HomeMy WebLinkAbout0933 MAIN STREET (OST.) UNIT #A - Health 933 Main Street, Osterville
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Commonwealth of Massachusetts
Title 5 Official Inspection Fora
=�do Subsurface Sewage Disposal System Form Not for Voluntary Assessments
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933 A Main Street 4
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Property Address
Richard Calahan ?X
Owner Owner's Name -ff
information is / 0
required for every Osteryille ✓ MA 02655 7-23-19 wl
page. City/Town State Zip Code Date of Inspection =.!
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
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Important:When e
A. Inspector Information `��o°��;..••..filling out forms p /aGj q
on the computer,
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use only the tab James D.Sears JAMES m
key to move your Name of Inspector =�' SEARS
cursor-do not Capewide Enterprises S* 'c
use the return
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153 Commercial Street ��%�.,F 5 INS?"
"ICI Company Address
Mashpee MA 02649
City/Town State Zip Code
508-477-8877 - S1623
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ® Passes
,
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
7-24-19
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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
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Commonwealth of Massachusetts
,9 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
933 A Main Street
Property Address
Richard Calahan
Owner Owner's Name
information is required for every OSterVllle MA 02655 7-23-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.An failure
criteria not evaluated
Indicated below.
Y a uated are .
Comments:
The system is a 1500 Gal.Tank D Box and chamber's
2) System Conditionally Passes:
❑ One or more system components as described in the
Conditional Pass section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
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t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
I�
Commonwealth of Massachusetts c usetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
...........V 933 A Main Street
Property Address
Richard Calahan
Owner Owner's Name
information is required for every Osterville MA 02655 7-23-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of,sewage backup or breakout 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:
i
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
i�
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
0 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
!% 933 A Main Street
Property Address
Richard Calahan
Owner Owner's Name
information is
required for every Osterville MA 02655 7-23-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (Cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
` ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
,A Title 5 Official Inspection Form
> Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
933 A Main Street
�u
Property Address
Richard Calahan
Owner Owner's Name
information is Osterville MA 02655 7-23-19 required for every ,
page. City/Town 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 easspmM is less than 6" below invert or available volume is less
than '/2 day flow /-F 4 c/1/.1 G'
❑ ® 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 groundwater elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® . The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Ip Title 5 Official Inspection Form
R Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
933 A Main Street
Property Address
Richard Calahan
Owner Owner's Name
information is Osterville
required for every MA 02655 7-23-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
LtSinsp.d.c-rev.7/26/2018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
`1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
933 A Main Street
Property Address
Richard Callahan
Owner Owner's Name
information is required for every Osterville MA 02655 7-23-19
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): NA Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220
Description:
1500 Gal. Tank D Box and Chamber's.
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection El Yes_ ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ® Yes ❑ No
Water meter readings, if available last 2 ears usage NA
9 ( Y 9 (gpd)):.
Detail
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
Date
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I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
'•u
933 A Main Street
Property Address
Richard Calahan
Owner Owner's Name
information is required for every Osterville MA 02655 7-23-19
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: NA
Was system pumped as part of the inspection? ' ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
I ,
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Io Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
933 A Main Street
u
Property Address
Richard Calahan
Owner Owner's Name
information is required for every Osteryille MA 02655 7-23-19
page. City/Town 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:
NA/New D Box 7-2014.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 22"
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH.-40.
t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
L
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
933 A Main Street
u Property Address
Richard Calahan
Owner Owner's Name
information is
required for every Osteryille MA 02655 7-23-19
page. City/Town State Zip Code 'Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene
El other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 Gal. Precast H-10
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or 28"
,baffle II
�
Scum thickness 211
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle 16"
How were dimensions determined? Tape- Sludge Judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at working level. Tank and inlet cover at 1' below grade Woutlet cover at 2". In and outlet
tee's. Nosign of leakage or over loading. Note: Tank to be maint: pumped after inspection
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
r
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
< Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
933 A Main Street
Property Address
Richard Calahan
Owner Owner's Name
information is
required for every Osterville MA 02655 7-23-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade:
feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene y El other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or,Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�o
!% 933 A Main Street
Property Address
Richard Calahan
Owner Owner's Name
information is required for every Osterville MA 02655 7-23-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16"x16"-1' below grade w/two lines out. Box is New 7-2014 w/cover at 6"
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
f
cN, Commonwealth of Massachusetts
Title 5 Official Inspection Form
�e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
933 A Main Street
Property Address
Richard Calahan
Owner Owner's Name
information is required for every Osterville MA 02655 7-23-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order:. ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number:
2
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields K number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
i
Type/name of technology:
t51nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
M1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
=u-
933 A Main Street
Property Address
Richard Calahan
Owner Owner's Name
information is required for every Osterville MA 02655 7-23-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is two 500 Gal. Dry well chambers. Chambers at 16" below grade.wet bottom w/clean
wail's.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
L_
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
933 A Main Street
emu, Property Address
Richard Calahan
Owner Owner's Name
information is
required for every Osterville MA 02655- 7-23-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids '
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
I .
i
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
v
933 A Main Street
Property Address
Richard Calahan
Owner Owner's Name
information is required for every Osterville MA 02655 7-23-19
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.
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t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
� h Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
933 A Main Street
�u Property Address T .
Richard Calahan
Owner Owner's Name
information is required for every Osterville MA '02655 7-23-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar,
❑ Shallow wells
N° -
Estimated depth to high ground water: 10'
feet
Please indicate all methods used to determine the high ground water elevation-,
® Obtained from system design plans on record
If checked, date of design plan reviewed: 12-14-15
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.Kat 933B. 12-14-15 10' no G.W.. Bottom of chamber's at 4' below grade. Bottom of chamber's at
6'above T.H. Depth.
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 117 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
933 A Main Street _
V
Property Address
Richard Calahan
Owner Owner's Name
information is required for every Osterville MA 02655 7-23-19
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3; or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6 (Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank-Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
30 M 1 o e
C/CAMQFfS
is
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
No.4938 �_3`3 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer.
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
NpliLation for bisposal *pstrm Construction Permit
Application for a Permit to Construct( ) Repair X Upgrade( ) Abandon( ) ❑Complete System Individual Components
Location Address or Lot No. 9,33 A PIW S'i 8$7- Owner's Name,Addre s and 1. o.
lv(CL l�4 s� (G
Assessor's Map/Parcel S'-3 ro ��'1�- 3 - ceI7exy(&L6
Installer's Name,,M dress,and Tpel.No. Designer's Name,Address,and Tel.No.
JA
MF�
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision at
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature ofltepairs or Alterations(Answer when applicable)
t
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 He
Signe Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued
^h•._ - _r�s�._-. Hwy, ...r' '°�,�r'�/'�.,,ti.,;F � 4a "�.. 3 b ^� - y,,�, r'4.• c4.i.. .a s-.'a w `�.,,•r.__.,r-ti:a.t
No. ✓/t" fF , 4 Fee
THE-COMMONWEALTH OF MASSACHUSETTS Ent 'ncomputer:&
Ye
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
S
Zfpp. Ion for Disposal *pstem. eonstrUction 3pprmit,.
Application for a Permit to Construct( ) Repair jX) ,UpgLde( ) Abandon(h') [:]Complete System Xt Individual Components
r
Location Address or Lot No. 9 33,E"&0tj sr QS-r- Owner's:Name;Address,,and Tel.No.
Assessor's Map/Parcel ( 5 RO L?�.QK 3�, CXV 7�Y14LF.
Installer's Name, ddress,and Tel.No. 50 S-q_17t .$211 Designer's.Name Address,and Tel.No.
C4P46(AllaE�R-aSQ .-r' �. 4>GJA,4_rJ, Y
Type of Building: h '"
Dwellging N f Bedrooms ; 1 Lot Size sq.ft. Garbage Grinder(Y )
Other{° Type of Building :' l.. No.of Persons Showers( ) Cafeteria( )
Other Fixtures' Ar; 1
Design Flow(min.required) ' gpd Design flow provided / gpd
Plan Date Number of sheets A Revision Date
Title
Size of Septic Tank " Type of S.A.S.
Description of Soil i
Nature of Repairs or Alterations(Answer when applicable) s" {
4
' Date last inspected:
Agreement:
gyp- 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. { 'r
�. }
All
,5 ,1 rSignc; l Date
d
' Application Approved by �j Date
Application Disapproved by Date
for the following reasons
±. Permit No. i Date Issued rn,
e
------------
• a ' V
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Corn fiance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired O Upgraded( )
Abandoned( )by C04P6W f D6/P o6�C B O(JP— C[�l
at - lr¢(itJ b S7" — has been constructed m accordance -:
with the provisions of Title 5 d the for Disposal System Construction Permit Xo�l47 5dated r
Installer 44A A44SOCT d V t_- CO Designer N A
#bedrooms I Approved design flp� gpd
'The issuance of this permit shall no be construed as a guarantee that the system will fuin'c�tioonn desigded.
Date �, If
/6 Inspector
�
p \Ij U
------------------- --------------- --------- ------------- --------------
No. Fee l
THE COMMONWEALTH OF MASSACHUSETTS w
PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS
Disposal 6pstem Construction joermit
Permission is hereby granted to Construct( ) Repair(X) Upgrade( ) Abandon( )
• System located at 9 33 A &W S~r 037- zV iLk.:
and as described in the above A p.c.ationfor Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
s
Provided:Construction must b completed within three years of the date of thi fp`ermit.
Date �llg� Approv by
Y
TOWN Or�BARNSTABLE
:.00ATION 3Al A 1,41 A �f 6` y pa'SEWAGE #
VILLAGE f ire 2 V®L 1-e ASSESSOR'S MAP& LOT 117. l 8 3
INSTALLER'S NAME&PHONE NO. J/D A4 A C 0 Al Red E;- :'&A
SEPTIC TANK CAPACITY Z G G
` LEACHING FACILITY: (type) C,4&4l0-&ize) Sm®�
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: Y 17 COMPLIANCE DATE: cl- �' ` 7
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet'
Private Water Supply Well and Leaching Facility (If any wells exist.
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
t`
Furnished by
Y
cR
W
W �
ti
k
t'
TOWN OF BARNSTABLE 4
L^ ,AT10N / 3 A4 4 /A/ S! SEWAGE #
VILLAGE 0 SreK-VIZZe ASSESSOR'S MAP &LOTI/7y/�3
INSTALLER'S NAME&PHONE NO. /% C d,44 9 C X• S oN .
SEPTIC TANK CAPACITY /46
LEACHING FACILITY: (type) e C!i A x G eg (size)
NO.OF BEDROOMS .� {
BhMRLR OR OWNER
PERMITDATE:!Z ° ' �� COMPLIANCE DATE: A0�' e
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom-of Leaching Facility Feet
Private Water Supply Well and Leaching Facility .(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility)D Feet
Furnished
M
d\
�F
,,
a
r
f No. �' �-' �� Fee 5 0 .0 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer.
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZippYication for �Diopogal *pgtem Congtruction Vendit
Application for a Permit to Construct( )Repair( )Upgrade(XX)Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 933 Main Street Owner's Name,Address and Tel.No. 5 0 8—4 2 8—8 6 7 2
Osterville,Mass. 02655 933 Main Street Osterville,Mass. 0
Assessor'sMap/Parcel Ruth Callahan 02655
Installer's Name,Address,and Tel.No. — — Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 8
J.P.Macomber & Son Inc. J.P.Macomber & Son Inc.
Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632
Type of Building:
Dwelling X No.of Bedrooms 3 Lot Size sq.ft. Garbage GrinderlJO )
Other Type of Building Res. No.of Persons 1 Showers( ) Cafeteria( )
Other Fixtures
Design Flow 3 3 0 gallons per day. Calculated daily flow 3 x 1 1 0 gallons.
Plan Date 9/19/9 7 Number of sheets Revision Date
Title
Size of Septic Tank 1 500 gallon tank- Type of S.A.S. 3-330 Cultec recharger
Description of Soil Loamy sand to medium fine sand.
Nature of Repairs or Alterations(Answer when applicable) Omit cesspools Install 1 -1 5 0 0
gallon septic tank, 1 -Distribution box.and 3-330 cultec rechargers
packed in 3 of stone.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by thi Bo d o . ealth.
Signed Date 9/1 9/9 7
FM4Application Approved by Date
Application Disapproved for the following reasons
Permit No. _ Date Issued EP
�No i 9i .sdr� o ._ Fee 50100
e.' s•� 4
- THE COMMONWEALTHOF MASSACHUSETTS -Entered i�n1puter.
Yes
PUBLIC HEALTH DIVISION-TOWWOF"BARNSTABLES MASSACHUSETTS
01pprication for Mi5po0a1 '*p5tem Congtruction Permit
Application for a Permit to Construct( )Repair( )Upgrade(X�Abandon( ) El Complete System El Individual Components
Location Address or Lot No. 933 Main S e e t Owner's Name,Address and`Tel.No. bUd—4 —
8672
Osterville,Mass. 02655 933 Main Street Os'terville,Mass. 0
Assessor'sMap/Parcel Ruth Callahan 02655
I t r' ame A ress an Te ,No. Desi ner's Name,Address and Tel.No. .,
3s. .i1acdmbet ion Inc. J. .Macomber & Son Inb.
Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632
Type of Building:
Dwelling X No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinderg0 )
Other Type of Building t�es* No. of Persons �— Showers( ) Cafeteria( )
Other Fixtures
Design Flow 330 -' gallons per day. Calculated daily flow 3 x 1 10 ,gallons.
Plan Date 9 97 ._ Number of sheets Revision Date
Title
Size ofi Septic Tank"1 500 ,,gallon tank. Type of S.A.S. 3-330 Cultec recharger
Description of Soil Loamy sand to medium fine sand.
� I
Nature of Repairs or Alterations(Answer,when applicable)
Omit cesspools . Install 1 -150.0
gallon septic tank,1 =Distribution box.and 3-330 cu tec rec argers
packed in 3 ' of e./
Date last inspected: / r
Agreement: `
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has:been iss .d by thi od f ealth.
d
f
Signe Date 9/19/9 7
Application Approved by 6•, Date
Application Disapproved for the following reasons
t Pem t No. '' Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNS TABLE, MASSACHUSETTS
Certificate of Complialnce
4
1 THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( ) Upgradedx(XX)
µ' AbandSjd 1 by J.P.Macomber & Son Inc.
y.S FI a n tree stervi e, ass.
at h s been constru ted in accordance
with the r vi o of Title.5 and the fo Dis al S stem Construction Pe t No 7'',�` 7*da d �
p .Macomber & Sonp°lsncy .
Installer Designer
The issuan e f thisirmit s b� of be construed as a guarantee that the s�y;te will functio�j as de�igne'
Date �, `� "-° Inspectp `
No.�/� -��'----------------_-----------Fee $ 50.0 -....
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
lwiopogar *p5tem Con5txuction Permit
Permission is hereb n ed tp Co E�rruuct Re l ra 1, X Abandon
System located at tMaintre�t)Ospe�Vi � ,`M s ( )
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:C struction`must be completed �
et within three years of the date ofermit.
Date: 'P y �' % / Approved
CERTIFICATION Or SI<L'I'CII AND APPLICATION FOR A DISP(..
WORKS CONSTRUCTION pLR.N•11'I' (NVI'I'flOU'I' DESIGNED PLANS)
I,Joseph P.Macomber Jr_, - ccrtily that tltc application for disposal works
construction permit signed by nlc �'.::ted _9/19/97 , concerrung the
prjperty located at 933 Main Street osterville,Mass. meets all of the
following criteria:
�• There are no Nvetlands within 30U fc.t of the proposed septic system
W There are no pri\,ate wells wittii" 151 I'rct of the proposcd septic system
• The observed groundwater table is I ftct or greater bclo%y llle bottom of the Icachillb facility
• There is no increase in flow alldlOf change in use proposcd —
f , • There are no variances requested or uccd.d.
W
SIGNED : DATE: 9/1 9/97
LICEN' SEPTIC SYSTEM !NSTi• ,LLER IN THE T0WN OF BARNSTABLE NUMBER
(Attach a sketch plan of the proposcJ s)s;cn1. Also if the licensed installer posesses a certified plot plan,
this plan should be sAniticd].
sTr I bu rzm,
39)ariC 7;4-,v K.
0 7,
xp;v
TOWN OF BARNSTABLE
LOCATION 7.3 3 4 A litl S'r .& 3 SEWAGE # 1
V.II LA.GE Q S re/P L1/L L 42 ASSESSOR'S MAP & LO
TIlLif ___�c.; ,
INSTALLER'S NAME&PHONE NO. Tf A4 A C U Nt Pn�R t s OI✓
S1WM'TANK CAPACITY p a n
LEA PIING FACILITY: (type) CNRMLffA'gsize) DO
No.":OF:BEDROOMS
BtTIiDER OR OWNER
PERMIT DATE: I6 ^ COMPLIANCE DATE: 9'�
SeMat on Distance Between the:
Maaimiim Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Priw:atf?Water Supply Well and Leaching Facility (If any wells exist
otiate or within 200 feet of leaching facility) Feet
Ede;,of:Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
i Furnished by
t
� I
SEWAGE PERMIT NO. WATER .TABLE
LOCATION NO. STREE / /1r/ J/.
INSTALLERS NAME & ADDRESS
D ATE PERMIT ISSUED �� 79
DATE OF INSTALLATION ����
DRAWING OF INSTALLATION ON BACK
�;
i
d
�f'r � C
J� ���
{,�......�� r
6
W
No......2 ......... F�$.:.::......: ......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
ApplirFation for Uigpuiiagl Works (Snnitrnrtinn rantit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at:
------------------------- ...-----------...----............---------4 .: ...------------...............- -----
....9 .0
.0. xajp
Location-Address or Lot No.
....
nad ),A)--....F 4 $•boax........--•------•--....... ...................................... .............
Installer .-••- --- ----•-- •-•-•-•--•--.-..' Address......................... ............•
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( }
P4 Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
aOther 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 ( ) I ,
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........................
R+ --------------•---•----------------- ........................................_.......---------.........__.... .._..........--
O Description of Soil........... ---.9.K0.L1.0-----------------=--------------
V =- ---•-------•-•=--------------••---------•-•-•--•••---_..._.....--•-------••-•••--------...
---------------------------------------------------------------------------------•-----------------------------------=-------------- 1
U Nature of Repairs or Alterations—Answer when applicable._____`.11)1)�_.-4 _!�d10.0_. j___ ________________
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITi!;
p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance hakeisued by the hoard of health.
S' ned4/ - - __
Date
Application Approved By.....7=' ...... .- Date
Application Disapproved for the following reasons__________________________________________
•---._....•.....................................................................
------------------------------------------------------•-----------•----=-•.....t-•---------------•-------•••---•----•--•--•--------------•--•---•--•-----------••--••••••-•...-•-----•----••--------•-•.
` Date
Permit No..................
........................................ Issued --••----------------
- Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
,fir ........OF....... `..>€ ej, '_.. -
Appliration for Disposal Works Toustrurtion rnmit
Application is hereby.made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
y
..... _ ......_Zr�.. •--•------------------------•- -•---... ........---.....-•-•--•-- ------------------------..................
�y Location-Address - or Lot No.
... ..... ..�. ........................................................
ne Address
a •-•-•---- . .......
Installer Address
d Type of Building Size Lot............................Sq. feet
/ Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons.............____.._____-- Showers ( ) — Cafeteria ( )
a
� Other fixtures .........................--------•-•---------..........................................................................................................
W Design Flow............................................gallons per person per day. Total daily flow----........................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter................ Depth................
x Disposal Trench—No--------------------- Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No---_---------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Other Distribution box ( ) Dosing tank ( )
Z Percolation Test Results Performed by---------------------------------------------------------------------------- Date........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit-___-__---.__._-•_.- Depth to ground water........................
�.. . ,
D Description of Soil..........= ' ''
x
rJ
W --------------------------------------- ------------------------------------------------------- - ------•-
UNature of Repairs or Alterations—Answer when applicable �.: � "� _` ... �!?... r ..4.........................
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 i sued by the oard.of health.
fr Date,
Application Approved By.:_. ....... -A":1 11�e
---------------•-----••--•••••--- ••--�� ��Date
Application Disapproved for the following reasons:-------•---------------------------------------------------------------- ---------------------------------------
...................•-----....--------.........---------------••-••--------•------••---.................-••----•--••---------•-•--•---•----•-------------•--------------------------------------...._....
Date
PermitNo......................................................... Issued.......................................................
-- Date _
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
•. � Y
aryla .....OF... �. =�jF .............................
01rdifiratr of Bump iFaatrr
THIS„ISO .CERTIFY, That the Individual Sewa e Disposal System constructed ( ) or Repaired )
b --------- .� . •.
Installer rr r
.._. .. �,
has been installed in accordance with the provisions of T 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No. _..__ . '.: ........... dated___`I`..�q. d
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...•-••--•---•................................................•--------._...... Inspector.......................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH -
..
_OF..... ...........................
�! 2. ? ................
.MJ . f�..h �9,e:�.w��..�°.e�a� -
No.- ............. FEE........................
Disposal parks (11.111notra ion perutit
Permiss>on is hereby granted---- �'- _-622 ............................................
to Construct
) or Re)aarF( ) ,an Individual evtra_ge Disposal System -' ---
at No.... . .E � y... ...�" _. :. � ;r� _. ..- ------------------
St eet
as shown on the application for Disposal Works Construction Per't .. ................................
` � 7C'
Dated
............... . ..............A�� - ------------------------------
7 Board of He�lph'
DATE..-•-• % J V
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS