HomeMy WebLinkAbout0087 MAIN STREET (OST.) - Health 87 Main Street
Osterville
A = 185 - 06'2
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TOWN OF BARNSTABLE
LOG;1ON O M'41 S 1- SEWAGE#
VILLAGE OS1 VA ASSESSOR'S MAP&PARCEL
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING,FACILITY- (type) C �.TS (size)
NO.OF BEDROOMS 10
OWNER, � S
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY EA PekTton F0r Z
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LOCATION ' SEWAGE '. PERMIT NO.
Q .-7
VILLAGE
INSTA LLER'S NAME Z ADDRESS
Or
R UiIDE.{-R OR OWNER
din
DATE PERMIT ISSUED 19
S�
DATE COMPLIANCE ISSUED
I�
ti
0
®v �DOL o
�d
L0C,ATIOt� SEWAGE PERMIT NO•
VILLAGE INSTALLER'S NAMOE i ADDRESS
0 U I L DE R OR/� OWN ER
D TE PEItMIT -ISSUED
DATE COMPLIANCE ISSUED � gv
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f
/ale
No..... Q-� F�B...$...5-0�........
THE COMMONWEALTH.OF MASSACHUSETTS
BOAR® OF HEALTH
...........Town...........OF............ Barns-table
Appliration for Dispooal- nrks Tnntrnr#iun amit
Application is hereby made for a Permit to Construct ( ) or Repair (x ) an Individual Sewage Disposal
System at:
......QQ. eXV,U1_Q .A.....426E.-•------•------ .................-.................................................................................
Location-Address or Lot No.
.Axtb.133 ? .1 ........................................................... 87...Main..S..........�sterville.�.. ._..026 . ...............
ner
aA..&-_B..Cess,�ool_,Seryice ..........................• 128---Bishogs-Terrace...Hyannis: MA 02601
Installer Address
Type of Building Size Lot.... ..................Sq. feet
,., Dwelling—No. of Bedrooms...................5..........._..........Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons....5........_------------ Showers — Cafeteria
Q' 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 ( )
`.� Percolation Test Results Performed by.......................................................................... Date........................................
,--4
,.� Test Pit No. 1................minutes per inch Depth of .Test Pit.................... Depth to ground water........................
fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
�+ •----------------------------•-------•--...-•----•--------•--..................--.................----........--•---...--------•-•------.:....---------
0 Description of Soil............j3amd------------------------------------------------------------------------------•--•--••-•••--------------------•-----•---......................._..
W
V .---------------------------•-•-----•-----•-------------------•-....................------•------•---....-------------•--------------------•-•-----•--•--------••-----------------•---......•--------•--.
----•----------------------------------------------------•-----------------------------.....-•----••----------------......--------------------------•---------------•-•---------------------------------
U Nature of Repairs or Alterations—Answer when applicable._._installatiQn._Df..a._..one..t llousand_. lQQQ)----
.gallon._pre_=cas-t,--st.nne...Packad.--(extra... tone)..leach_-pit...(cverf]-Qw).-............................................
Agreement: ;
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT E 5 of the State Sanitary Code— The undersigned further agrees not t lace the system in
operation until a Certificate of Compliance has been issued by the b alth.
Signed- •-- •• • s.. ...9.4.4_4$9...........
Da e
ApplicationApproved By-- ---------------------•-.._....--•---------------•---..........----•----..................-- ............9./ 7aQ.----------
Date
Application Disapproved for the following reasons---------------------------------•-----------------------------•----------------•-------------------------....._
--------------•----...........-•-•------------------------...............-----------........_..---•------
Date
Permit No........ Q-.......................................... Issued.............. l.V/Q...-----.............._..
Date
U
No......B0-.. �P. Fes$....$... .00......_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.....................Town........_O F..............Barnstable......
for Disposal iVorks Tonotrurtion jinmit .
Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal
System at:
•8?.Main_St., ,Osterville,. NlA .026,55................
Location.Address or Lot No.
Arthur Schilling......................................................... $7.Main.St_•.,...Osteryille,--n.....02655.........----...
a A__& B Cesspool Service. 128 Bishops Terrace. Hyannis_,.._n....02601
Installer Address
Type of Building Size Lot----------------------------Sq. feet
U Dwelling—No. of Bedrooms--•----------------5------__--_ -__--Expansion Attic ( ) Garbage Grinder ( )
Other—Type e of Building No. of persons ..................... Showers — Cafeteria
a yP g ----------•--•••----------- P ( ) ( )
Q 1 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.
3 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........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
�+ -----------------------------------------------------------
---...
•-------•-----------------------------•-•-----• ----------------
ODescription of Soil----_---•-Sand...--------•-•-•...............•--•-------••------------------------------------••-----.........------------------------•-•--...--•--.....--------
x
W --••-------------------------•-----------••---------•---•----•-•---•----•-------•------...........------•--•----••----------------------------••---••---------•-----------------------------------------
UNature of Repairs or Alterations—Answer when applicable... (2,00Q)....
..(extra...st9ne)... ............................................
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 lipalth. ;
Signed .. lc ,�,� '` t° 91.-418Q----.......
ApplicationApproved By.................................................................................................. ............9111�0...........
Date
Application Disapproved for the following reasons---------------------------------------------------------------------------------------------•--------........_
--•--••-•---.....---•--------•-•---------------------------------------------------------- •-•----•--.....•---------------------.....-----•------------------------------------••----------------......_
*� Date
PermitNo........80-......................................... Issued_-------------9/4/80.....................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
r BOARD OF HEALTH ;,_• ._
.................l own............`.;O F..............Barnstab le.....................--------................
Trrfifiratr of Tontplianrr
TTHIS IS TO CERTIFY That I dividual S wa e Disposal System constru tta�d or I�.ep�t red (X)
A & B Cesspool Service, N8 Tishops e.=ace, Hyanhis, MA 02.11 - )775-OZb4•
by--------------------- - - --..-...v-••----•--------------------------------•-----------------••--••--•----••---•----------------•---•-•--•--•---.-.-----••-----•----------•------------
87 Main St., Osterville, MA 02655 ns kilr Schilling
at.....................................................................................................................................................................................................
has been installed in accordance with the provisions of TLE „j of TJie State Sanitary CQc�-0scribed in the
application for Disposal Works'Construction Permit No.............. .... .. ........._ dated_._..__y._/._....................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON RUE® AS UARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE. 9/ w/8o ,,. ,:.. ... •::'i Inspector ............................ ...... x
.. .......................... _ ,. r+^ Va.:
/ THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
y/40
Town '"". Barnstable
....................OF.--- .......................... 5.00 ` .
No.80. ... FEE........................
Disposal Works TDonotrudion rrntit
Permission is hereby granted--A__& B Cesspool Service----------•-•-------------•-----------------------------..............................
to Constr ct (( ) or Repair (X IndLv,.uaL S ge D's sal S s
7 )!Main St., bste4i e, MA OZ��j - ` urehlling
-----------•--•-------•----•-•-----••-•--------------•-----------••............
_ /as shown on the application for Disposal Works Construction P St __No.._,___ ._ ated.............9........... ...4/80............. /l
..........
9/ 4/$Q s Board of Health
-----------------
DATE............. ---------------------------------•---.......... ................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS -
_ Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments «
°M 87 Main Street w:
Property Address NZ
Pamela Foss
Owner Owner's Name --j
information is
required for every Osterville MA 02655 6-22-17 e,
page. City/Town State Zip Code Date of Inspection(0
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 rms A. General Information
on l the comng out oputer, I"OF
use only the tab 1. Inspector:
key to move your
cursor-do not JAMES v'
use the return James D.Sears
key.
Name of Inspector
,
Capewide Enterprises
IC—V Company Name � �7� . ..
.... . � •
153 Commercial Street
gpstiNSPG������
I� Company Address _
Mashpee MA 02649
City/Town State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
I certify that I 'have personally inspected the sewage disposal system at this address and that the
information reported below is true,accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further.Evaluation by,the Local Approving Authority
6-22-17
spector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
87 Main Street
Property Address
Pamela Foss
Owner Owner's Name
information is required for every Osterville MA 02655 6-22-17
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The system is a 2500 Gal. H-20 Tank D Box and two pits.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N. ❑ ND (Explain below):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
G Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 87 Main Street
Property Address
Pamela Foss
Owner Owner's Name
information is required for every Osterville MA o2655 6-22-17
page. Cityrrown State Zip Code Date of Inspection
B. Certification
❑ 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
M 87 Main Street
Property Address
Pamela Foss
Owner Owner's Name
information is required for every Osterville MA 02655 6-22-17
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems: .
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility.or system.component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
1-1 ® ' Liquid depth in is less than 6" below invert or available volume is less
than Y2 day flow PST.5
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 87 Main Street
Property Address
Pamela Foss
Owner Owner's Name
information is Osterville MA 02655 6-22-17
required for every
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 supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
0 ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure. . .
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection
❑ ❑ Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
u W Title 5 Official Inspection Form,
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 87 Main Street
Property Address
Pamela Foss
Owner Owner's Name
information is required for every Osterville MA 02655 6-22-17
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the'owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the,system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ , Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility'owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 9 Number of bedrooms (actual): 10
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 1100
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 87 Main Street
Property Address
Pamela Foss
Owner Owner's Name
information is Osterville MA 02655 6-22-17
required for every
page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
The system is a 2500 Gal.Tank D Box and two pits. H-20 units.
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 2015-120,000Ga
g ( Y g (gP )). 2016-122,000Gal's
Detail:
Sump pump? ❑ Yes ® No
Present
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft.,etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
u W Title 5 Official Inspection Form .
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 87 Main Street
Property Address
Pamela Foss
Owner Owner's Name
information is required for every Osterville MA 02655 6-22-17
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
Z. Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doc•rev.6/16 `Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
u W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 87 Main Street
Property Address
Pamela Foss
Owner Owner's Name
information is Osterville MA 02655 6-22-17
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1985 6-2019 New D Box.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 44"
feet
Material of construction:
❑ cast iron E 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH -40.
Septic Tank(locate on site plan):
Depth below grade: 34"feet
Material of;construction:
® concrete ❑ metal ❑ fiberglass F-1 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: 2500 Gal. Precast H-20
Sludge depth:
2"
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 87 Main Street
Property Address
Pamela Foss
Owner Owner's Name
information is required for every Osteryille MA 02655 6-22-17
page. Cityfrown 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 NA
Scum thickness
Distance from top of scum to top bf outlet tee or baffle NA
Distance from bottom of scum to'bottom of outlet tee or baffle NA
How were dimensions determined? Asbuilt- Plan -Tape
Sludge Judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at working level. Tank at 34" below grade w/inlet cover steel at grade in black top drive.
Inlet tee. Note: outlet cover under black top drive way. Need to raise cover to grade.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 87 Main Street
Property Address
Pamela Foss
Owner Owner's Name
information is Osterville MA 02655 6-22-17
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity, gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
87 Main Street
Property Address
Pamela Foss
Owner Owner's Name
information is required for every Osterville MA 02655 6-22-17.
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Box is H-20- 35" below grade in drive way w/two lines out. Box is New 6-2017.
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.):
3
* If pumps or alarms are.not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located; explain why:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments.
87 Main Street
Property Address
Pamela Foss
Owner Owner's Name
information is Osteryille MA 02655 6-22-1.7
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)-
Type: Ili
® leaching pits number: 2
leaching chambers number:
❑ _ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
overflow cesspool number:
El innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil;condition of
vegetation, etc.):
Leaching is two pit' s. Older pit at 40" below grade w/steel cover. Pit full. Newer pit at 39" below
grade w/steel cover at grade. 1'water in pit w/clean wall's. No sign of over loading.
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of'scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No -
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
87 Main Street
Property Address
Pamela Foss
Owner Owner's Name
information is required for every Osterville MA 02655 6-22-17
page. City(rown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level.of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 87 Main Street
Property Address
Pamela Foss
Owner Owner's Name
information is required for every Osterville MA 02655 6-22-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
A R®A/-
d
° y
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
87 Main Street
Property Address
Pamela Foss
Owner Owner's Name
information is required for every Osterville MA 02655 6-22-17
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑' Shallow wells
Estimated depth to high ground water: T.H. 12' - Lot 20'+
feet
Please indicate all methods used to determine the high groundwater elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
T.H. on Design plan 3-14-85 no G.W. at 12'+. Rear of lot Drops off to water 20'+.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 87 Main Street
Property Address
Pamela Foss
Owner Owner's Name
information is required for every Osterville MA 02655 6-22-17
page. Cityrrown State. Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
_ I
No. e " 1 '0 Fee
✓
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Application for Migagal *pgtem Con.5tructiou permit
Application for a Permit to Construct( ) Repair(K) Upgrade( ) Abandon( ) ❑ Complete System Individual Components
Location Address or Lot No. 81 HAW r 6ST a Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel + 5 ® G� MST w S T 05 TZ--P—VtC -
Installer's Name,Address,and Tel.No. 5O� Designer's Name,Address and Tel.No. �- .
CAPrW e,vl10 g 61k�ALSZ5
1 Cal S 1
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( )
Other Type of Building ( E5! a10'JI-iA, No.of Persons Showers( ) Cafeteria( )
Other Fixtures
ZL
Design Flow(min.required) gpd Design flow provided gpd
-Wt,—Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) Xtj5-4 1u A-)OO t4-1� + 7Lsc<
Stl3S' t� FI a•v It►S 'P7t Gc a�rrc£r
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of 1kalth.
Signed Date �p '^ odd t 7
Application Approved by Date 6—
Application Disapproved by: Date
for the following reasons
t'
Permit No. — Date Issued -lQ
L.
N _. - 1.o. (/ 1# ��F' �l;'.. .,��a t� ...� Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
.J1 ZIpprication for �Dtooal �&vwm Construction Permit
Application for a Permit to Construct O Repair(�) Upgrade( ) Abandon O ❑ Complete System Individual Components
Location Address or Lot No. 81 H A t o S 6ST, Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel tj 9'7 MA tall ST t9.ST�<CLC—
Installer's Name,Address,and Tel.No. 5O� 4 �$, Designer's Name,Address and Tel.No.
CAP�c�1�E' �JCa�'1.P/dt��S KJ �/
153 M t
Type of Building: F
Dwelling' No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( )
Other \Type of Building RE5.&—IPt?#J"r A4, No.of Persons Showers( ) Cafeteria( ).
Other Fixtures //
Design Flow(min.required) g'pd,,4Design flow provided /" gpd
Plan Date Number of sheets Revision Date
.'Title l
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) X tj5-"4_L_ tiQe...) {-{ lkl:S�
k1S§X 6 A-) S(;:_7Pb G
y'
Date last inspected:
-
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health. p
Signed / Date W 1 " ;t 0 l 77
�.�.1. .p lam_
Application Approved by Date
Application Disapproved by: Date - `
-----tee
for the following reasons
Permit No. ;lot — f Date Issued
` �D
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE MASSACHUSETTS
c Certificate of Compliance
r THIS IS TO CERTIFFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( �) Upgraded ( )
Abandoned( )by
at S-] R& 0 5[ 5`j 41([L, has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 1126 1,17 —/8 S dated
Installer (N ( Designer N _
#bedrooms Approved desygn-ffi0 AIR-- gpd
The issuance of this pe;tnit hall�not b,construed as a guarantee that the system wl//Il functi n as d s ned.
Date l/D 1 ! Inspector
_——
No. �,a �----.---.-------- -----� Fee 7 -5 ---
THE COMMONWEALTH OF MASSACHUSETTS t
PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS
Tigpo5al 6p5tem Con6truction Permit
Permission is hereby granted to Construct ( ) Repair (X ) Upgrade ( ) Abandon ( )
System located at N Al A) S'T bTZ=T- DSZOL IL,L,5
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title S and the followingilocal provisions or special conditions.
Provided: Construction must be completed within Aree years of the date of this pe�nit---"�
Date 4 n— 1 ( Approved by
Commonwealth of Massachusetts,
Title 5 official Inspect on dorm
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
87 Main street
Property Address
Pamela Foss
Owner Owner's'Neme
information is Osterville MA 02655 1'2/01/1'1'
required for every
page. Cityrrown State Zip Code• Date of Inspection,
Inspection results must be submitted on this form.Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the fonrr.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1 Inspector:
key to move your
cursor-do not Michael Kellett
use the return Name of Inspector
key.
Aardvark Environmental Inspections
Company Name
P.O.Box 896
Company Address
East:Dennis MA 02641
City/Town state Zip Code
508-385-7608 St 3742
s J Telephone Number license Number
_= B. Certification
C- s
tl;certify that-t'have personally inspected the sewage disposal system at this address and that the
c-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
Fes- csewage d'i`sposal systems. tam,a DEP approved system inspector pursuant to Section 15.340 of
Title 6(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the.Local Approving Authority
12/03111'
Inspecto sSignature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system 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 DER The original should be sentto the system owner
and copies sent to the buyer,if,applicable,and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system:will'perform in the future under
the same or different conditions of use..
t5ins•11/10 • Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form;
Subsurface Sewage.Disposal System Form-Not for Voluntary Assessments
\Vi�t'j
87 Main street
Property Address
Pamela Foss
Owner Owner's Hame ,
informati for every on is
required osterville MA 02655 12/01/11
-
page. cityrrown State Zip Code Date of Inspection
B. Certification (cone.)
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.
F _
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-11/10 Title 5 Official inspection Form:Subsurface.Sewage:Disposal System•Page 2 of 17
Commonwealth.of Massachusetts .
Title 5 Official Inspection Form
s, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
87 Main street:
Property Address
Pamela Foss
Owner Owner's Name
information is t
required for every Osterville MA 02655 12/01/11
page. Cityrrown state Zip.Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cunt.);
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will
pass inspection if(with approval of Board of'Health):
❑ broken pipe(s)are replaced''. ❑ Y ❑' N ❑' ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N. ❑ ND(Explain below):
El distribution box is leveled or,replaced ❑ Y ❑ Nf El 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 pipes)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::
El.-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(1xb)that the system is not functioning,,in a mannerwhich will protect public health,
safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspoolor privy is within 50 feetof a:bordering vegetated wetland or a salt marsh
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
r
Title 5 Official Inspection Form
Subsurface Sewage Disposal System.Form.-Not for Voluntary Assessments, '
87 Main street
Property Address
Pamela.Foss
Owner Owner's{dame
information is required for every Osterville 'MA 02655 12/01/11
page, Citylfown State Zip Code Date of Inspection
B. Certification (cunt.)
2. System will fail unless the Board of Health(and Public Water Supplier,if any)
determines that the system is functioning lin a manner that protects the public health,
safety and environment`
❑ ' The system has.aseptic tank and,soil absorption;system(SAS)and�the.SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS.and'the.SAS is.within 50:feet of a private water
supply well.
El 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 we l 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:
li to All Systems::
D System Failure Criteria Applicable able y
Y PP
You must indicate"Yes".or"No"to each of tlhe following for all inspections:
Yes No
❑ ® Backup of sewage into:facility or system component due:to,overloaded or ,
clogged SAS or cesspool
® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded,or clogged SAS or cesspool
El ® Static liquid:level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ Liquid depth in cesspool is less than 6"below invert or available volume is less
than%day flow,
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
s
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s, Subsurface.Sewage Disposal.System Form. Not for Voluntary Assessments, <
87 Main street
Property Address
Pamela Foss
Owner Owner's Name
information is Osterville MA 02655 12/01/11
required for every
page. City/rown state- Zip Code Date of inspection
B. Certification (cont.)
Yes No
El Z . Required pumping more than 4 slimes in:the last year NOT due to clogged or
obstructed pipe(s)..Number of times pumped;:
❑ ® Any portion of the SAS,cesspool or privy is below high ground'water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface.water supply.
❑ ® Any portion of a cesspool or privy,is within a Zone 1 of a,public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a.cesspool or privy is less than 1001 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 otherfailure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
El IQ 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 erast 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 Il of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered`yes"in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the.
system in accordance with 310 CMR 15.304.The system owner should;contact the appropriate
regional office of the Department.
t5ins•11/10 Tf le 5 Official Inspection Pone:Subsurface Sewage Disposal System•Page 5 of 17
J
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
87 Main street.
Property Address
Pamela Foss
Owner Owner's Name
information is Osterville _ MA. 02655 12/04/11
required for every
page_ Cityrrown state Zip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate"yes"`or"no"as to each of the following:
Yes . No
® ❑ Pumping,information was provided:by the owner,occupant,or Board of Health
❑ ® Were any of the system components pumped out in the;previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
®- ❑ -Were as built plans of the system obtained and examined?(If they y 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 aK 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?
® 0 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 ow,
® ❑ Existing;information. For example,a plan at:the Board of Health.
^❑ Determined in the field (f any of the failure criteria related to Part C is at issue
approximation of distance isunacceptable)[310:CMR 1,5.3O2(5)J
D. System Information
Residential Flow Conditions:,
Number of bedrooms(design): 10 Number of bedrooms{actual): 10
DESIGN flow based on 310 CMR 15.203 (for example:110 gpd,x#of bedrooms): 1714
t5ins•11/10 Title 5 Offcial Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Titre 5 Official Inspection Forest
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
87 Main street
Property Address
Pamela Foss
Owner Owner's Name
information is required for every Osterville MA 02655 112/01/11
page. Cityrrown State Zip Code Date of`1'nspettion
D. System 'Information
Description:
y 3
Number of current residents:
Does residence have a garbage grinder? ® Yes ❑ No
Is laundry on a separate sewage system?. [if yes separate inspection requiredi, ❑ Yes ® No
Laundry system inspected? ' . ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings,if available(last2'years usage.(gpd)):,
Detail"
Sump pump? ❑ Yes ® No,
Last date of occupancy: - current
Date
Commerciallindustrial'Flow Conditions:
Type of Establishment:,
Design flow(based on 310 CMR 1'5203):, a Gallons perday(gpd)
Basis of design flow(seats/persons/sq.ft..,etc):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? El Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings,if available:
mns•11/10 TXe 5 Ofrcial lnsperlion Fomr:.Subsurtace Sewage Dlspmr System Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection For
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments.-
87 Main street
Property Address t
Pamela Foss
Owner Owner's Name
information is required for every Ostefville MA 02655 12/01/11
i
page. CitylTown State Zip Code Date-of Inspection
D. System Information (coat:)
Last date of occupancy/use: Date
Other(describe below): ^
t
General Information
Pumping Records:
Source of information:
Was system pumped as part of,the inspection? El Yes ® No
If yes,volume pumped:
gallons
How was quantity pumped determined?,
Reason for pumping:
Type of System:
® Septic tank,distribution box,soil absorption system
El Single cesspool
❑ Overflow cesspool
Privy
❑ Shared system(yes or no) (f yes,attach previous inspection records,if any)
❑ Innovative/Alternative technology:.Attach a.copy of thel current operation and
maintenance contract(to be obtainedl 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Dtsposat System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposall System Form Not:for Voluntary Assessments
y� 87 Main street
Property Address
Pamela Foss
Owner Owner's Name
information is Osterville MA 02655 12/01/11
required for every
page. City/Town state Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components,date installed(if known)and source of information:
08/15/85 per BOH
Were sewage odors detected when arriving atthe site? Yes No
Building Sewer(locate on site plan):.
Depth below grade: f 7
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,evidencer of leakage,.etc.):::
Septic Tank(locate on site plan)
2.8
Depth below grade: . feet,
Material of construction:
®concrete ❑metal ❑ fiberglass ' E polyethylene ❑other(explain)
If tank is metal,list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) 0 Yes ❑ No
Dimensions: 2500 gal
r a 8"
Sludge depth:
t51ns•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of.Massachusetts
Title 5 Official Inspection Form:
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
87 Main street
Property Address
Pamela Foss
Owner Owner's Name
information is required for every Cistefville MA 02655 12/01./11
page. City/Town State 'Zip Code Date of Inspection
D. System Information (cunt.)
Septic Tank(cunt.)
Distance from top of sludge to bottom of outlet tee or baffle:
27"
10"
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: 15"
How were dimensions determined? measured
Comments(on pumping recommendations,inlet and,outlet tee or baffle condition,structural integrity,
liquid levels as related to outletinvert,evidence of leakage;,etc.)::
The tank was sound and tight with tees in place and liquid at outlet invert.The tank needs to be
pumped and should be pumped on a regular basis.The outlet endwas paved over and checked with
a mirror.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete El metal []fiberglass 0,polyethylene ❑ other(explain):
Dimensions:
Scum thickness
p .
Distance from top of scum to top of outlet tee or baffl e
Distance.from bottom of scum to bottom of outlet.tee or baffle
Date of last pumping': Date
t5ins 11/10 Title 5 Official Inspecdon Form:Subsufface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Tide 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
87 Main street
Property Address.
Pamela Foss
Owner Owner's Name
information is required for every OstenAlle MA `02655 12/01/11
page. City/Town State Zip Code Date of inspection
D. System Information (cone..) y
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 attime of inspection)(Iocate on:site plan):
Depth below grade:
Material.of construction: ti
S
❑concrete ❑metal' ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions: -
Capacity:
gallons
Design Flow:' q gallons per.day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm inworking;orden ❑ Yes ❑ No
Date of last pumping: Date
Comments.(condition of alarm and floatswitches,etc.): '
{
"Attach copy of current pumpingr contract(required). Is copy attached. ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspectlon Form:Subsurface Sewage Disposal System•Page 11 of 17
r
Commonwealth of Massachusetts
Title 5 official Inspection form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
87 Main street
Property Address
Pamela Foss
Owner Owner's Name
information is required for every Osterville MA 02655 12/01/171''
page. City(rown state Zip Code • Date of Inspection
D. System information ,(cunt.)
Distribution Box(f present must be opened)(locate on site plan):
Depth of liquid level above outlet invert
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 box was below the paved drive.
Pump Chamber(locate on site plan):.
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of;pump chamber,condition of pumps,and appurtenances,etc.):
Soil Absorption System(SAS) (locate on site,plan;excavation not required):
If SAS not located,explain why:
t5ins•11/10 Title 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'
,.�'• 87 Main street
Property Address
Pamela.Foss
Owner Owner's Flame
information is required for every Osterville MA 02655 12/01/11
page. City/town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits • number:: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number,length,:,.
❑ leaching fields number,dimensions:
❑ overflow cesspool number.:
, v
❑ innovative/alternative system
Type/name of technology:
Comments(note condfion of soil,signs of hydraulic failure,,levetof ponding,damp soil,condition of
vegetation,etc.):
This system has a 8'x6'precast;pit surrounded by 4'of stone.The pit had 26"of liquid with light
staining just above.
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 groundwatevinflow ❑ Yes ❑ No
i5ins-i 1/10 ides Officiai inspection Form:Subsurface Sewage Disposai System•Page is"of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection form,
Subsurface Sewage Disposal System Forrn Not for VoluntarjAssessments
87 Main street
Property Address
Pamela Foss
Owner Owner's Pdame
information is required for every Osterville MA 02655 12/Ol111
-
page, CityrTown State Zip Code Date of inspection
D. System Information (cost.)
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
y
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.):
t5ins-11/10 Title 5 Official Inspection Forth:Subsurface Sewage:Disposal System•Page 14 of 17
CommonweaM of Mamachuseft
Title 5 Official Inspection Form
Subsudace Sewage Disposal System Form-Not for Voluntary.Assessments
87 Main street
Property Address
Pamela FOSS
Owner Owners Name
Wormation is Osterville MA 02655 12101111
required for every Sfatie *Code Data of Inspection
Page-
an
®. System Information (coat.)
Sketch Of Sewage Disposal Systetn:Provide a view of the sewage disposal system;including ties to
at least two permanent reference landmarks or benchmarks.Locate-aU wells within t 00 feet.Locate
where public water supply enters the Wilding.Check one of the boxes below.
® }sand-sketch in the area below
❑ drawing attached separately
3�
lb
qa O
Tate 5 Oftiar Fmm:subswftwe SawaVD cyst—•Page 15 or 17
funs•11M0
Commonwealth of Massachusetts
Tine 5 Official Inspection Form,
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
87 Main street
Property Address
Pamela Foss
Owner Owrm's Name
information is Osterville MA '02655 12/01/11
required for every
page, Citylrown State Zip Code Date of Inspection
D. System Information,(cont.)
Site Exam:
® Check Slope
❑ Surface water .
® Check cellar
❑ Shallow wells
Estimated depth to high ground water:y 20.0
feet
Please indicate all methods used to determine the high groundwater 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)
f
❑ Checked with`local Board,-of'Heaft hi -explain:
❑ Checked with local excavators,installers (attach documentation)
® Accessed USES database explain::
You must describe how you established the high groundwater elevation:.
USGS maps show an elevation of over 20.0 feet..
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5ins•11l10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
87 Main street
Property Address
Pamela Foss
Owner Owner's Name.
information is required for every Osterville MA 02655 12Y01/11'
page. Cityrrown state Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection.Summary:A„B,C,D,or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information Estimated depth to high.groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11/10 Title 5 Official Inspection Form_Subsurface Sewagebisposal System•Page 17 of 17
COMMONWEALTH OF MASSACHUSETTS ,
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: . 87 Main Street
Osterville:MA 02655 cl
Owner's Name.:. Warren Foss
�7 d
Owner's Address:
Date of Inspection: -May 23, 2007
Name,of Inspector: (Please Print) James M. Ford
Company Name: James M.Ford
Mailing Address: P.O.Box 49
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.basedW my_
training and experience in the proper,function and maintenance of on site sewage disposal systems. I am` EP
approved system inspector pursuant to Section 15.340 of Title,5(310 CMR 15.000). The system: c_
t c- w gyp,
✓ Passes i00
Conditionally Passes U-4 '
e ds Further Evaluation by the Local Approving hority. -i
u7
• it - _ �• -�'
>v 7�
p
Si nature: Date: M 30 200
o
-Inspector's
. g.
The system inspector shall\subco of this.ins ection re ort.to the A rovin Authori Boar of Health or
Y PPY p p Approving n'
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: 87 Main Street
Osterville, MA
Owner: Warren Foss
Date of Inspection: May 23. 2007
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.
IVD 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 e NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 87 Main Street
Osterville, MA
Owner: Warren Foss
Date of Inspection: May 23, 200'
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 11
OFFICIAL INSPECTION FORM-NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 87 Main Street
Osterville, MA
Owner: Warren Foss
Date of Inspection: May 23, 2007
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 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 thatthe 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 h of apublic 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
j ^
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 87 Main Street
_ Osterville. MA
Owner: _Warren Foss
Date of Inspection: May 23, 2007
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: 87 Main Street
Osterville, MA
Owner: Warren Foss
Date of Inspection: May 23, 2007
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms.(design): 10 Number of bedrooms(actual): 10
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 1714 Qnd
Number of current residents: Unknown
Does residence have a garbage grinder(yes or no): nla
Is.laundry on a separate sewage system(yes.or no):, n/a [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
COMMERCIALANDUSTRIAL
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: Unavailable
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:`
Date of installation unknown
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: 87 Main Street
Osterville, MA
Owner: Warren Foss
Date of Inspection: May 23, 2007
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.grader
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: 2500 gal: (H--20)
Sludge depth: --
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: 8"
Distance from top of scum to top of outlet tee or baffle-
Distance from bottom of scum to bottom of outlet tee or baffle:
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.).
The inlet cover was to grade. _There did not appear to be any si ns 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 1.1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 87 Main Street
Osterville, MA
Owner: Warren Foss
Date of Inspection: May 23, 2007
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 invert: --
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 under asphalt and could not be inspected
PUMP CHAMBER: . None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working orderr-(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 87 Main'Street
Osterville MA
Owner: Warren Foss .
Date of Inspection: May 23, 2007
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located.explain why:
Type
✓ leaching pits,number: 1 6'x 8'(1000.eal.)wl4'stone• 1-6'x 6'(1000_aal)wl4'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 older pit was full up to the inlet nine The newer nit had 2'of water on the bottom. There did not appear to be any signs of
failure. Steel covers were to Qrade. There was a cesspool off the older nit which was filled with concrete and sand
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
r
•
' Page.10 of i 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 87 Main Street
Osterville, MA
Owner: Warren Foss
Date of Inspection: Ma
v 23, 2007
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.
O -
/`
y
3 �a 3y
1.0 j
it
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
- SYSTEM INFORMATION(continued)
Property Address: 87Main Street
Osterville. MA
Owner: Warren Foss
Date of Inspection: May 23, 2007
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 20+/- feet
Please indicate(check)all methods used to determine the high groundwater elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet.of SAS)
✓ Checked with local.-Board of Health-explain: topoaphic and water contours naps
Checked with local excavators,installers-(attach documentation)
Accessed USES database-explain: : . .
You must describe how you established the high ground water elevation:
Using Barnstable topographic and water contours maps, the inaps were showing approximately 20'+/-to ground water at this
site.
This report has been prepared only for the septic system and components.described herein. This septic system has been
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 fixture. There have been no warranties or guarantees, either expressed, written or implied,
relating to the septic system, the inspection, this report andlor any components of the septic system which have.not
been located and inspected.
11
f
No................ ... Fss/..�.O°._....._
THE COMMONWEALTH OF MASSACHUSETTS
BOAR OF -HEALTH
OCSL�/ ................OF.........Q..... .g..l..°1..�.. ...........................................
Appliratiun for Uiipu,aal Works Cnunitrurtitun ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( Individual Sewage Disposal
System at: ,�
....:. _..... ��.!.�S..I................................................ ...... .....................................................
ocafon A'rVZ ss� o. Lot No.
Oler ........................................ . .................- ......... _Address---........................................
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms................................ _Expansion Attic ( ) Garbage Grinder ( )
pa, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
fl,
� Other fixtures -----•--------•-• .....................................................................................................................................
W
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
fx Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
W 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 ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ t
O .......................................................Description of Soil ... ---- - - -- ,
W •----------------•••-----•----------------------•--------•-------------•-------•---•••-------------------•-- -- ..... ........•
x Nature of Repairs or Alterations—Answer when a licable...__ .._5.___ _ ._.__ _t�_5s.a�s.__
U .-•------------ .......ca.�PP.. ........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of AITLE 5 of the State Sanitary Code The undersigned further agrees not to place the system in
issued boars n am health
operation until a Certificate of Compliace has been i .
.,
Signed.... %•-•-- ..... _ . ..............
Date
Application Application Approved By-- -- --ra ......................................................
Date
Application Disapproved for the following reasons:..............................................................................................................
........-•-------------------------------•-------------------...---......-----------------.......-----...._..................-----------------------------------•---------•----•-------------•-----•-----
Date
PermitNo....----.�- ............Z/ '51-------------- Issued........................................................
Date
FmijNo.......................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR OF HEALTH
--------------- _.........
oWde) .......OF.................
likation for Disposal Murky Tonstrudion ramit
Application,14 hereby made for a Permit to Construct or Repair Individual Sewage Disposal
System at:
4_12..!�.Sl............................................. ......
....................................................
—tipn-Adoress or Lot No.
......... ...CIIIVL62..�t.............................. . ..... -----------------
-----•...................*",-"*-----------------
Owners ,j ms
Addr
Installer Address
Type of Building Size Lot............................Sq. feet
U
Dwelling—No. of Bedrooms............................................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.
1:4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No..................... Width..............._._.. Total Length............._...._. Total leaching area ...................sq. ft.
Seepage Pit No............:........ Diameter.................... Depth below inlet......_............. Total leachirig area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
)-4
9X4 Test Pit No. 2................minutes per inch Depth of Test Pit............_.__._.. Depth to ground water............_...........
0 Description of Soil....._..::.............................................................................................................................................................
U ....................................................................................................................................................................................
.............................................................................................................. -- ------------- ------------- -- ------ ..............
U Nature of Repairs or Alterations,—Answer when applicable
T ....
........S ._.--------------------OL±2...... ......... ------ ...........
Agreement: C?
The undersigned agrees to install the aforedescribed Individual Sewage Disposal Systemin accordance with
the provisions of T I TIS 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been is;VeVdoard�health" .
/-� '_. ............. A101.Signed.......0 .2..... ....... ........
Application Approved- By---..--- . ............................... - --------
Date
Application Disapproved for the following reasons:.....................................I............I
-------------------------------------------
..................................................................................................................................................................................*......
Permit No..... .. ........... 41 Issued............................................Date. .....
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...............OF........ .....................................
(Infifirab of Toutpliaurr
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed or Repaired
by........... ...........................................................................;.........................................
nat.1ler
t
. .....................0...S. L
at........ ........ L-tl------- ........................ .......*......*------**----------
has been instilled in accordance with the provisions of TITLE 5 of The State Sanitary Coe as described in the
application for Disposal Works Construction Permit No....153�.4-A.... dated---..- ':. -� .1 ! .�T....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE C STRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
,DATE................. ............................. �`Inspector........ ....................b.
-----------------&I....................
j
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
424Mce° .A......................OF....... kh...............................
0 0
No.a. Fn...... .........
rks TottstrWiott Pprutit
Permission is hereby granted... : .:i. ..F ....� -.64 r
...........................................................................
to Construct or Repair ( 4Y"an Individol Sewage Dis osAl' Szy§,tem
........ ;7.......... _�57L............0.4 .....................................................
at No.... 7t..Street.1 .................
as shown on the application for Disposal Works Construction Permit No.. a:=Wdat ed...
--- ........
................. ..............
..................... ...Board of Health
DATE...--- 1.�...�. ...........................
FORM 1255 A. M. SULKIN, INC., BOSTON
---------------
to Q SENDER: Complete items 1,2,3 and 4.,
T
o Put your address in the"RETURN TO"space on the ;
3 reverse side. Failure t"do this will prevent this card from'
being returned ta.-you.The return receipt fee will provid00
T you the name of the person delivered to and the date of
delivery:;For additional fees the following services are:
c available. Consult postmaster fo.r fees and check box(es)
for service(s) requested. ,
1.XKb{Show to whom,date and address of delivery.
W
2: ❑:Restricted Delivery. ~_. .
3. Article Addressed to:
Mr. Arthur Schilling .
87 Main St.
OSTERVILLE MA 02655
4. Type of Service: Article Number
❑ Registered ❑ Insured
?F'11 Certified ❑ COD P 522 444 254
LLJJ Express Mail
Always obtain signature of addressee or agent and
DATE DELIVERED.
17 5. ignatur —Ad r see
� X �
W6. Sig ure— Agent
41
.X
.4 7, Date/of of ,
m
2 S. A d. see's Address(ONLY if requested and fee,par
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-
UNITED STATES POSTAL SERVICE
OFRCIAL BUSINESS
SENDER INSTRUCTIONS �•
Print your name,address,and ZIP Code in the u
space below.
• Complete items 1.Z 3;and 4 on the reverse.
• Attach to front of article if space permits, PENALTY FOR PRIVATE
otharwke aft to back of article. USE,M
• Endorse article"Return Receipt Requested"
adjacent to number.
-RETURN
TO BOARD OF HEALTH - TOWN OF BARNSTABLE,
i (Name of Sender) j
P. O. Box 534
I (No.and Street,Apt.,Suite,P.O.Box or R.D.No.) -i
ity, rate,and P Code)
P 522 444 254
RECEIPT FOR CERTIJFIED MAIL
NO INSURANCE-COVERAGE PROVIDED
NOT FOR INTERNATIONAL MAIL
(See Reverse)
A Sent to.
Mr. 'Arthur Schillin _
Street and No.
1
w
P.O.,State and ZIP Code
O
d
c7 Postage $
vi
Certified Fee.
Special Delivery"Fee
Restricted Delivery Fee
Return Receipt Showing
to whom and Date Delivered
a-o Return receipt showing to whom,
w Date,and Address of Delivery
r
TOTAL Postage and Fees $ 1.65
U.
g Postmark or Date
chi
E Mailed 3/l/85
0
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cn
a
STICK POSTAGE STAMPS TO ARTICLE TO COVER FIRST CLASS POSTAGE,
CERTIFIED MAIL FEE,AND CHARGES FOR ANY SELECTED OPTIONAL SERVICES.(see front)
1. If you want this receipt postmarked,stick the gummed stub on the left portion of the address side of the article 1
leavino.the receipt attached and present the article at a post office service window or hand it to your rural carrier.
(no extra charge)
2. Ibyou do not want this receipt postmarked,stick the gummed stub on the left portion of the address side of the I!
art.cle,date,detach and retain the receipt,and mail the article.
3. If you want a return receipt,write the certified mail number and your name and address on a return receipt card,
Form 3811,and attach it to the front of the article by means of the gummed ends it space permits.Otherwise,affix
to back of article. Endorse front of artile RETURN RECEIPT REQUESTED adjacent to the number.
4. If you want delivery restricted to the addressee, or to an authorized agent of the addressee, endorse
RESTRICTED DELIVERY on the front of the article.
5. Enter tees for the services requested in the appropriate spaces on the front of this receipt.If return receipt is re-
quested,check the applicable blocks in item 1 of Form 3811.
r
6. Save this receipt and present it if you make inquiry.
s
Bfff ER & NYE, INC.
Registered Land Surveyors and Civil Engineers.
7 Parker Road/Osterville,Massachusetts 02655/Tel. (617)428-9131
WILLIAM C.NYE,R.L.S.-President
RICHARD A.BAXTER,RL.S.-Vice President PETER SULLIVAN,P.E.-Vice President-Engineering
March 4, 1985
. f
Mr . Arthur Schilling
87 Main Street
Osterville, MA 02655
Dear Arthur :
This letter shall document our meeting of March 1,
1985 . Baxter & Nye shall provide the required design
services to upgrade the existing septic system at 87
Main Street. . The new system will be designed to accomo-
date .10 bedrooms and a garbage grinder . After reviewing
the available information on the existing system, I
will informally discuss with the Board of Health a proposed
design solution.
I trust that this meets your present needs.
Very truly yours,
f�� 4
Peter Sullivan, P .E.
PS/fmj
CC: Mr . John M. Kelly
Director. of Public Health
MEMBERS OF
CAPE COD SOCIETY OF PROFESSIONAL ENGINEERS AND LAND SURVEYORS I AMERICAN CONGRESS ON SURVEYWG AND MAPPING
MASSACHUSETTS ASSOCIATION OF LAND SURVEYORS AND CIVIL ENGINEERS
r +
March 1, 1985
Mr. Arthur Schilling
87 Bain Street
Osterville, Ma. 02655
NOTICE TO UPGRADE YOUR ON-SITE AGE D1SP SYSTEM
The Department of Public Works h s otified that your on to sewage
disposal system required pumpi n Septemb 10, 18, 20, and 21, 1984,
and again on January 4, 23, an bruary 20, 5.
You are directed to obtain the se v es o a licensed disposal works in-
staller to upgrade your - to se a system within fifteen (15) days
of receipt of this n on y Regulation 15.02 (19) of 310
CMR 15.00, Minim Requirem for Subsurface Disposal of Sani-
tary Sewage.
You may request hearing before Board of Health if written petition
requesting same i eceived withi even (7) days of receipt of this no-
tice.
NoD
d re n a fine of up to $500. Each separate days
fa complyh an order shall constitute a separate violation.
P BOARD OF HEALTH 1
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JohDirealth
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Noveml,er 29, 1984
Mr. Arthur Schilling
87 Main Street
Osterville, Ma. 02655
Dear Mr. Schilling:
The Department of Public Works has notified us that your on-site sewage
disposal system may be inadequate. Their records indicate that your
system was pumped September 10, 18, 20, and 21, 1984.
We strongly recommend that you obtain the services of a licensed disposal
works installer to evaluate "and upgrade your system.
We request your voluntary compliance; however, if this is not forthcoming,
we will require you to upgrade your system in accordance with State and
local regulations.
Enclosed is a pamphlet explaining the importance of maintaining your
on-site sewage disposal system.
'lease call 775-1120, extension 157, if you have any questions.
Very truly yours,
John M. Kelly
Director of Public Health
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