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HomeMy WebLinkAbout0360 MAIN STREET (OST.) - Health 360 MAIN STREET Qsterville A = 165 — 028 W • 41jl*'�,, 41 e. u ° n " n a _ f. ° :u " o ° r � u � ., m ..a :i ., ° , � �°a ., .. ,. " " � • .� ° a a a ° " a " � n { i yN � a ° " - ° m ° ° " 9 " - n ° ° •c 4 e a a ° ° V ° a ° d. .° ° e ° ° { ° 7 Commonwealth of Massachusetts / Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 360 Main St. Property Address Morin �4= Owner Owner's Name information is required for every Ostervllle ✓ MA 02655 5/23/19 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any )z way. Please see completeness checklist at the end of the form. A. Inspector Information r - Frank Nunes III �.S' l z) Q 13 Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 Cityrrown State Zip Code 508.272.6433 13010 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 16.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails t 5/23/19 lnspectokOjgnatu Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer,if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. ).l t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 c Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 360 Main St. Property Address Morin Owner Owners Name information is required for every Osterville MA 02655 5/23/19 page. CitylTown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicE1ed below. Comments: 2) System Conditionally Passes: ❑ One cr more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic.tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance 'indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts (o Title 5 Official Inspection Form I' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 360 Main St. Property Address Morin Owner ion is Owner's Name informrequired for every Osterville MA 02655 5/23/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ .ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board.of Health): - ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which`require further evaluation by the Board of Health in order to determine if. the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc°rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts (o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 360 Main St. Property Address Morin Owner Owners Name information is required for every Osterville MA 02655 5/23/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ - Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 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 supp y well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) . System Failure Criteria Applicable to All Systems: t You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Foam:Subsurface Sewage Disposal System•Page 4 of 18 I�_ Commonwealth of Massachusetts ►9 Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 360 Main St. Property Address Morin Owner Owner's Name information is required for every Osterville MA 02655 5/23/19 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/Z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ = ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] 0 ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ _ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA, Yes No t ❑ ` ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ' El the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts ►ip Title 5 Official Inspection Form 1' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 360 Main St. Property Address Morin . Owner Owner's Name information is required for every Osterville MA 62655 5/23/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should ccntact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system.received normal flows in the previous two week period? ` ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ' ❑ Was.the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. for example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts r: Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 360 Main St. Property Address Morin Owner Owner's Name information is required for every Osterville MA 02655 5/23/19 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): . 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): ; Detail: F Sump pump? ❑ Yes ® No .. Last date of occupancy: occupied Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ( Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 360 Main St. Property Address Morin Owner Owners Name information is required for every Osterville MA 02655 5/23/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: No recent pumping per owner Was system pumped as part of the inspection? ❑ Yes E No If yes, volume pumped: gallons r How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 _- Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts (P Title 5 Official Inspection Form I' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 360 Main St. Property Address Morin Owner Owner's Name information is required for every Osterville MA 02655 5/23/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP.approval. ' ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 11/29/12 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): 26 . Depth below grade: feet 1 Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance.from private water supply well or suction line: feet feet . , Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form l' Subsurface Sewage Disposal System Form :Not for Voluntary Assessments 360 Main St. Property Address Morin Owner Owners Name information is required for every Osterville MA 02655 5/23/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) . 6. Septic Tank(locate on site plan): 2' ' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) Tank appears to be structurally sound, covers raised to 12"of grade If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500g Sludge depth: 2" 11 Distance from top of sludge to bottom of outlet tee or baffle ?12 6" Scum thickness >21, Distance from top of scum to top of outlet tee or baffle >2,' Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping suggested every 3yrs to prolong the life of the system t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 f Commonwealth of Massachusetts 19 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 360 Main St. Property Address Morin Owner Owner's Name information is required for every Osterville MA 02655 5/23/19 page. Cityrrown State Zip Code Date of Inspection - D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: . ❑ concrete - ❑ metal ❑fiberglass ❑ polyethylene ❑ other,(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee.or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 71 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade:, , Material of construction. ❑ concrete ' ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): r r Dimensions: Capacity: gallons Design Flow: . gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form � I° Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 360 Main St. Property Address Morin Owner Owner's Name information is required for every Osterville MA 02655 5/23/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 011 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box is 3' below grade, cover raised to 12", no adverse conditions,.use caution irrigation line is directly over the cover E t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 360 Main St. Property Address Morin Owner Owner's Name information is required for every Osterville MA 02655 5/23/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. l 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 1 Type: El leaching pits number: ❑ leaching chambers number: 3 ❑; leaching galleries number: leaching trenches number, length: leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts (o Title 5 Official Inspection Form - I° Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 360 Main St. Property Address Morin . Owner Owner's Name information is <' • required for every Osteryille MA 02655 5/23/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System(SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of, vegetation etc.): Chambers were video inspected, effluent is approximately 18" below the invert, no indication of past hydraulic failure " 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site.plan): Number and configuration � Depth—top of liquid to inlet invert Depth of solids layer Depth of s.wm layer Dimensiors of cesspool Materials of construction Indication,of groundwater..inflow " tr ❑<Yes ❑ Nof Comments (note condition of soil,,signs ofhydraulic failure,-level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 j1 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts (o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 360 Main St. Property Address Morin Owner Owner's Name information is required for every Osterville MA 02655 5/23/19 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 360 Main St. Property Address Morin Owner Owner s Name information is required for every Osterville MA 02655 5/23/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately r . v . a . t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 16 o I TOW"N--Q STABLE LOCATION 3 6 a. p' SEWAGE# a%^-A-5 � VILLAGE R'S MAP&PARCEL rn j4 - INSTALLER'S NAME&PHO :� SEPTIC TANK CAPACITY SY7D LEACHINGFACH=-.(type) SE1J l 5 (size) NO.OF BEDROOMS . t OWNER PERMIT DATE: kz4v-lz= COMPLIANCE DATE: I//�qh. Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching FacilityFeet Pdvate Water Supply Well and Leaching Facility(If any wells exist on -site or within 200 fret of leaching facility) AX_Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) T_ -_--Feet FURNISBM BY Tic lay; /41 :1 A3 311 3n�: a� , r: i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 360 Main St. Property Address Morin Owner Owners Name information is required for every Osterville MA 02655 5/23/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimateddepth to high ground water. >132" feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 2012 NGW 132 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: 4' seperation per 2012 compliance ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping, the site is 47'msl and nearby surface water is at 4'msl You must describe how you established the high ground water elevation: See above Before filing this(Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 - T, Commonwealth of Massachusetts ,F Title 5 Official Inspection Form I 11. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 360 Main St. Property Address Morin Owner Owners Name information is required for every Osterville MA 02655 5/23/19 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked Z C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist).completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on,pg. 16 or attached For 15: Explanation-of estimated depth to high groundwater included i t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 C� rbml l TOWN OFa;B . ..:STABLE � .y 4 r LOCATION �`6D Gij/ � � +� SEWAGE# a% a`S VILLAGE 05'N-Vt LNL L , SSOR'S MAP&PARCEL INSTALLER'S NAME&PHONES tO;, .�)l�h• "'2�tC��l U b'i W�' 3- Yd) SEPTIC TANK CAPACITY S LEACHING FACILITY: (type) " S C 5 (size) / NO.OF BEDROOMS OWNER } 1 PERMIT DATE: / COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 0 Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY A `for% /41 : A3 �/ z 3-3 �J . .�f ��� 9 3P GIle x tt { Mi No. Zo �� r Fee /J � .- THE COMMONWEALTH OF MASSACHUSETTS ' Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftpliCatlon for misposal 6pstem Construction Permit Application for a Permit to Construct( 4-"'Repair( ) Upgrade( ) Abandon( ) Complete System ❑Individuat Components Location Address or Lot No. o M�>� 1 t / Owner's Name,Address,and Tel.No. Ub=3s"3 7G Assessor's Map/Parcel A4 ? + Zi! r Ine�s""talller's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. P Type of Building: e Dwelling No.of Bedrooms q Lot Size �L�© sq.ft. Garbage Grinder( ) Other Type of Building<1-�6L4_ „ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) !4q() gpd Design flow provided 55 gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank 15o0 6,4►. Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 he system in operation until a Certificate of Compliance has been issued by this Board of H alth. Signed ' DateZ d0 Application Approved by Date Application Disapprove y Date for the following reasons Permit No. 20 1 Z 75 2 Date Issued g t y M q { No. 70 (Z `��� .^. 8 ` r f,"+t`, Fee x' THE COMMONWEALTH OF MASSACHUSETTS ,_" Entered in computer: i - :a ". Yes PUBLIC HEALTH DIVISIAN'"`TOWN OF BARNSTABLE, MASSACHUSETTS * r �. application fOr DIsposaY _�pstem Construction Permit Application for a Permit to Construct( Repair( ) Upgrade( ) Abandon( ) Vmplete,System ❑Individual Components Location Address or Lot No.,�� M�� I '1 Owner's Name,Address,and Tel.No. ljp -3Sr 7G Assessor's Map/Parcel.XA/p 7 ��k' IndIs""talller's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. vv hJl✓ ' -ZGJ ��ll ''�Srx 17o Type of Building: 1 . Dwelling No.of Bedrooms 'Lot Size sq.ft. Garbage Grinder( ) 4 Other Type of Building<, �, ,� No.of Persons Showers( ) Cafeteria( ) 1, } Other Fixtures Design Flow(min.required) INC) gpd Design flow provided 5 gpd„mow Plan Date Number of sheets Revision Date Title Size of Septic Tank / 5 00 K"4, Type of S.A& Description of Soil i Nature of Repairs or Alterations(Answer when applicable) API I f �$ Date last inspected: Agreement: r 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 the system in operation until a Certificate of Compliance has been issu4bythis Board of H alth.d Date p d Application Approved by 2 Date Application Disapprovemy Date for the following reasons Permit No. 70 1 Z — Z7 2 Date Issued -012 --------=--------------------------- _ _ = _ - --=---------------------- -_------------- k` THE COMMONWEALTH OF MASSACHUSETTS s BARNSTABLE,MASSACHUSETTS +. z Certificate of Compliance THIS IS TO CERTIFY,^that the On-site Sewage Disposal system Constructed( ✓� Repaired( ) Upgraded Abandoned( )by k/ (L_� Z'. {.Vl 4 L at '� �n o �0 tir � i� / f 4 d (, has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit NoZ012-Z52 dated 8 tl 20 1 2 Installer Designer #bedrooms Approved design flow 44o gpd The issuance of this permit shall no. t be coestrued•,,as a guarantee that the system ill function de ed. Date I .� ' Inspector I N Z,`5 � - o. Fee .SO �v THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal *pstpm Construction Permit Permission is hereby granted to Construct(✓) Repair( ) Upgrade( ) Abandon( ) System located at i and as described in the above Application for Disposal System Construction Permit. The applicant recognized his ty to comply with f Title 5 and the following local provisions or special conditions. II Provided:Construction must be completed within three years of the date of this permi Date ?a12 Approved by DEC-17-2012 06:11 From:BARNST HEALTH 15087906304 To:5084574444 P.1/1 Town of Barnstable Regulatory Services Thomas F. Geiler,Director "" KAM ' Public Health Division. �6g9• a� o i Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 509-790-6304 Date:S117112, Sewage 1Permitff c;2-0/07 A Assessor's Map/Parcel 5�r I staller&ft-.;igyner Certification rtifiiication Form Designer: Installer: �,4.i 77_-4 F[.[-/cA re-­, Address; ��Oi/ Address: -mot was issued a permit to install a (date) (installer) - /� septic system ate/�j ,�/ DS. 4`,aced on a design drawn by (address) : ! 6 h JL? le— dated- t— '-= - ESlgn ) I certify ghat the septic system referenced above was installed substantially according to the desigl.i, which may include minor approved changes such as lateral. relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major. changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State &Local Regulations. Plan revision or ec;rtificd as-built by designer to follow. Stripoul. (if r(;quircd)was mspcctcd and the soils were found sati, ory. /,///pz��e zl� JOHN (Iffistaller's.Signature) P. `v v L'OYLE,lit P1o.335891 . Y_1r)_e'A-W/r'S Signature) (AiT SUR Here) `� PLEASE RETURN TO BARNSTABLE PUBLIC HF.AI,TU . , ON. CERTIFICATE OF COMPLUNC:E WILL NOT BE ISSUED r1NTIL BOTH THIS FORM AND AS- BLTILT CA,1 D ARE RECEIVED BY THE 1BARNSTABLE PUBLIC HEALTH DIVISION. TTIANK YOU. q:office forrm\dnigncrcerrifination foan.doc J DARTMOUTH POOLS &SPAS, INC. 880 MT. PLEASANT STREET NEW ]BEDFORD, MA 02745 508 - 998-7100 l 37' i O ? 19 pp'() JJ.��� � \u t�i c•�`�,— vi — � 11t , ��U` NOYIE.iII , , /J Ly r �. ' ;i.� Gov:✓_%.vTio/v i - ". . r_- _._ s 1I I O STE 'X/2-z i �E✓T 2i� D/ I � G6' ycp Town of Barnstable Po 3 �5 Department of Regulatory.Services J Public Health Division Date > �/ ' , ta39 200 Main Street,Hyannis MA 02601 r ' Date Scheduled c _ • Time Z6 Fee Pd. Soil Suitabilio .Assessment.f or ►fie e dais ®sal Performed'By: Witnessed LOCATION& GENERAL INFORMATION Location Address 3 6 0 MA/,el 5-7- eC-7 Owner's Name ./C//it/ /n p,Q/1v1 0-5 TER V1 L L C Address Lt/%A/l ;1VO /g 1/2_-- /L 4-®S? ✓ p, � Assessor's Map/Parcel: M P /��3' / ,�de�'' Engineer's Name j,-�L>i�� ASsc�✓ NEW CONSTRUCTION REPAIR Telephone j Land Use X63'/DEi9L Slopes(96) /Q Surface Stones /�� Distances from: Open Water Body Z0111 ft Possible Wet•Area�� �ft Drinking Water Well Dralhags Way Z,0t7 ft Property Line ZO R Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) • N 30' TP-i Parent material(geologic) Depth to Bedrock Depth to Groundwater. Standing Water in Hole: /r/Q/✓LG Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in"obs,hole: In. Depth to loll mottle!: ht, Dcpth to weeping fmm side of obs.hole: itl, Groundwater Adjustment lG. Index Well# Reading Date: Index Well level____-�' Adj,ihetbr— Adj.Groundwater Level )PERCOLATION TEST bate 23 /z xlg /6 A I Observation Hole# 7P- V- J.- Time at 9" Depth of Pere Z 5'"3?y Z�'`t 5�0 Time at G" Start Pre-soak Time @ /�%OD /! ��i /2 : - — Time(9„G„) End Pre-soak Z V q /A) /d'3 d Z l/t•G ,I Site Suitability Assessment: Site Passed V Sitq Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back--------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. ! Barnstable Conservation Division at least one(1)week prior to beginning. Q:\S EPTIC\PERCFORM.D O C F DEEP.OBSERVATION HOLE LOG Hole# 710-1 Depth from Soil Horizon Soil Texture .Sdil Color Soil, Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. • i to �Y,96'Gravel) 0 N Ao ,9 ,clay ",9t DEEP OBSERVATION HOLE LOG Hole# 2- Depth from Sol[Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.Consistency,%Gravel) 19 . It 72 c, A66P, -.14- AM 16111,e- 7� Z `=/24' C2- CMAj No.t/Z� DEEP OBSERVATION HOLE LOG Hole# �-3 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in,) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. o Ito c e D y- 2 G`' 8 SgNoy LoA 7 /D /z 7 Ard /r- DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Noll Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones',Boulders. ` Consistoncv TIT 27 "- 7--" G', /4&b. SjAa Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes Within 500 year boundary No V+ Yes ' Within 100 year flood boundary No._ J/ Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? yE S If not,what is the depth of naturally occurring pervious matarial? Certification I certify that on 9-5� (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required tr ' ' g,expertise and experience described in 10 CMR 15.017. Signature Datb — 9-3 Q:\.SEPT1aPERCP0RM.D0C July 14, 2012 RE: 360 Main St. Osterville Ma,02655 To whom it may concern: My name is Paul A. Looney and I am writing to you in regards to the property Iisted at 360 Main St. Osterville, Ma 02655 map 165/028. -1 owned this property from 1998-2012 and it was always a 4 bedroom home. In fact the town has it assessed as a 4 bedroom home therefore, paying taxes as a 4 bedroom home. It has been brought to my attention that the Town of Barnstable Board of Health has it listed as a 3bedroom and think that this is an error. Thank i AAR1 %& S`p,`�P'�+�,20 to • '• �.�y44 - ,, ',,I,,•aUbuN OPT .• • _ _ rr-; - Commonwealth of Massachusetts r _ . Title 5 Official Inspection Form Subsurface Sewage Disposal System form -Not for Voluntary Assessments 360 Main Street Property Address Paul Looney w, Owner Owner's Name information is required for every Osterville MA . 02655 4/12/12 page. City/Town State Zip Code • Date of Inspection , { Inspection results must be submitted on this form. Inspection forms may not be altered in any. way. Please see completeness checklist at the-end of the forms , Important:When filling out forms A. General' Information " � y on the computer, - ` � use only the tab . 1. Inspector: key to move your ' I cursor-do not a Ricky L. Wright use the return • key. • B & B Excavation,I nc. rob Company Name 14 Teaberry Lane Company Address Forestdalle MA 02644 City/Town State Zip Code -508-477-0653 S14595 Telephone dumber License Number ' . B. Certification I certify that] 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 � Conditional) P asses❑ y ❑ 'rails, • ❑,,,;Needs Further Evaluation by the Local Approving Authority 4/13/.12 Inspector's Signature Date The•system inspector shall submit a copy of this inspection report to the Approving Authority (Board t 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 tha ystem owner shall submit the report to the a• "�ro riate regional office of t e EP Th ,1 l ,;_� P PP P 9 D eon Ina .ouId be sent to th. ���.�. .��..�, _...��. e 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 a0gress h�wMe'siysterIwill perform in the future under the same or different conditions of use. t5ins•t 1/10 Title 5 icial JD j� Off Ins edi on F u surface Sewa //(JP s tisal S st m• Pa e1of17 9P Y 9 t i Commonwealth of Massachusetts . W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments, 360 Main Street ,M ` we ' Property Address Y ,, Paul Looney Owner Owner's Name Z i ' information is Osterville MA 02655 4/12/12 required for every - page. Citylrown +• 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: µ ® I have not found any information which indicates that any of the failure criteria described, in 310 CMR 15.303 or in 310 CM 15.304 exist. Any failure criteria,not evaluated are indicated below. Comments:, . _ r., r . , • r 1 r ., • 'B) System Conditionally Passes: t ❑ 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 e 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 Com liance indicating that the tank is less than 20 years old is available: . ❑ Y ❑ N ❑ ND (Expla in,below): ---------------------------- 1 - , . a •' yr. ♦. .. l5ins•11/10 4 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of)7 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments " ° 360 Main S,:reet (•M Sn i z Property Address Paul Looney a � Owner Owner's Name y information is MA '' 02655', '4/12/12 required for every Ostervllle ` , page. City/Town 'State Zip Code Date of Inspection B. Certification (cont.) , B) System Conditionally Passes (cost.): w `. ❑ 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): r ;❑ , distribution box is leveled or-replaced ❑ Y. •❑ •N ❑ Nb,(Explain below): a e The system required pumping more th• an 4 times a r I_ year due r Y q P to broken or obstructed,inspection P 9 Y cted pipe(s). The system will ass Ins ection if with a r v , Y p p ( p o al of the Board of Health ❑ broken pipe(s) are replaced+, .❑ Y ❑ N ❑ .ND (Explain below):. . '❑ obstruction is removed' ' ❑ Y „ ❑'N ❑.ND.(Explain below): q C). Further Evaluation is Required by the Board of Health: ❑ Condi"ions 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 A. ' 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 _. ❑ Cess' ool or privy is within 50 p p y feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts " W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 360 Main Street, Property Address F t Paul Looney Owner Owner's Name information is required for every Osterville MA ' 02655 4/12/12' - page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and.Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment:, The system has 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. 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 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 r 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 town overloaded s ® or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less . than 1/2 day flow t5ins•11/10 • Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 ` ' Commonwealth of Massachusetts Title 5 Official Inspection Form fi _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ^M 360 Main Street Property Address Paul Looney Owner Owner's Name information is `MA.- 02655 4/12/12 ` required for every .Osterville ` page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No f 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. z ❑ .r ® • 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 A a< system passes if the well water analysis;performed at a DEP certified a laboratory,for fecal coliform bacteria indicates absent and the presence . of ammonia nitrogen and nitrate nitrogen is equal to or1ess 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.] a Z., The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000g pd. ® 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 alarge 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"' es" or"no"to each,of the following, in addition to the - questions in Section D. - ,• • . .,.Yes "No _ ;� , 4 � •i .; - ❑ ❑ 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 E] Area-1WPA)'or a mapped Zone 11 of a public water supply,well .If you have answered "yes" to any question in Section E the system is•considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered,a significant threat under Section E or failed under Section D shall upgrade the system.in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department: t5ins 11/10 ;,, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection( Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. °M 360 Main Street Property Address ' Paul Looney - Owner Owner's Name information is required for every Osteryille MA 02655 4/12/12^ ' r 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 . . El ®n• Pumping inform ation 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 ofEl 0 „ this inspection? , ® ❑ Were as built plans of the system obtained and examined? (If they were,not vi a a table note as N/A) = . ® ❑ Was the facility or"dwelling inspected for signs.of sewage backup? , R ® ❑ Was the site inspected for signs of break out?. ® ❑ ' Wereall 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? ` El ® 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 T Residential Flow Conditions: } A Number of bedrooms(design): 3` ;•NNumber of bedrooms(actual): 3 `• t DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd"x#of bedrooms): n 330,.' t5ins•11 h 0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts ; Title 5 Official InspectionForm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 360 Main Street Property Address Paul Looney Owner Owner's Name information is required for every Osterville MA y 02655 _ 4/12/12 page. Cityrrown State . _Zip Code Date of Inspection D. System Information' Description: r ' r ` - a ♦ t • ' y, ., , " III Numberof current residents: - Does residence have a garbage grinder? ❑ Yes ® ~No Is laundry'on a separate sewage system? [if yes separate inspection required]' W ❑•Yes E No _ Laundry system inspected? « s x ❑ Yes ,Z No Seasonal use? - ❑• Yes .N,'No Water meter readings, if available last 2 ears usa. e d n/a _ 9 ( Y 9 (gp ))� � � , Detail: ' Sump pump? h ❑ Yes ®_ No Last date of occupancy: . n/a r. Date . Commercial/Industrial Flow Conditions: Type of Establishment: Design flo°Ai(based on 310 CMR 15.203): Gallons per day(gpd) Basis of,design flow(seats/persons/sq.ft., etc.): ' Grease'trappresent? ❑ Yes ❑ :No ,. Industrial waste holding tank'present? ❑ Yes ❑, No a ' Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 4 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form y Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � 360 Main Street Property Address d. Paul Looney , Owner Owner's Name information is Osterville r MA . 02655 4/12/12 required for every - - page. City/Town State Zip Code bate of Inspection D. System Information (cont-) Last date of occupancy/use: Date ' Other(describe below): General Information .T - Pumping Records: Source of information: Was sys:em'pumped as part of the inspection? ET Yes ❑ No If yes, volume pumped: ua gallons' s How was quantity pumped determined?, Reason for pumping: , a Type of S stem: YP Y Se tic tank, distribution,box soil absorption system - ❑: Single cesspool 4 K Y ' ❑ Overflow cesspool ❑ Privy . t El., _ Shared system (yes or no),(if yes, attach previous inspection records, if any) y ❑ Innovative/Alternative'technology. Attach a copy of the"current operation and maintenance contract(to be obtained from system I owner and a ' Y ) copy of latest.. inspection of the I/A system by system operator under contractAr ' ❑ "' 'Tight tank. Attach a copy of the DEP approval ❑ Other(describe): r t5ins•11/10 ' R. y , Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts � W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments 360 Main Street Property Address . Paul Looney ; Owner Owner's Name information is Osterville t MA 02655, 4/12/12' + 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 ofAinformation: 1995 Were sewage odors detected when arriving at the site?,- " ❑ 'Yes ® No' Building Sewer(locate on site,plan): F17 _ Depth below grade: 4 r'3, feet Material of construction: El cast ikon ®40 PVC El other.(explain): , Distance.from private water supply well or suction line; feet - .* Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection, building sewer appeared to be in working order no sign of leakage or blockage. Septic Tank(locate on site plan): .. Depth below grade: r 2'8 . feet I% !Material cf construction: ' ® concrete metal ❑ fiberglass ❑ polyethylene ❑ other(explain) . R. If tank is metal,.list age f years Is age confirmed by a Certificate of Compliance? (attach.a copy of_certificate) ❑ Yes ❑ No 5.8x5.8z10'6" Dimensions: Sludge depth: no,sludge ` t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 360 Main Street Property Address Paul Looney , Owner Owner's Name information is osterville MA 02655 =4/12/12 required for every ` page. Cityrrown 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 no sludge Scum thickness - no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom ofr outlet tee or baffle no scum How were dimensions determined? scour 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.): _ At time of inspection, septic tank appears to be structurally sound no sign of back-up, baffles present. Grease Trap(locate on site plan): :. Depth below grade: feet Material of construction: ❑ concrete ❑ metal ; , ❑ fiberglass [],polyethylene ❑ other(explain): Dimensions: Scum thickness 1 Distance from top of scum to top of,outlet tee or baffle yg 1 Distance from bottom of scum,to bottom of outlet tee or baffle - A Date of last um in P p _ Date t5ins•11/10 i. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth.of Massachusetts ` 4 W Title -5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 360 Main Street Property Address Paul Looney Owner Owner's Name information is Osteryille "' MA 02655 4/12/12 required for every , page. Citylrown State Zip Code ;Date of Inspection D. System Information (cont.), Comments (on pumping recommendations, inlet and outlettee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): i. 1 A Tight or Holding Tank(tank must be pumped at.time of inspection) (locate on site plan): ; Depth below grade: Material of construction: ' El concrete �', ❑'metal ❑ fiberglass El polyethylene ❑ other(explain): + Dimensions: f b Capacity: - gallons - -Design Flow: . gallons per day Alarm present ., > 0-Yes., El,No' } F - Alarm IeveL - , Y Alarm inwo}rking order:' :❑ Yes ❑ No0. r.. Date of last pumping ° Date, > Comments (conditionof alarm and float switches, etc:): ro "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes No t5i6s•11/10 + Title 5 Official Inspection Form-Subsurface Sewage Disposal System•page 11 of 17, . T� JN Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments • 4 °y 360 Main Street _ Property Address Paul Looney ,. Owner Owner's Name " information is M1 required for every Osterville MA• 02655 4/12/12 page. City/Town State , Zip Code Date of Inspection . D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): ; Depth of liquid level above,outlet invert H 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.): , At time of inspection d-box appears to be in working order no sign or leakage or car 'over. r r Pump Chamber(locate on site.plan): Pumps in working order, ❑ Yes ❑ No F Alarms in working order: t ❑ 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 nor:,located, explain why: , r t5ins-11/10 �. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 i Commonwealth of Massachusetts T W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 360 Main Street e Property Address Paul Looney Owner Owner's Name information is required for every Osterville Y MA 02655 4/12/12 ' page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type .. ❑ n leaching pits number: ❑ leaching chambers number: J ❑." leaching galleries number: ®:. . leaching trenches number, length: 2, ❑ r leaching fields number, dimensions: • � overflow cesspool number: .- • ' ❑ innovative/alternative system ' 3 r Type/name of technology: ` Comments (note condition of soil,.signs of hydraulic failure, level of ponding,ydamp soil, condition of vegetation, etc.): At time of inspection leaching was dry - no sign of hydraulic failure. t" Cesspools.(cesspool must be pumped as part of inspection):(locate on�site plan): Number and configuration R x �. .. Depth-`top of liquid to inlet invert µ Depth of solids layer Depth of scum layer. -Dimensions'of cesspool ' °Materials.of construction Indication'of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 ' I Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 360 Main Street ` Property Address Paul Looney Owner Owner's Nam' " information is Osterville ! MA 02655 r `4/12/12 required for every , page. City/Town , State Zip Code Date of Inspection D. System Information (cont:) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,' etc.): f` • Privy (Iccate on site plan): ' Materials of construction: '' Dimensions _ - ,.' Depth of solids +" - ," - r• } ' ' * . Commerts (note condition of soil, signs of hydraulic failure, level of ponding,.condition of vegetation, etc.): I r F r t l5ins 11/10 1 y Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 OL Commonwealth of Massachusetts q. Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form Not for Voluntary Assessments °M 360 Main Street Property Address Paul Looney Owner Owner's Name information is Osterville *'MA 02655 4/12/12-required for every - ' page. Citylrown State :,Zip Code Date of Inspection D. System,Information (Pont,): .. 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 • Ar M1 -.i 5 0 - , M 1. •_ .. ... I a i .. • r a1 - �!_ .. ' • y ' ..ems d f _ ..• .. �, .. f:i�,. .. . � _ �. � ,. r;` .. R ro'b ,. Sri a b • t5ins•11/10 _ f q Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 k - - R Commonwealth of Massachusetts W Title 5 OfficialInspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 360 Main Street Property Address ; Paul Looney k . Owner Owner's Name information is required for every Osterville -MA 02655 4/12/12 page. City/Town State Zip Code Date of Inspection _ D. System Information (cont.) fi Site Exam: ® Check Slope ` ® Surface water ® Check cellar ® Shallow wells . >20' Estimated depth to high,ground water: feet - Please indicate all methods-used to determine the high ground water elevation: _ ❑ Obtained.from system design plans on record If checked; date of design'plan reviewed: Date " ' ® Observed site(abutting`property/observation hole within 150 feet of SAS) ❑ Checked with local Board of.Health -explain: _ r Checke d with - th lo cal x• ❑ excavators, installers attach documen� i tat on ❑ Accessed USGS database-explain: You must,describe how you established the high groundwater elevation: - Before filing this Inspection Report, please see Report Completeness Checklist on next page: a t t5ins-11/10 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 wM 360 Main Street Property Address Paul Looney } Owner Owner's Name information is required for every Osterville MA 02655 4/12/12 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist, t E Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems]completed E System Information—_Estimated depth to high groundwater , E Sketch of Sewage Disposal System'either drawn on page 15 or attached in separate file .. •..r {- a [ .. • .. ti. v .. a \ 5M1 a ...y 4 • ... a • r a ' . w rs •. �r F � � . _ .fir ► . y. - • 't5ins•11/10 «Y . •, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Executive Office of Enviroranental Affairs Dept. of Environmental Protection One winter Street,Boston,Ma. 02108 l u D.E.P. Tittlee V S Septtic Inspector P.O. Box 2119 Teaticket, MA 02536 WILLIAM RWELD (50$) 564-68I3 Governor ARGEO PAUL CELLUCCI Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ��. ✓, PART A iIECEi"tJrE cap CERTIFICATION � A A' q Property Address: �, 360 Main St.Ostervilie o Address of Owner: JA 1 4 1998 -� Date of Inspection: 1/6/98 (If different) ti, TOWNO,,q h�an Name of Inspect or: John 13raci Estate of Towns-Mary Towns:101 Mayflower Terr.Sfouthyla oufh 02664 ' I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) rj Company Name,Address and Telephone Number: �.f 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 performed based on m training and experience in the proper function and and complete as of the time of inspection. The inspection wasp y g P P maintenance of on-site sewage disposal systems. The system: X Passes This Inspection Is based on criteria dented In Title V _ Conditional) Passes code 310 CMR 16.303.My findings are of how the system y is performing sit time of the inspection.My inspection does _ Needs Fur er E5 luation By the Local Approving Authority notlmpty any warranty or guarantee of the longevnyorthe Fails ,, - septic system and any of Its components useful life. Inspector's Signature: Date: imig8 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: I r' Check A, B,C,or D: „ A] SYSTEM PASSES: ` x I have not found any information which indicates that the system violates any of the failure criteria y' defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or-repair,passes inspection.. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic.tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Cdfhpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection, or the septic tank,whether or metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 0/12797) One Winter Street` • Boston,Massachusetts 02108 is FAX(617)556-1049 0 Telephone(617)292-5500 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 300 Main SL Osterville Owner: Estate of Towns-Mary Towns:101 Mayflower Terr.South Yarmouth 02664 Date of Inspection:1/6198 _ Sewage backup or.breakout.or. hioh.static water level observed.in.the distribution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced —The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within,100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within.a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3 Other 0] SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.. Yes No Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. Disciiarge or ponding of effluent to the surface of the ground or surface waters.due to an overlea�ded or clogged cesspool. SAS is in hydraulic failure.. (revleed 04127)971 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 300 Main St.osterville Owner: Estate of Towns-Mary Towns:101 Mayflower Terr.South Yarmouth 02664 Date of Inspection:116198 D]SYSTEM FAILS(continued) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. — Liquid depth in cesspool is less than 6"below invert or available volume is less than.1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. s u — — Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no — acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You-must indicate either"Yes"or"No"as to each of the following: The following criteria appi.y to large systems in addition to the criteria: The system serves a facuity with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is wi-.hin 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 li of a public water supply well) The owner or operator of any such:system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 anc'6.00. Please consult the local regional office of the Department for further information. r, (revised 0412A87), SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST , Property Address: 360 Main St Osterville Owner: Estate of Towns-Mary Towns:101 Mayflower Terr.South Yarmouth 02664 Date of Inspection:116198 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: _X_ — Pumping information was requested of the owner,occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal — flow rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this inspection. x As built plans have been obtained and examined. Note if they are not available with NIA. x = The facility or dwelling was inspected for signs of sewage back-up. x The system does not receive non-sanitary or industrial waste flow. _c_ The site was inspected for signs of breakout. x All system components,excluding the Soil Absorption System,have been located on the site. x The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. x The size and location of the Soil Absorption System on the site has been determined based on — _ The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is — — unacceptable)[15.302(3)(b)j y 1. (revlsed 0412V97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 300 Main St.Osterville Owner: Estate of Towns-Mary Towns:101 Mayflower Terr.South Yarmouth'02664 Date of Inspection:116109 FLOW CONDITIONS - RESIDENTIAL: d Jbedroom for S.A.S. Design flow: 440 g•p• Number of bedrooms: 4 Number of current residents: e Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings,if available:(last two(2)year usage(gpd): nfa Sump Pump(yes or no): No Last date of occupancy: May COMMERCIAL/INDUSTRIAL: Type of establishment: n1a Design flow:0 gallons/day Grease trap present:(yes or no) Nc Industrial Waste Holding Tank present:(yes or no)_No Non-sanitary waste discharged to the Title 5 system`.(yes or no) Nu Water meter readings,if available: We Last date of occupancy: rda OTHER:(Describe) We Last date of occupancy: t , GENERAL INFORMATION PUMPING RECORDS and source of information: Na System pumped as part of inspection:(yes or no)Nu If yes,volume pumped:o gallons u ` Reason for pumping: rVa TYPE OF SYSTEM 1. _ x Septic tank/distribution box/soil absorptions system Single cesspool - Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components;date Installed(if known)and source Information: 1900 ySewage odors detected when arriving at the site:'(yes or no)f-No f (revlaed 04dien f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 300 Main St osterville Owner: Estate of Towns-Mary Towns:101 Mayflower Terr.South Yarmouth 02004 Date of Inspection:116198 SEPTIC TANK: x (locate on site plan) Depth below grade: +' Material of construction:x concreate_metal_FRP_Polyethylene_other(explain)` If tank is metal, list age o . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: t.e'6"H6s7'•w4.10' Sludge depth:+" Distance from top of sludge to bottom of outlet tee or baffle: 26"' Scum thickness Distance from top of scum to top of outlet tee or baffle:6" 5 Distance form bottom of scum to bottom of outlet tee or baffle: 17" How dimensions were determined: measured Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level'in relation to outlet invert,`structural integrity, evidence of leakage,etc.) Septic tank is structurally sound.Recommend pumping septic system every two years. GREASE TRAP:_ (locate on site plan) a. Depth below grade: nra Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: nra Scum thickness:rva Distance from top of scum to top of outlet tee or baffle:rra Distance from bottom of scum to bottom of outlet tee or baffle: nla Date of last pumping;,r, r t Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) BUILDING SEWER: A (Locate on srte plan) Depth below grade: vv- Material of construction:_cast iron x_40 PVC._other(explain) Distance from private water supply well or suction lineP Diameter: 4 i Qimments: (conditions of joints,venting,evidence of leakage, etc.) h , 4 (rsviaed04r27)8T1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) a Property Address: 350 Main St 0sterville -Ma Towns:101 Mayflower Teti.South Yarmouth 02664 Owner: Estate ofToulns ry yfl Date of Inspection:1161e9 TIGHT OR HOLDING TANK: ' (locate on site plan) Depth below grade: Na t Material of construction:_concrete_metal_FRP_Polyethylene—other(explain) X Dimensions: rua Capacity: .nla gallons Design flow: rda allons/day Alarm level:_nra Alarm in working order?--_Yes No. Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) rda e t DISTRIBUTION BOX: x (locate on site plan) Depth of liquid level above outlet invert: nla Comments: o etc.' of leaka ge e into or out of box of solids carryover,evidence ' ution is a ual evidence ) (note if level and distribution q Y9 "ox Is structurally sound. PUMP CHAMBER: (locate on site plan) .. Pumps in working order.(yes or no' No e working order es or no Alarms in o Ye: 9 (Y Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) rda (revlsed 04127)97) I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) I o Property Address: 360 Main SL Osterville Owner: Estate of Towns-Mary Towns:101 Mayflower Terr.South Yarmouth 02664 Date of Inspection:116199 SOIL ABSORPTION SYSTEM(SAS):x (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Na Type: leaching pits,number: rye leaching chambers,number:Na M leaching galleries,number: Na leaching trenches, number,length: 2 leaching fields,number,dimensions:wd'L30'D•2' overflow cesspool,number:Na Alternate system: Na Name of Technology:_Na Comments:(note condition of soil,signs of hydraulic failure,level of•ponding,condition of vegetation, etc.) System Is Nnctloning properly. CESSPOOLS: (locate on site plan) I� Number and configuration: rft Depth-top of liquid to inlet invert: n►a Depth of solids layer: Depth of scum layer: Na Dimensions of cesspool: nla P i Materials of construction: Na Indication of groundwater: rda inflow(cesspool must be pumped as part of inspection) Na Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Na PRIVY: ; locate on site Ian ( plan) Materials of construction: We Dimensions: Na „ Depth of solids: Na Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc:) Na <.. reviaedOA D97 1 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 360 Main St Osterville Estate of Towns-Mary Towns:101 Mayflower Terr.South Yarmouth 02884. 118198 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) v FIA e, , c g A A - A6 : CA co 30 ec �7 q t Dave 9 of 10 (revised 04WI97) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 350 Main St.Osterville Estate of Towns-Mary Towns:101 Mayflower Terr.South Yarmouth 02664 ° 116198 Depth of groundwater 12• m Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property,observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers x Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS maps and charts (revm.de4n7197) i�q• 10 0[ 30 TOWN OF BARNSTABLE LOCATION y rl��i S� SEWAGE #9 - VILLAGE �gY ASSESSOR'S MAP & LOr/"��- � INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: ��'�'�� -S (type) (size) NO.OF BEDROOMS F BUILDER OR OWNER 3�NCOMPLIANCE PERMITDATE: �/�' ��' DATE: —z Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If anyawetlands exist within 300 feet of leaching facility) , Feet Furnished by . ��. ,/ ,,,111 �� ��r��-5� .. � �� as , i'-� S�• �'6 . ��3��� -J No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Application for ;Dtopool *p5tem COri!5trurtton VCrmtt Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. �\ ���Cv�.i1�`� � !%i.dtv 5i � ��`(\1✓u5T Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow �s gallons per day. Calculated daily flow ^�� gallons. Plan Date Number of sheets Revision Date Title Description of Soil i/in�z ��� e c,. Nature of Repairs or terations(Answer when applicable) 'tNS�d�-� 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 d not to place the system in operation until a Certifi- cate of Compliance has been iss "s B d oi-41"! Signed Date������ Application Approved by Application Disapproved for the lowi reasons Permit No. �.�� — ?s 21 Date Issued �% ^�,- ^ L►' ——————————————————————————————————————— --- -''S..•aa .......-...,. --�.. .-....-�- .�...'a.ry,`.`.'. .,,ter...+... ..rr;i+••,.._..,-•.. •. •i.,+.....:.,�... "` .r.... .-,-.T_.'�. _ Fee z` - T T THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH'DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS� y. ZIpprication for ni!5pool *pMem Conelruetiott Permit Application is hereby mad-_for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. Installer's Name,Address,and 7e1.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow '`-� 7 gallons per day. Calculated daily flow — -?3 gallons. Plan Date Number of sheets Revision Date Title Description of Soil ✓k"z / U� -eca S'A, -Nature of Repairs or A}t�etations(Answer when apP,licable) W S�`0 \ `S CI'U t�� \L Date last inspected: Agreement: ; The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system 1 in accordance with the provisions of Title 5 of the Environmental Code d not to place the system in operation until a Certifi- cate of Compliance has been is d Si'tied ' Date ddl� Application Approved by - Application Disapproved for theYollowl`4 reasons , Permit No. 2>3 Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of Compliance - THIS IS TO C r Y, at t - ' Swage Disposal System installed(t )or repaired/replaced on -_�- by k-o�c�•� yS for 3(00 'as yob VV cc w has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated _1 Use of this system is conditioned on compliance with the provisions set forth b .^ y r No. 3 Fee " '— THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE, MASSACHUSETTS 1=igoga1 *p'.5t'em Construction Permit Permission is hereby granted tc to construct( )repair(%-J'a-i On-site Sewage Syst tit located at 3 d U _I OS re�u�� and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be compLted within two years of the date below. Date: �r Approved by I CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated �` �'S , concerning the r property located at fin ' - °v '1`^� meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • . There are no variances requested or needed. SIGNED DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE.TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. 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