.
(revised 8/15/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 171 Hollins Worth Road Osterville ,Mass .
Owner: Robert Depasqua
Date of Inspection: 9/2 7/9 5
FLOW CONDITIONS
m ,
RESIDENTIAL:
Design flow: 5M a�llpns
Number of bedrooms: 9
Number of current residents:j)k
Garbage grinder (yes or no):jVQ
Laundry connected to system (yes or no):Yr,5
Seasonal use (yes or no):&-o j
Water meter readi gs, if availabl �;6'
LiD
Last date of occupancy: ��
COMMERCIALIINDUSTRIAL:
Type of establishment: I///
Design flow: Rallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECOR S and source of i format* n:
System pumped as part of inspection: (yes or no) - '
If yes,, volume pumped. QQ gallons
Reason for pumping: F -,V 75- [°.I�C1TY,A'JJ�TI� UL'eidi 1Z11tr JA.'vUQ,—
TYP��E,�OF SYSTEM
�4 Septic tank/distribution box/soil absorption system
izf Single cesspool
Overflow cesspool
A/1 Privy
/�Shared system (yes or no) (if yes, attach previous inspection records„if.any),
Other (explain)
APPROXIMATE: AGE of all components, date installed (if known) and source of-information: V
Sewage odors detected when arriving at the site: (yes or no)
(revised 8/15/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C.
SYSTEM INFORMATION (continued)
Property Address: 171 Hollings Worth Road 'Ost'erville ,Mass .
Owner: Robert Depasqua "
Date of Inspection: 9/2 7/9 5
SEPTIC TANK:
(locate on site pl n)
Depth below grade:'
Material of construction: concrete _metal _FRP_other(explain)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: _
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from borom of scum to bottom of outlet tee or baffle:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet,in`vert, structural '
integrity, evidence of leakage, etc.)
GREASE TRAP:/¢
(locate on site plain)
Depth below grader
Material of construction: _concrete _metal _FRP other(explain)
W.
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or.baffle:
Distance from bottom nt From t- bottom of outlet,tee oMa efil e
/56�
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet.invert, structural
integrity, evidence of leakage, etc.)
(revised 8/15/95) 6 m
„
V
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Ad*ess:171 Hollings Worth Road Osterville ,Mass .
Owner: Robert Depasqua
Date of Inspection: 9/27/95
TIGHT OR HOLDING TANK4l✓ o F
(locate on site plan) '
Depth below grade:
Material of construction: concrete metal FRP_other(explain)
Dimensions: 'V
Capacity: gallons
Design flow: allons/day
Alarm level: /J1
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
WAtie,
DISTRIBUTION BOX:11owle—
(locate on site plan)
Depth of liquid level above outlet invert: H
Comments:
(note ii level and distribution i; equal, evidence of solids can,over, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:�Vir1�
(locate on site plan)
Pumps in working order.(yes or no)/Z//�
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95)
SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 171 Hollings Worth Road Osterville ,Mass . '
Owner: Robert Depasqua
Date of Inspection: 9/2 7/9 5
SOIL ABSORPTION SYSTEM (SAS):2
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
J
If not determined to be present, explain:
Type.
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
oveAvw cesspool, number:
Comments: (note ondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
FIAL , ?� t Jt%Yg £
CESSPOOLS: _
(locate on site plan)
l
Number and configuration:
Depth-top of liquid to in rt: fU v
Depth of'solids layer:
Depth of scum layer: -7•�
Dimensions of cesspool: _
Materials of construction: N e
Indication of groundwater: A,49A/e— ������o� �� S `p���
inflow (cesspool must be pumped as part of inspection)
Cop-ments: (note condition of soil, signs of hydrauliS failure, level of ponding, corAtion of vegetation, etc.)_
I Ad
PRIVY:
(locate on site plan) �y
Materials of constrc
/utin: /���7 Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding,.condition of vegetation, etc.)
ooyllrC/
(revised 8/15/95) 8
SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 171 Hollinsworth Road Osterville,Mass .
Owner: Robert Depasqua
Date of Inspection: 9/2 7/9 5
SKETCH OF SEWAGE DISPOSAL SYSTEM: •
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' p v v y/Are
DEPTH TO GROUNDWATER
Depth to groundwater: v;"4 fL feet _
method of ddte7ination or approximation: ! 1 v
66
(revised 8/15/95) x.
9
TTlT'/rrt•(�T.TTST�T:nTT�TTTT.T.::•T.�:T'�[T:TrTtT1T.�Z1�TL:.r..� .... ._. _ .. �.. • _ .. T�.Tr�•�
1 TOWN OFBa rn s to bl P BOARD OF HEALTH
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
F..•-;••-r•:-:: --.*:-"--- ..rr..n•r.:r.:—r.-rrrrs��'r-•.:—i....
raacsr.--s--r.n—srrx-s�-:ert-rrs�-•s--r..� e-.s-srr::r:zrrss.-rrs-rrrrrrrr..•.—rrr•r.•ter._.
-TYPE OR PRINT C1.EARLY-
PROPERTY INSPECTED
STREET ADDRESS H111linggworth Rona Osteryille,Mass .
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME Robert, T)epggqu%;
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P. Macomber Jr. .
COMPANY NAME J.P.Macomber & Son Inc.
COMPANY ADDRESS Box 66` Centerville ,Mass . 02632
Street Town or City Stato LIP
COMPANY TELEPHONE (508 1775 3338 FAX (508 790 -1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
complete as of the tirne;,.of :inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one :
System PASSED
Tile inspection %4hich I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 . 303 . Any failure
criteria not .evaluated are as stated in the FAILURE CRITERIA section of
this form .
XZXXX System FAILED*
The inspection, which I have conducted has found that the system fa-ils to
protect the public ,_health and the environment in accordance with Title
5 , 3.10 CMR 15 . 30.3 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature - Date 9/28/95
One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the I30ARD OF HEALTH.
If the inspection FAILED, the owner or operator shall upgrede ' the eystem
within one year of the date of the inspection, unless allowed or required
otherwise as provided in 310 CMR 15 . 305 :
y partd.doe
Ccm-imcnvwec^^ ,/1 wCr �e7S
,1 ill 1 V, I V la C\.�r. .
Execuruve Gtfice cr ^vlrcrl^-enrc, ,•ii.. S
Department of
Environmental Protection
' Water Pollution CcnTrol Tecnnlccl tamwence ana Training SecTlons
VAUlam F.We d
Trudy Cox•
;.a. y,ECEA •
Thomas 9. Powws •
:.cwq Cam�cl+r
06/12/95
ATTN: Joseph P. Macomber, Jr.
Joseph Macomber and Scull
PO Box 66
Centerville, MA 0263 -
Dear Joseph P. Macomber, Jr . , _
4
I am pleased to inform you that you have attended training, met
the experience qualifications, and have passed the Title 5 System
Inspector exam, pursuant to 310:CMR 15. 340 . The passing grade for
the exam was 39/52 or 75% .
This is an official notificacionl. that you are a Certified Department
of Environmental Protection System Inspector pursuant to 310 CMR 15 . 340 .
You will receive a System Inspector certificate at a later date.
If you have any fur-her questions, please write to me at the following
address:
Kimball Simpson
1). E.P. Training Center
50 Route 20
Millbury, MA 01527
Thank you very much for }oa: time and consideration: in this matter.
Sincerely,
Kimball T. S'.meson,
DEP Training or Directcr
r�
405� N.
Route • Millbury, MA FAX 5r&755.9230 • ,n• 508-756-7:°' " ``
........
Water
Conservation
SAVE Tips . .
ME! p
CHEGk FOR LEAKS
Water Loss in Gallons Due to Leaks
Leak
this Loss Per Day Loss Per Month
Size
120 3,600
' 360 10,800
• 693 20,790
• 1,200 36,000
1,920 57,600
3.1096 92,880
I� .0 4;296 128,980 80
® 6,640 199,200.-
5 984 200,520
0.424 252,720
9,888 296,640
11,324 339,720
12,720 381,600
14.952 448,560
.1
a
l ® CAT I N 5EWAGE PERMIT 930.
VILLAGE
IgFSTA i LER' �J�� AC�E� b ADDRESS
LL,.r,G`u✓'b-.RrZ.� ! A �/'/�tad j 9
a
ORq-� 0 V Q ER
h�
DATE PERMIT ISSUED3 „ �
DATE COMPLIANCE ISSUED � ��
Y
z
0
P
B�NC�
No....& '.r.4-4_ F.Es....... d... ....
THE COMMONWEALTH OF MASSACHUSETTS �.
BOAR® OF HEALTH
OF..........................................................................................
Appliratilan for Disposal Works Tonstrnrtiun Urrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: q ... a
cation-A dress or Lot No. a
a
Address j
a ............................................ ...............................
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms.___.____________________________________Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons....... ........_..__._.. Showers ( /) — Cafeteria ( )
Other_fixtures ...........................................................---------------------------------------•--------------•••••-----...---•-•----......._------
W Design Flow...... �...............................gallons per person per day. Total daily flow.....11-0_..............................gallons.
WSeptic Tank—Liquid capacity/OZIA..gallons Length................ Width__----_...______ Diameter---------------- Depth................
x Disposal Trench—No. .............. Width.................... Total Length............................... Total leaching area....................sq. ft.
Jr
Seepage Pit No...../............. Diameter.... ___...._... Depth below inlet................
Total leaching area_..�(_.......sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by-------------............................................................ Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Li, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
04 ------•--------•----------------•-----------•-•----•----•-•---•.....--••--•..........--------------•.........................................................
0 Description of Soil........................................................................................................................................................................
U •-------------•-------------.....-------•--------••••-••-----•-••-•-•...................-----•------.......--------------------••-••----•--------•----•--•--•----•-------------•---•---•-......-----•---
W -------------------------- -------------•------------------------------------------------...-------•-------------------------------------------------------------•-----•--.......---------....---.••-•--
UNature of Repairs or Alterations—Answer when applicable............................................................................:...................
...-----•-----------------------••••-----•----------•---•--•-----•--•--•------...._...............-------•----------•--------...------------------------------------...------••. •-----•..._.._.......
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITLIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health. n
Signed-----. .... -----------------
Application Approved BY -r � 'ae_. 1.._.//%' ....... .... ��•---
Date
Application Disapproved for the following reasons----------------•---------------•--------------------------------------------•---•------•-•-----•------•••-.-----
.............•-----....--••-•--•-•----------•-------•--------•-•-•--------•-••---•--••----•-•--------•-...---••---....---••••-------•-------------•-------------•----------•--------•-----------•---••-•-
Date
PermitNo......... ------------------- Issued-..................-Date te..--...............------------
z
i
THE COMMONWEALTH OF MASSACHUSETTS"
BOARD OF HEALTH
'.OF..........................................................................................
ApplirFation for Disposal Works Tumilrurtion nuti#
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
--------- -------------------------------------•------------------------------------------------------------
s✓ cation-A ress or Lot No.
6 _ .........................•.... ..........--......................................................................................
w r Addre s
Installer Address
Type of Building Size Lot...........:................Sq. feet
U Dwelling—No. of Bedrooms.._..I..................... .. .Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons.......a................ Showers ( /) — Cafeteria ( )
Q' Other fixtures --------------------------- -
W Design Flow......S•,!:�------------------------------gallons per person per day. Total daily flow-----Ila.............................gallons.
WSeptic Tank—Liquid capacity/00,6..gallons Length................ Width-_--__-____.____ Diameter................ Depth................
x Disposal Trench—No- -------------------- Width..... Total Length............ Total leaching area....................sq. ft.
Seepage Pit No....... Diameter......?........... Depth below inlet....0............. Total leaching area.60f9.._....sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(z, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ---••------•....••-•--------•---•-........••-•--••••-•••••••••••----•-•-•--...._•-•.............•-•----......-••••••---........---••...._ ..........................................................
0 Description of Soil................................................................................................................... .....................................................
------------------------------- ---------------
-----------•-----------------••-•-•--•---•----•------------------------------•-----=--•--••--•---•---•-•-•----•-••---------•---•----•..._.....
U Nature of Repairs or Alterations Answer when applicable..............................................................................................
i
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code`— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed --f -�---------------• •-e0- t �-
c/ D to
? • f z 6
Application Approved By —--••--.... — ...._..-/J� - ......... ........... --.
Date` ---••-•---
Application Disapproved for the following reasons:..............................................................................................................-
-•••----•-•-••-•----•---•••--•-•-•-----•....-•----•--------•-----•---•--•-••-••---•-----•-•-•-•----•••--•.--------------•---•-----•-•.--•--••-----•-•------•--•----•••--------•------------•----....._..
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................O F.f...................................................................................
(9rdifirFatr of Tontplianrr
TIS TO C IFY, t the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by - +-=•..... ........... .....•--•-- -- .. .- ----- ..............................................
y�,••-• n -- -•- _Installer �
_ • ...
has been installed in accordan with the provisions Of T = 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.__.-_ -_--' '/,01)-_- dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................•--•----•-•--...-------••---••...........-•-•....... Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
No...........i.. ....... FEE........................
Disposal Works TFUInstrurtion firrmit
Permission is hereby granted........... .1—re-----•-- `" -----------------------•------------------------•----•--.............................
to Construct ( or Repair �,an Individual Sewage Dis osal System
atNo......... ..... ?. -----• Zf............... --•--------------------------------------------------------------------------------------
- Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
.... K_,41s.............. . .......................................
/ Boa
DATE......................-...........9V 1-,lsf�- ......................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS