HomeMy WebLinkAbout0104 KING ARTHUR DRIVE - Health FliKing Arthur rive
osterville
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104 KING ARTHUR DR., OSTERVILLE
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UPC 12134
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��,.►► TOWN OF BARNSTABLE
LCCATION 1 Dy I�1 w ArVl�e,,- br: SEWAGE # 1 73
VILLAGE n sritJ, ASSESSOR'S MAP & LOT IyS O
INSTALLER'S NAME&PHONE NO. COr�Oh i!AJ^/JU A
SEPTIC TANK CAPACITY /UFO G A I C eAA.i 1J—En X
LEACHING FACILITY: (type) l 0UO (size)
NO.OF BEDROOMS L I
BUILDER OR OWNER V1 C.^i a bl
PERMITDATE: �� o-7Ib) 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
a �3. 3a
3 Ay - 32�
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TOWN OF ARNSTABLE
L&ATION I^ SEWAGE #'
VU;LAGE O ASSESSOR'S MAP & LOT �ys Oy
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY C-l"D
LEACHING FACILITY: (type) �� Cox (0 (size)
NO.OF BEDROOMS 3
BUILDER OR OWNER VI G � TD bJ/1
PERMITDATE: 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 leac g n facility) Feet
�j ty),_.
Furnished by L Sper,T7&l •� �0�
A ' 'B
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c Ja
.O a 193- a�
3 Ay- 3a
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LOCATION
O`� T SEWAGE PERMIT N0.(03 ,
)-67
VIaILAGE
INSTA LLER'S NAME i ADDRESS
r
B U I L D.E R OR OWNER
DA T E P ERMIT I S S U ED
DATE COMPLIANCE ISSUED _� ��
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No......... FEB :::211)..............
THE COMMONWEALTH OF MASSACHUSE77S
BOARD OF HEALTH
OF....3 ...... ...........................................
----ba-f-w- -—--------------- .........
Allpfiration for Uhiposat Works Toutiuurtion ramit
Application is hereby made for a Permit to Construct ( or Repair an Individual Sewage Disposal
System at:
SI
........................................ .
.......... ..... ..................&.1
4p
ca�i ,�Addr.ess... or Lot No.
.... .. ..... .. .... ................*... . ..... ............................ ....................................
W' ...........f.c:7 dres's
I -----------------------
......Installer Address
Type of Building Size Lot....!1 6& .d..S q. feet
Expansion Attic Garl5age Grinder ( )
Dwelling—No. of Bedrooms
Other—Type of Building 11 j ......No. of p ersons............................ Showers Cafeteria ( )
Pa Other fixtures ....................................
------------------------*----------------------I-------- ------------------------
Design Flow...............S�_�-------- --4gallons per person per day. Total daily flow_____,....36.........................gallons.
Septic Tank 4 Liquid capaci ......gallons Length,_______________ Width..____._.__._.._ Diameter................ Depth____.______..__.
Disposal Trench—N .................. Width____ ............. Total Length.__.__._.____ .... Total leaching area....................sq. ft.
Seepage Pit No......... iameter......... ..... Depth below inlet__._.___ _. Total leaching area...�—Ia,/...sq. f t.
Other Distribution bok (I Dosing to
Percolation Test Result Performed nk ....... Date../:Z-=A41— 7
..........................
... Depth to ground water_____,_____._:___.__._..
2-------minutes per inc Test Pit No. I___„ . .____.minutes h Depth o t Pit____________________
Test Pit No. 2................minutes per inch Depth of Test Pit____.____.______.._. Depth to ground water___________.___._.._...
.............. ........ -------- .........................
0
. .................Description of Soil---'�....0..—At./ .. lam` ......&./
-------------------*..........-------------------------------- ......*-------------------------*-------- ------*---------------------------------------------------------------*........
........................................................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable..............................................................................................
........................................................................................................................................................................ ..............................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TL I 1�LE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued b the boar of health.
5ignd. .—Aw.. .......................................
ae
Application Approved By_....-------
Date
Application Disapproved for the following reasons:.................................. ..............................................................
..................................................................................................................................................................7......................................
Date
7f•.......................
Permit No........ .............................. Issued...15�
Date
No.. G _ ---- Fms..... ..............
9-
THE COMMONWEALTH'OF MASSACHUSETTS
BOARD OF HEAL H
-'..............OF.... . ......
........ ..............................................
` ...
Appliration for Dispas al lgorkii Tonatrnrtion amit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
s
S s at
§ N
cat Address r110,
No4
w r dress rr ems•
W
Installer Address r+
g
Type of Building Lot.... .... .. ........Sq• feet
d n x Si
Dwelling—No. of a Bedrooms,t------- ----------------------.........Expansion Attic ( ) Garbage Grinder ( )Other—Type of Building _f __r''..........No. of persons............................ Showers ( ) — Cafeteria ( )
Other fix S........................................................
x,.
W Design Flow..}........................ gallons per person per day. Total daily flow............................................gallons.
R: Septic.Tank—Liquids capacity t,..:....'gaIons Length................ Width Diameter._._........._.. Depth................
Dispbtdl"Trench ' N Width. Total Len gtllfie - - Total leaching area....a ---sq. ft.
{
3 ,Seepage Pit No iameter : Depth be}ow,inlet ... Total leaching area..................sq. ft.
z Other Distribution box,(Y# ). Dosing ��„ 7
a H '0� KK lJ4
a Percolation Test Result Performed by......................:___.____.._.....__.._ ��_..._..__ Date.. ..._:............................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water
rZA Test Pit No. 2................minutes,-. inch Depth of I e Pit._ ._.............. epth to ground water ...................
O Description of Soil...`........
.... ~
.... ..
.:.:. .. _ h
......................•----•----•----••----...-----------------------------...------.................---=---:_::.........•....-----•--
x
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 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;bx the board of health.
ed .:_ ::.. .... .�--------------------- - y '�
l �
Application Approved By.............. F=-----------........................---............
..----....... .. ----•-•--------------------------•-----:.
Date
Application Disapproved for the following reasons---------------•----•--...--•---•----------------------•---•------------------------....._......_........_...._
.. .... ...............•--------•-....---.......-•----------•-------------------••--------------------------------------------------------•--.......---
Date
PermitNo......................................................... Issued•...............................................
Date
i
THE COMMONWEALTH OF MASSACHUSETTS
"' BOARD OF HEALTH
1.6t"'^'L:......:.............OF. . . . ........ ••.................(9rrtifirtttel of f 1int1t iFaairr ,,,...
TH IS TO Y, Th the Individual Sewage Disposal Sy tem constructed ( ) or Repaired ( )
by
at .. --••-- -- ..... ........ ••----
has been installed in accordance with the provisions of TIT 3 - State Sanitary Cci._ /e i in the
application for Disposal Works Construction Permit No......................................... dated...::.�_.�_.... �.._.___..__._
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS UE® AS A GUARANTEE THAT THE
SYSTEM'.,WILL�FUNCTION"SATISFACTORY
/ rr
DATE.............. . 1..�.:-... - -- ..........................
THE COMMONWEALTH OF MASSACHUSETTS
`' - BOARD QF HE 'T
� .`." ...................O F...:.. r -°� . ..................... ^,".. ..
No........ FEE .: ...........
Mop 19 ottri�rtion rr i't'
Permission is hereby granted -�'..:�. .........................................................w...........................••...
to Constr tic +fir Repair ( a Indivlr3u ew 1' Ystem
at No !'` tom`-:...
s Stre � ..J t Kwrfyr�
as shown on the application for Disposal Works Construcrion -- r�/kry Dated..`. ✓' j
Board of Heal
DATE --- ------- ............................................................
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PRO-T-ECTON OVED
NOV 2 ,9.2004
TOWN OF BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION iJtAF
PARCEL i A:.
Property Address: 104 King Arthur Drive (r�
Osterville. MA 02655
Owner's Name: Kathleen Busse
Owner's Address:
Date of Inspection: November 5, 2004
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O.Box 49
Osteryft MA 02655-0049
Telephone Number: _(508)862-9400
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: November 8, 2004
The system inspector shall sub ' a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector.and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 104 King Arthur Drive
_ Osterville. MA
Owner: Kathleen Busse
Date of Inspection: November S. 2004.
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as.approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain-
2
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 104 King Arthur Drive
Osterville, M.4
Owner: Kathleen Busse
Date of Inspection: November 5. 2004
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
,
The system has aseptic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
..CERTIFICATION (continued)
Property Address: 104 King Arthur Drive
Osterville. MA
Owner: Kathleen Busse
Date of Inspection: November 5, 2004
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid'level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ 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.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply. I
✓ 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails. I have determined that one ormore of the above failure criteria exist as
described in 310 CMR 15.303',therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria abo"ve)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
C Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
E SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address,: 104 King Arthur Drive
Osterville. MA
Owner: Kathleen Busse
Date of Inspection: November 5. 2004
Check if the following have been,done: You must indicate"yes"or"no"as to each of the following:
Yes No
✓ _ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the.system components pumped out in the previous two weeks?
✓ _ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ _ Was the site inspected for signs of break out?
✓ _ Were all system components,excluding the SAS,located on site?
✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage-disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
✓ _ Existing information. For example,a plan at the Board of Health.
✓ _ Determined in the field(if any'of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)].
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 104 King Arthur Drive
Osterville, MA
Owner: Kathleen Busse
Date of Inspection: November S, 2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: I
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] .
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Pumped 1217101 -per owner
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: _gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,distribution.box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) {if yes,attach previous inspection records,if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Installed in 1979-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 104 Kihiz Arthur Drive
Osterville, MA
Owner: Kathleen Busse
Date of Inspection: November S, 2004
BUILDING SEWER(locate on site plan)-
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 10"
Material of construction: concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 Qal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: I"
Distance from top of scum to top of outlet tee or baffle: ` 10"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How were dimensions determined: Mmeasurinz 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.):
Cement tees were present. The liquid level was even with the outlet invert There did not appear to be any signs of 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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,.evidence of leakage,etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) .
Property Address: 104 King Arthur Drive
Osterville, MA
Owner: Kathleen Busse
Date of Inspection: November 5, 2004
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: sallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping: ,
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (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 was level and clean. Plo solids were present The cover was 6"below Qrade
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.):
8
i
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 104 KinQArthur Drive
Osterville MA
Owner: Kathleen Busse
Date of Inspection: November 5, 2004
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type .
✓ leaching pits,number: I -6'x 6'(1000aL) w/1'stone(per as built card)
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
Innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
There was approximately 1.5'ofliauid on the bottom The scum line was approximately Y up from the bottom There did not
appear to be any signs offailure. The bottom to grade was 9' The cover was Y below grade
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: 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.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 104 Kin-Arthur Drive
Osterville, MA
Owner: Kathleen Busse
Date of Inspection: November S. 2004
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet: Locate where public water supply enters the building.
/a- 3b
Ga- a-
70 n3 3a
a Cl
3 A4- 3�
10
f
-i
Page 11 of I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 104 King Arthur Drive
Osterville, MA
Owner: Kathleen Busse
Date of Inspection: November 5, 2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 30;+/- feet,
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours mans
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using Barnstable topographic and water contours maps, the maps were showing approximately 30'+/-to Around water at this
site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees,either expressed,written or implied,relating to the system, the inspection and/or this report.
11
i
U0 ? - Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ZlppYiratton for Mt. ppaal *pgtem Conmrurtton J)ermit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. P►jOJ 4R 'CDR. Owner's Name,Addre s dTel.No.
U I/i c �� 'ry ra -w
Assessor's Map/Parcel 7 S_ Q G� /okl I�t N A ap
Gs kizv,//E oats
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank 10 00 (2 Type of S.A.S. 402 f vv-
Description of Soil
Nature of Repairs or Alterations(Answer when ap licable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue y this oard of lth.
Signed Date oZ Q/
Application Approved by c Date
Application Disapproved for the following reasons
t
Permit No. UU - 737 Date Issued 1 a o d
— ------------- ----- _ --------------
iy
TOWN OF BARNSTABLE
LOCATION /0 I kSIC A('V'�fe- Z)r SEWAGE # c901 -73
VILLAGE C)STe�v, ASSESSOR'S MAP & LOT IyS O
INSTALLER'S NAME&PHONE NO. 6Or�0h
SEPTIC TANK CAPACITY /O7O C,A I i -�X
LEACHING FACILITY: (type) ,
(size)
NO.OF BEDROOMS
BUILDER OR OWNER VI/Lki a L1
PERMITDATE: I�� D-7l b�COMPLIANCE DATE: / /0 oZdO/
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
A /
qa- 30
a-
a
Fee
.THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
ZIpprication for DioowaY *p5tem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) O Complete System ❑Individual Components
Location Address or Lot No. /O q 14j)V6� q RV FP 'DR, Owner's Name,Addre s 4d.Tel.No.
V OS R u:�dAE 1�1 C ! . �'s t►11 r p
Assessor's Map/Parcel �i` G 'v -- � �u�a N la Rug� k
Installer's Name,Address,and Tel.No. J•, Designer's:Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size " sq. ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 0""gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title ?.
Size of Septic Tank i1 Type of S.A.S.
Description of Soil
Nature of Repairs or Altera`tion1s(Answer when ap lica`ble)
;R( ol,4c
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued y this oard oa th.
Signed ✓ Date ./'off ✓ 01
Application Approved b x %a
PP PP Y Date G
Application Disapproved for the following reasons
Permit Now OU 1- 73-7 c Date Issued 1 0 0
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE; MASSACHUSETTS
Certificate of Compliance (b-'2^\r
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( Repaired( )Upgraded( )
Abandoned( )by
at. ` A� u 1D , GS dQ uj// has been constructed in accordance
with the provisions of Tit e 5 and the for Disposal System Construction Permit No. 7 00 l 7T 7 dated u G
Installer t✓<- Designer
The issuance his permi shall not be construed as a guarantee that the system will unction as designaed
Date ! 1 Inspector ��,,T �, {
_ _
—
No. a fed . . - Fee V[/'r
THE COMMONWEALTH OF-MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
` igo�aY.0pttem Construction Permit
Permission is hereby granted to Construct( Repair( )Upgrade( )Abandon( ) 'j r2QX
System located at /0 M U,h!,�, A V 1,5 L CL
and as described in the above Application for Disposal System'Construction Permit. The applicant.recognizes his/her duty to .
comply with Title 5 and the following local provisions or special conditions.
Provided:Constructio must be completed within three years of the date of this p t.
I �/n / r
Date: V Approved by """�' � .• P ,�
ry -
a
i
` e %
COMMONWEALTH OF MASSACHUSETTS VVV
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS -
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART;A
CERTIFICATION
Property Address: 104 King Arthur Drive
Osterville, MA 02655
Owner's Name: Vicki Tobin
Owner's Address: Same
Date of Inspection: December 7, 2001
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford Map: 145
Mailing Address: P.O. Box 49 Parcel: 044
Osterville,MA 02655-0049
Telephone Number: (508) 862-9400
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
`Conditionally Passes
Needs rther Evaluation by the Local Approving Authority,
Fails
` z
Inspector's Signature: Date: December 11, 2001
The system inspector shall subl a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
r
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 1 1 i 3
OFFICIAL INSPECTIONFORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART A
CERTIFICATION.(continued)'. .
Property Address: 104 King Arthur Drive
Osterville MA w
Owner: Vicki Tobin
Date of Inspection: December 7 2001 4 '
Inspection Summary: Check A,B,C,D orkE%ALWAYS complete all'ofSection D
•
A. System Passes:
I have not found any information which indicates that any of the failure criteria desc'ribed'in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are:indicated below.
Comments: x
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.
F•' S s -i
Answer yes, no or not determined(Y,N,ND) in the for the following statements. If"not determined",please,
explain.
The septic tank is metal and over 20 years old*R or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System,will pass inspection-if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is'structurally sound,not leaking and if a�Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken,or
P p� ) P
obstructed i s or due to a broken,settled or uneven box.,System will passins ection�if with'
approval of Board of Health):
broken pipe(§)are replaced a'k
obstruction is removed
" distribution box is leveled or rep aced y
ND explain: ,
The system required pumping more than 4 times`a year due to broken'or obstructed pipe(s). The system will
ti pass inspection'if(with'approval�of the Board,of Health): -
M.
broken pipes)'are replaced s
* obstruction is removed
ND explain:
Page 3 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM'
PART A
CERTIFICATION (continued)
Property Address: 104 King Arthur Drive
Osterville, MA
Owner: Vicki Tobin
Date of Inspection: December.7, 2001 .
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of I 1 ,
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY,ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 104 King Arthur Drive
Osterville, MA
Owner: Vicki Tobin
Date of Inspection: December 7. 2001 s
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:.
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_ ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less,than 6"below invert or available volume is less than ''%day flow
✓ Required pumping more than 4 times'in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a�surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone I 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.].
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd'to 15,000.
gPd•
You must indicate either`yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply `
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped
Zone II of a public water supply well Y
If you have answered"yes"to any question in Section E the system is•considered a significant threat,or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 104 King Arthur Drive '
Osteniille' MA
Owner: Vicki Tobin
Date of Inspection: December 7, 2001
Check if the following have been done: You must indicate"yes"'or"no"as to each of the following:
Yes No
✓ Pumping information was provided by the owner, occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ _ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as'part of this inspection ?
✓ Were as built plans of the system obtained and examined?(If they were not available note as MA)
✓ Was the facility or dwelling inspected for signs of sewage backup? -
✓ — Was the site inspected for signs of break out? a
✓ _ Were all system components,excluding the SAS; located on.site?
✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees, material of construction,dimensions, depth of liquid,depth of sludge and depth of scum?
✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
✓ _ Existing information. For example,a plan at the Board of Health.
✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)]..
5
Page 6 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
-
Property Address: 104 King Arthur Drive
Osterville, MA
Owner: Vicki Tobin
Date of Inspection: December 7, 2001
FLOW CONDITIONS
RESIDENTIAL -
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):. `330
Number of current residents: 2 -
Does residence have a garbage grinder(yes or no No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): 1999 56,000 gals.; 2000=13,000 gals.
Sump Pump(yes or no): No '
Last date of occupancy: Currently.occupied = l:
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no): -
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
- GENERAL INFORMATION
Pumping Records
Source of information: Pumped on Jan. 24197 and Mar.'25/99-per treatment plant
Was system pumped as part of the inspection(yes or no): No p
If yes, volume pumped: Qallons--.,How was quantity pumped determined? ,
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank, distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes,attach previous inspection'records,if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
1979-per as built card
Were sewage odors detected.when arriving at the site(yes or no): No
. 6
Page 7 of 11
OFFICIAL INSPECTION,FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
'SYSTEM INFORMATION (continued)
Property Address: 104 King Arthur Drive
Osterville, MA
Owner: Vicki Tobin
Date of Inspection: December 7, 2001
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron ✓ 40 PVC _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints, venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 10"
Material of construction: ✓ -concrete _metal a fiberglass polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 10"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How were dimensions determined: Measuring 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.): ;
Cement tees were present. The liquid level was even with the outlet invert. There were no signs of 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(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY§ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 104 Ki,nz Arthur Drive
Osterville, MA
Owner: Vicki Tobin
Date of Inspection: December 7, 2001
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)'
Depth below grade:
Material of construction: _concrete metal fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no): -
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):'
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet inveri: 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 was level. Roots were growing inside the D-box. A new D-box was installed(see Permit No 2001-737)
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.):
8
Page 9 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 104 King Arthur Drive' `
Osterville. AM
Owner: Vicki Tobin
Date of Inspection: December 7, 2001
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 6'x 6'with 1'stone
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields, number,dimensions:
overflow cesspool, number:
Innovative/alternative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation,
etc.):
The pit had 2'of water on the bottom. The scum line was 2'6" up from the bottom There were no signs offailure The bottom
to grade was approximately 9. The cover was 3'below grade
CESSPOOLS: None (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:
R
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: None (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY"ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM,
PART C< by
SYSTEM INFORMATION (continued)
Property Address: . 104 King Arthur Drive°
Osterville, MA
Owner: Vicki Tobin r
Date of Inspection: December 7, 2001
F Map: 145.
Parceh,044 1
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate.where.public water supply enters the building:
b
e
a
C s
lit
ALi
3: „
6.,
e k ,
a i
a.
s
f '
Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 104 King Arthur Drive,
Osterville, MA
Owner: Vicki Tobin
Date of Inspection: December 7, 2001
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 30' +/- feet (Adjusted High Ground Water Level:21.1') _
Please indicate (check)all methods used to determine the high ground water elevation:
✓ Obtained from system design plans on record- If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain: _.
You must describe how you established the high ground water elevation:
The bottom of the leach pit to grade was approximately 9. A test hole was done when installed and no water was observed at
14'. Using the Barnstable topographic map and the Cape Cod Commission water contours map the maps were showing
_approximately 30'+1-to groundwater at this site. Using the Cape Cod Commission Technical Bulletin the high ground water
adjustment for this site(SDW 253, Zone C, 10/01)was 8.9.
r f -
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
11 '.
d
Grp► .
6roU j w47] ,- I eve .l
ECO 'T'ECH
ENVIRONMENTAL AEG 2
" �� 3 1999
THIS FORM IS A FACSIMILE OF THE STANDARD SEPTIC INSPECTION FORM ISSUED BY THE MAS a USE eO,J' N
DEPARTMENT OF ENVIRONMENTAL PROTECTION (revised 9/2/98) 7! '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A LP ti
CERTIFICATION
Property Address: 104 King Arthur Drive,Osterville Name of Owner Michael McEll' oig t
Address of Owner 45 Dudley Road, Billerica,MA 01821
Date of Inspection: August 21, 1999
Name of Inspector:(Please Print) David D.Coughanowr, R.S.
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: Eco-Tech Environmental
Mailing Address: 43 Trianeie Circle Sandwich MA 02563
Telephone Number: (508) 888-0185
CERTIFICATION STATEMENT:
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on-site sewage disposal systems.The system:
_X Passes -
C�o,F► r RAJy _
�1�' ��,ufthe ua, By the Local Approving Authority
kO OAVID ry
G Y.
g COUGHANOWA '
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Inspector's Signature isT > Date: 0 f/$t�2-2-1, WqVV G/
1TAR
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)
within thirty(30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd
or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department
of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,
and the approving authority
NOTES AND COMMENTS
Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure
criteria listed below.The septic system has been evaluated according to the conditions observed on the day it was inspected.No estimate
or guarantee of system longevity is made or implied by a passing determination.
The System Inspector shall submit a copy of this inspection report to the Approving Authority Board of Health or DEP)
within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd
or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department
of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,
and the approving authority.
revised 9/2/98 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 104 King Arthur Drive,Osterville .
Owner: Michael McElligot
Date of Inspection: August 21, 1999
INSPECTION SUMMARY: Check A, B, C,or D:
A] SYSTEM PASSES:
_X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303
exist.Any failure criteria not evaluated are indicated below.
COMMENTS:
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;or the septic tank,whether or not metal,is cracked,structurally
unsound,shows substantial infiltration or exfiltradon,or tank failure is imminent.The system will pass
inspection if the existing septic tank is replaced with a complying septic tank as approved by the
Board of Health.
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 leveled 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
revised 9/2/98 Page 2 of 1 1
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' t I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 104 King Arthur Drive,Osterville
Owner: Michael McElligot
Date of Inspection: August 21, 1999
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect the public health,safety and 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 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 WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF
ANY) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT
PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100
feet of a surface water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone 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 912198 Page 3 of 1 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A '
CERTIFICATION (continued)
Property Address: 104 King Arthur Drive, Osterville ,
Owner: Michael McElligot
Date of Inspection: August 21, 1999
D) SYSTEM FAILS:
You must indicate either"Yes" or"No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 1.5.303.
The basis for this determination is identified below.The Board of Health should be contacted to detennine what
will be necessary to correct the failure.
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.
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 NOT 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.
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 colifomt bacteria,volatile organic compounds,ammonia nitrogen
and nitrate nitrogen
E) LARGE SYSTEM FAILS:
You must indicate either"Yes" or"No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
_ The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a
significant threat to public health and safety and the environment because one or more of the following
conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA)or a
mapped Zone II of a public water supply well.
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2).Please
consult the local regional office of the Department for further information.
revised,9/2/98 Page 4 of 11
A '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST.
Property Address: 104 King Arthur Drive, Osterville
Owner: Michael McElligot
Date of Inspection: August 21, 1999
Check if the following have been done:You must indicate either"Yes" or"No" as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant or Board of Health:.
X _ 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.
X _ As built plans have been obtained and examined.Note if they are not available with N/A
X _ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
X _ The site was inspected for signs of breakout.
including
X _ All system components,excludin the Soil Absorption System.have been located on the site.
-X_ _ 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:
X _ existing information. For example,Plan at B.O.H. y `
_X_ 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))
X _ The facility owner(and occupants,if different from owner) were provided with information on:the
proper maintenance of Subsurface Disposal System.
revised 9/2/98 Page 5 of]1
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SUBSU
RFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 104 King Arthur Drive,Osterville '
Owner: Michael McElligot _
Date of Inspection: August 21, 1999
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 g.p.d./bedroom.
Number of bedrooms (design): 3 Number of bedrooms(actual): 3
Total DESIGN flow: 425 g dd '
Number of current residents
Garbage grinder(yes or no): no
Laundry(separate system) (yes or no): no :If yes,separate inspection required,
Laundry system inspected (yes or no)
Seasonal use (yes or no):no
Water meter readings,if available (last two year's usage(gpd):_1997:9M *pd
1998: 1140 �sD17
Sump Pump (yes or no): no
Last date of occupancy:current r
COMMERCIAL/INDUSTRIAL: '
Type of establishment
Design flow: gpQ ( Based on 15.203)
Basis of design flow
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:
System pumped May, 1999 (Occupant) '
System pumped as part of inspection: (yes or no) No
If yes,volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM:
X Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) ( if yes,attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract'
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components,date installed (if known)and source of information:
An:20+ years Certificate of Compliance issued 3/13/79 to John Maffei (BOH permit#79-63)
Sewage odors detected when arriving at site: (yes or no) no
revised 9/2/98 Page 6 of 1 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 104 King Arthur(Drive,Osterville
Owner: Michael McElligot
Date of Inspection: August 21, 1999
BUILDING SEWER: ,
(Locate on site plan)
Depth below grade: 1.5 ft
Material of construction:_cast iron —X_40 PVC_other(explain)
Distance from private water supply well or suction line 20+
Diameter 4 inch
Comments: (condition of joints,venting,evidence of leakage,etc.)
Sewer is vented through roof and appears structurally sound with no evidence of leakage or backup into dwelling
SEPTIC TANK:
(locate on site plan)
Depth below grade: 10 in
Material of construction:X concrete—metal—Fiberglass_'Polyethylene—other(explain)
If tank is metal,list age_ Is age confirmed by certificate of compliance—(Yes/No)
Dimensions: 8 ft-6 in x 5 ft x 5 ft
Sludge depth: 4 in
Distance from top of sludge to bottom of outlet tee or baffle: 30 in
Scum thickness: 3 in
Distance from top of scum to top of outlet tee or baffle: 9 in
Distance from bottom of scum to bottom of outlet tee or baffle: 12 in
How dimensions were determined: Probe to top of tank
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.) Maintenance psrnP recommended within one year,but not required
at this time Liquid level at outlet invert Tank and tees appear structurally sound and functioning as intended No evidence
of Ieakaye in or out.
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 baffler
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 9/2/98 Page 7 of 11
i
.SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 104 King Arthur Drive,Osterville
Owner: Michael McElligot w
Date of Inspection: August 21, 1999
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 present
Alarm level: Alami in working order:Yes . No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: X
(locate on site plan)
Depth of liquid level above outlet invert: at outlet invert
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
D-box appears structurally sound with no evidence of leakage in or out Effluent level at nutlet invert
Few solids in tank.
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 9/2/98 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM,
PART C
SYSTEM INFORMATION (continued)
Property Address: 104 King Arthur Drive,Osterville ,
Owner. Michael McElligot
Date of Inspection: August 21, 1999
SOIL ABSORPTION SYSTEM (SAS):_ '
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
Type:
leaching pits, number: 1 _
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
Soils above leach pit appeared unsaturated No evidence of surface oonndeng,breakout, n g tae_tion.or
other evidence of hydraulic failure was observed Leach nit contained 39 inches of effluent in a 6 k nit
r
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 p
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 9/2/98 Page 9 of 11
L
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 104 King Arthur Drive,Osterville
Owner: Michael McElligot
Date of Inspection: August 21, 1999
SKETCH OF SEWAGE DISPOSAL SYSTEM: -
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
LEACH1
PIT LOCATIONS
2
D-BOX A B
1 25 f t 22 f t
SEPTIC 2 29 f t 32 f t
TANK o 3 46 f t 32 f t
W a A
3 BEDROOM
DWELLING
# 104
Z
J a
3 y ,
KING ARTHUR DRIVE s NOT TO SCALE
revised 9/2/98 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM'
PART C
SYSTEM INFORMATION (continued)'
Property Address: . 104 King Arthur Drive,Osterville
Owner: Michael McEll'igot
Date of Inspection: August 21, 1999
MRCS Report name
Soil Type
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater: 14+ Feet
Please indicate all the methods used to determine High Groundwater Elevation:
X Obtained from Design Plans on record
Observed Site(Abutting property,observation hole,basement sump,etc.)
Determine from local conditions
Checked with local Board of health
Checked FEMA Maps µ
Checked pumping records
Checked local excavators,installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Approved design plan on file with Board of Health showed no groundwater was observed in a witnessed test pit to a depth of 14 feet.
revised 9/2/98 Page 1 1 of 1 1
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