HomeMy WebLinkAbout0933 MAIN STREET (OST.) UNIT #C - Health 933 Main St,{, �17�
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 933 Main Street unit#3 (Gallery Place)
Property Address
LESLIE, CAROL J & LANE, PETER W
Owner Owner's Name -
requir required
is Osterville MA 02655 1/15/2012
required for every
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.
Important:When A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your p
cursor-do not Brian K. Tilton
use the return Name of Inspector
key.
The Building Inspector of Cape Cod, Inc.
r� Company Name
PO Box 307
Company Address
Eastham MA 02642
City/Town State Zip Code
508-255-9343 S14392
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that` he
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 Hof on s
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of,
Title 5(310 CMR 15.000). The system:
lk
C 9
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
1/15/2012
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•11110 Title 5 Official Inspection Form:Subsurface wage Disposal System•Page 1 of 17
i.
Commonwealth of Massachusetts
Wfflwffl
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 933 Main Street unit#3 (Gallery Place)
Property Address
LESLIE, CAROL J & LANE, PETER W
Owner Owner's Name
information is required for every Osterville MA 02655 1/15/2012
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
All components in place and functioning as designed.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
N/A
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
933 Main Street unit#3 (Gallery Place)
Property Address
LESLIE, CAROL J & LANE, PETER W
Owner Owner's Name
information is required for every Osterville MA 02655 1/15/2012
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditional) Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
N/A
❑ 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):
N/A
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•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
°M 933 Main Street unit#3 (Gallery Place)
Property Address
LESLIE, CAROL J & LANE, PETER W
Owner Owner's Name
information is required for every Osterville MA 02655 1/15/2012
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance: N/A
** 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:
N/A
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® 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 '/2 day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
,
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c�M 933 Main Street unit#3 (Gallery Place)
Property Address
LESLIE, CAROL J & LANE, PETER W
Owner Owner's Name
information is required for every Osterville MA 02655 1/15/2012
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped: N/A.
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ® the system is within 400 feet of a surface drinking water supply
❑ ® the system is within 200 feet of a tributary to a surface drinking water supply
❑ ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•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 933 Main Street unit#3 (Gallery Place)
Property Address
LESLIE, CAROL J & LANE, PETER W
Owner Owner's Name
information is required for every Osterville MA 02655 1/15/2012
page. Cityfrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 2 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°7M 933 Main Street unit#3 (Gallery Place)
Property Address
LESLIE, CAROL J & LANE, PETER W
Owner Owner's Name
information is required for every Osterville MA 02655 1/15/2012
page. CityTrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: Vacant
Does residence have a garbage grinder? ® Yes ❑ No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d Condo, see
g ( y g (gP )) below
Detail:
Two services to this complex, first 1 house abnd 2 cottages 223,000gal/20.11 201,000gal./2010
second serves 7 cottages for.. 267,000gal/2011 and 327,000gal/2010
Sump pump? ❑ Yes ® No
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment: N/A
Design flow(based on 310 CMR 15.203): N/AGallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.): N/A
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: N/A
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
, M 933 Main Street unit#3 (Gallery Place)
Property Address
LESLIE, CAROL J & LANE, PETER W
Owner Owner's Name
information is required for every Osterville MA 02655 1/15/2012
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
N/A
General Information
Pumping Records:
Source of information: Owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval,
❑ Other(describe):
t5ins•11/10 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
°M 933 Main Street unit#3 (Gallery Place)
Property Address
LESLIE, CAROL J & LANE, PETER W
Owner Owner's Name
information is required for every Osterville MA 02655 1/15/2012
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Unknown original, replaced leaching system in10/14/1997
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2.5
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
No evidence of leaks or clogs.
Septic Tank (locate on site plan):
2'
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 5'8"x 8'6"x 4'10"
Sludge depth:
10"
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
933 Main Street unit#3 (Gallery Place)
Property Address
LESLIE, CAROL J & LANE, PETER W
Owner Owner's Name
information is required for every Osterville MA 02655 1/15/2012
page. City/Town 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
20"
Scum thickness
4"
Distance from top of scum to top of outlet tee or baffle
4"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? Accusludge, Baffle stick and tape
measure.
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Liquid levels were normal with no evidence of leaks, back up or clogs, tees/baffles were in place and
functioning as designed. Pump at this time for regular maintenance, tanks should be pumped at least
every three years as regular maintenance.
Grease Trap (locate on site plan):
Depth below grade: N/A
feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
N/A II
Scum thickness N/A
Distance from top of scum to top of outlet tee or baffle N/A
Distance from bottom of scum to bottom of outlet tee or baffle N/A
Date of last pumping: N/A
Date
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
933 Main Street unit#3 (Gallery Place)
Property Address
LESLIE, CAROL J & LANE, PETER W
Owner Owner's Name
information is required for every Osterville MA 02655 1/15/2012
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
N/A
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: N/A
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
N/A
Dimensions: N/A
Capacity: N/A
gallons
Design Flow: N/A
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: N/A Alarm in working order: ❑ Yes ❑ No
Date of last pumping: N/A
Date
Comments(condition of alarm and float switches, etc.):
N/A
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�^M 933 Main Street unit#3 (Gallery Place)
Property Address
LESLIE, CAROL J & LANE, PETER W
Owner Owner's Name
information is required for every Osterville MA 02655 1/15/2012
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
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.):
No evidence of leaks or solids carryover, equal flow to each outlet and level.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
4
l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 933 Main Street unit#3 (Gallery Place)
Property Address
LESLIE, CAROL J & LANE, PETER W
Owner Owner's Name
information is required for every Osterville MA 02655 1/15/2012
page. CityTTown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 2/500 gal
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Lawn and pine tree over top, no evidence of breakout or hydraulic failure, chambes dry with no
evidence of back up.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration N/A
Depth —top of liquid to inlet invert N/A
Depth of solids layer N/A
Depth of scum layer N/A
Dimensions of cesspool N/A
Materials of construction N/A
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
V
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 933 Main Street unit#3 (Gallery Place)
Property Address
LESLIE, CAROL J & LANE, PETER W
Owner Owner's Name
information is required for every Osterville MA 02655 1/15/2012
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.):
N/A
Privy (locate on site plan):
Materials of construction:
N/A
Dimensions N/A
Depth of solids N/A
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
I
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
1
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c�M 933 Main Street unit#3 (Gallery Place)
Property Address
LESLIE, CAROL J & LANE, PETER W
Owner Owner's Name
information is required for every Osterville MA 02655 1/15/2012
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
W
B
DORCH
Al.= 30.5 .B1= 1G.5
�ti I]EC.K A2= 19.5' B2= 24.5'
a�
A3= 21.3' B3= 21.6'
C7
A4= 19' B4= 29'
05 04 2 10
A5= 19.4' B5= 37'
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
J
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 933 Main Street unit#3 (Gallery Place)
Property Address
LESLIE, CAROL J & LANE, PETER W
Owner Owner's Name
information is required for every Osterville MA 02655 1/15/2012
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 10.1' + adjusted, no water encountered
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:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Hand auger test hole within 50' of SAS to a depth of 13' no water encountered, corrected to estimated
high water table using Frimpter method
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
x
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
933 Main Street unit#3 (Gallery Place)
Property Address
LESLIE, CAROL J & LANE, PETER W
Owner Owner's Name
information is required for every Osterville MA 02655 1/15/2012
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
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Page 1 of 1
December 2011
USGS Site
Departure from Number****
Location Well No. Water Record Record g Avera a** links to USGS
Level* High* Low* Monthly Overall national water-level
database)
21.94
(adjusted
provisional not not
A I W available available
Barnstable 230 value 19.5 26.6 at this at this 413956070164301
to use until
time time
well can be
replaced)
not not
AIW available available
Barnstable 247 23.50 20.6 28.6 at this at this 414154070165001
time time
not not
Brewster BMW 21 9.21 6.9 13.6 available available 414518070020301
at this at this
time time
not not
Chatham CGW138 24.34 20.9 26.6 available available 414100070011101
at this at this
time time
not not
Mashpee MIW 29 7.90 5.6 10.0 available available 413525070291904
at this at this
time time
not not
Sandwich SDW 47.04 45.6 48.2 available available 414418070241601
252 at this at this
time time
not not
SDW available available
Sandwich 253 48.13 45.8 55.1 at this at this 41.4124070265901
time time
not not
Truro TSW 89 11.71 10.2 13.0 available available 420206070045901
at this at this
time time
not not
WNW available available
Wellfleet 17 10.62 7.3 12.8 at this at this 415353069585401
time time
http://www.capecodcommission.org/index.php?id=239 1/30/2012
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Barnstable
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HIGH GROUND-WATER LEVEL'COMPUTATION
Date: /
n J ?BIZ
Site Location: / 3,3 Main s�• ��� �- 3 Permit:
Il-,
Owner: �.� _ l.�vl.� Phone:
Contractor: T _ g o;Iclin�n Ree_�c< I*I;Phone: 502f' Z55-- 13
Notes:
STEP 1 Measure depth to water table
to nearest 1/10 ft. �J 2
(depth is in feet below land surface) Date: 0r' 17 �� �✓ LJO
m /d /yy feet below Is
STEP 2 Using Water-Level Range Zone and Index Well
Map locate site and determine:
A) Appropriate index well
B) Water-level range zone
STEP 3 Using monthly "Current Water Resources
Conditions" determine current depth to water C
level for index well.
mm/yy
STEP 4 Using Table of Potential Water Level Rise for
index well (STEP 2A), current depth to water
level for index well (STEP 3), and water-level
zone (STEP 213) determine water-level
adjustment. Z ` �' 0
STEP 5 i
Estimate depth to high water by subtracting the O� Q
water-level adjustment (STEP 4) from U 0
measured depth to water level ati site (STEP 1).
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NOTE* Tables 1-9 "Potential Water-Level Rise" are atta ed as worksheets to this file.
monthly index well data: www.capecodcommission.org/wells.htmi
203 498 757
4,S Postal Service
Receipt for Certified Mail
No Insurance Coverage Provided.
Do not use for International Mail See reverse
Sent to
Street&Number
Post Office,State,&ZIP Code r.
• G ill iC Ld3t �=� .
Postage $ „
Certified Fee
Special Delivery Fee
Restricted Delivery Fee
Ln
Return Receipt Showing to
Whom&Date Delivered
a Retum Receipt Showing to Whom,
C Date,&Addressee's Address
0 TOTAL Postage&Fees $
M Postmark or Date
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d SENDFR: I also wish to receive the
o ■Complete items 1 and/or 2 for additional services.
■Complete items 3,4a,and 4b. following services(for an
■P7int your name and address on the reverse of this form so that we can return this extra fee):
hard to you.
■Attach this form to the front of the mailpiece,or on the back if space does not 1. ❑ Addressee's Address
permit. m
4) ■Wnte'Retum Receipt Requested'on the mailpiece below the article number. 2. ❑ Restricted Delivery to
■The Return Receipt will show to whom the artice was delivered and the date «
delivered. Consult postmaster for fee. °.
3.Article Addressed to: 4a.Article Number _ 4)i
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Y9J 7�S 7 EE {� � 4b.ServiceType «'10 M
❑ Registered Certified IX
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❑ Return Receipt for Merchandise ❑ COD
7.Date of Delivery,
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5.Received By:(Print Name) 8.Addressee's A dress(Only if requested
and fee is paid) r
g 6.Sig ture:(Add ssse or Agent)
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PS Form 11, December 1994 102595-97-B-0179 Domestic Return Receipt
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Town of Barnstable 11A 11 -7 g�
.�. Department of Health, Safety, and Environmental Services
DAMMAM& Public Health Division
367 Main Street, Hyannis MA 02601 3
Office: 308-790.6263 Thomas A.McKean,Its,CHO
aNh
FAX: 508-790.6304 Director of Public Heft, .
2S 3
, qIs
DATE:
��-33 .
(� M
ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL
r
CODE, TITLE 5.
C(43/M,^
I �� Nay I on b,
The septic system owned by you located at 3 was inspected y -
o,,, fir. , a Massachusetts licensed septic inspector.
The inspection of your septic system showed that your system has failed under the
guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following:
-01r . ftF,
QkAeFa �e o� C �v/�u� Sc�
c(-, — co" &I t),0
You ard directed to hire a licensed Town f harnstable septic system installer to submit a
sketch diagram of a proposed system to the Town of Barnstable Health Division Office
(Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance
with 310 CMR 15.00, The State Environmental Code, Title 5 within (14) fourteen days of
receipt of this notice.
You are also directed to bring the septic system into compliance within days of
receipt of this order letter. -K(&v)
You are further directed to maintain the system by hiring a licensed septage hauler to
pump the septic system to prevent discharge of sewage or effluent into the buildings, onto
the surface of the ground, or in to surface waters.
Any person aggrieved by any order issued by the local approval authority may appeal to
any court of competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean, R.S., C.H.O.
Agent of the Board of Health
LT►� '
/V10 M'qP a,;-fet po-rcd.
DATE : 11 /19/97
PROPERTY ADDRESS : v
Osterville,
Mass .
t
On the above date, 1 Inspected the "ptic system at the -above address.
This system consists of the following:
1 . 1 -1000 gallon septic tank.
2 . 1 -Distribution box.
3 . 1 -1000 gallon precast leaching pit.
8aee-d on my InPr-ectlon, I certify the following conditions:
4 . This is a title five septic system.`( 78 Code )
S . The septic system is in failure. The leaching area is
. in failure. Must be replaced.
SIGNATURE :
Name : J . P . Macomber Jr,,. i
J_ P .-Macomber &- Son'_Inc ,
Company;
�ddresa :_ 5a�c-66------a_-- ---
__Centervi1Le `Mass__02632
Phone :- ' 5 a ' 338_______ I
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
)OSEPH P, MACOMBER. & SON, INC.
T+nki-C•upool�-L#Khfleldi
PumP+-d 4 Pnit.illyd
Town Sewer Connoctlont
P.O. Box 66 ' Centerville, MA 02632.0066
775.3339 775-6412
COMMONWEALTH OF N ASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
2 �h� DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON, MA 02108 617.292-55
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si.ILLIANtF HELD -
Go%cmor
ARGEO PALL CELLL'CCI r O DA 10
Lt Go%cmor SUBSURFACE SEWAGE DISPOSAL SYSTEM IN P ION �tFh1 W
PART A '9
CERTIFICATION d� � 9
y33 ,r91AIN Ste"
Property Address--5a-11er'-y---PAC Osterville,MA,Address of Own
Date of Inspection: 1 /19/97 (If different) 9-
Name of Inspector: JOseph R. Ma-Somber �r.
m I a a DEP approved system inspector pursuan to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: J.P.Macomber & Son Inc.
Mailing Address: BOX 66 rpnt-prvi 1 1 p, Mass. 32
Telephone Number: 5DR_775_3338
CERTIFICATION STATEMENT
I cen.fy that I have personally inspected the sewage disposal system at this address and that the information reportee celo� is u_e a-,-
and complete as of the time of inspection. The inspection was performed based on my training and experience ;n the prover tin-or. a
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
.Needs Further Evaluation By the Local Approving Author;ry
aIIs
Inspector's Signature: e . / Date: /—/ 4l7
The System Inspector shall submit a copy of this inspection repon to the Approving Authonry within thirty (30) days of comple(,n3
;nspect,on If the system ;s a shared system or has a design flow of 10,000 gpd or greater. the rnspec~or and the system o_T>ef sna)1 s.:o
the repon to the appropriate regional office of the Department of Environmental Protection The original sno,,lc oe Sent fo rr-e 5v e^ o
and copies sent to the buyer. if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
A) SYSTEM PASSES:
(Z 1 have not found any information which indicates that the system violates any of the failure criteria as derme-j r. 310) C•,•,
Any failure criteria not evaluated are indicated below.
COMMENTS:
B) SYSTEM CONDITIONALLY PASSES:
_ One or more system components as described in the 'Conditional Pass" section need to be replaced or repaired. 'ne s.s >-
completion of the replacement or repair, as approved by the Board of Health, will pass.
Ind Kate yes, no. or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined'. e=p:a
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Cen, .Ca:t
Compliance (anached) indicating that the tank was installed within twenty (20) years prior to the date of ire ;rs:, or
-
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or ez ;1lra;:pr
failure is imminent. The. system will pass inspection if the existing septic tank is replaced with a confo.rn,ng sr�:.c -3,
as approved by the Board of Health.
tr.vls.d 04/25/97) Nag. 1 of 10
0EP on the WOr10 Woe Weo nttp 1twww magnet state ma uvoep
Printed on RecyVeo Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
:open? .address: 3 Gallery Place Osterville,Mass .
owner: Frank Burns
o,!e of Inspection:11 /19/97
Bl SYSTEM CONDITIONALLY PASSES (co
ntmvedf
Sewage oackvp or breakout or high static water level observed in the distribution box is cue to o e•-
p,pe(s) or due to a broken, senled or uneven distribution box The system will pass inspect on
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than (our times a year due to broken or obstructed p pets! Tne s:s:e
nso.eCi.on if (with approval of the Board of Healthy
broken pipe(s) are replaced
obsuue-tion 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 fa:1tn2 !0 p:p:e:'
puolic neallh, saiery and the environment
t) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIOhIhC I" A
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
z/4 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) DE7ER,,1I\ES ?r +?
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a s.nace -are:
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a pubh, watef s o -el
,( The system has a septic tank and soil absorption system and the SAS is within 50 feet of a P—a:e tea!— s_x•
/G 1 The system has a septic tank and soil absorption system and the SAS is less than 100 fee! 'o.:t �0 r- _
pnva!e water supply well, unless a well water analysis for coliform bacteria and volatile organ:;
Ine well is Iree from pollution from that facility and the presence of ammonia nitrogen and n ;:a'.e
less Inan 5 ppm Method used to determine distance A14 (approximation not valid',
3) OTHER
A,)4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
• CERTIFICATION (continued)
Property Address: 3 Gallery Place Osterville,M4ass .
O-ner: Frank Burns
Date of Inspection: 1 1 /1 9/97
D) SYSTEM FAILS:
�You must indicate e,. er "Yes' or "No' as to each of the following
yr� y i have determined that the system violates one or more of the following failure triter a as del net :n 310 C ,2
f�— for this aetermination is identified below. The Board of Health should be contaned to determine -nat will De nec;s
the failure
Yes
� n-0
Backup of sewage into facility or system component due to an overloaded or clogged SAS a cessx-�'
Discharge or pondrng of effluent to the surface of the ground or surface waters due to an overioacee or c e3r
cesspool
Static liquid level in the, ,istnbulion boa above outlet inven due to an overloaded or cioggee SA'S c
_ l,qu-d depth n.c�tiKwdis less than 6•' below invert or available volume is less than Ii. day
Required pumping more than 4 times in the last year NOT due to clogged or obstructed
Number of times pumped Q
Any portion of the Soil Absorption System, cesspool or privy is below the high grounc-a.er e'e•a :c
Any portion of a cesspool or privy is within 100 feet of a surface water supply or iriouiar, :o a s:"a:e •-a e s_.
Any portion of a cesspool or privy is within a Zone I of a public well
Any portion of a cesspool or privy is within 50 feet of a private water supply well
Any portion of a cesspool or privy is less than 100 feet but greater than SO feet from a _.e• s__.
acceptable wale( quality analysis. II the well has been analyzed to be acceptaole, anac) c o, o
coliform bacteria. volatile organic compounds, ammonia nitrogen and nitrate nitrogen
E) LARGE SYSTEM FAILS:
you must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above.
_&�11 The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system :s a
public health and safety and the environment because one or more of the following conditions exist
Yes No
41A the system is within 400 feet of a surface drinking water supply
ZA the system is within 100 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 ^t _t= '.
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the grounc. a:e* :rea -e- _
requirements of 314 CMR 5 00 and 6.00 Please consult the local regional office of the Depariment for funher in!orrr.a,,c-
tr•�s••C 0�/l5/97) ➢�y• 3 of 10
l_
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORm
PART B
CHECKLIST
Property Address: 3 Gallery Place Osterville,Mass.
Owner: Frank Burns
Date of Inspection:1 1 /19/97
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes N
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and the system has been rece-,,ng nc.
now rates during that period. Large volumes of water have not been introduced into the system rece-:
as pan of this inspection.
_ As built plans have been obtained and examined. Note if they are not available with N/A
_ The faciliry or dwelling was inspected for signs of sewage back-up
The system does not receive non sanitary or industrial waste flow
_ The site was inspected for signs of breakout.
_ All system components..4e<luding the Soil Absorption System, have been located on the site
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condr:on o
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum
/ — The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the pro�r
Sub-Surface Disposal System
Existing information. Ex Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Pan C is at issue approximation n
o d distance is
unacceptable) 115.302(3)(b))
lr•vi••d 0�/75/97) D•g• 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Properly Address: 3 Gallery Place Osterville,Mass .
Owner: Frank Burns
Date of Inspection: 11 /19/97
FLOW CONDITIONS
RESIDENTIAL:
Design now _'JL:6� p.d./bedroom for S.A.S.
~'umber of bedrooms:
~'umber of current residents:,
Garbage grinder (yes or no):-&Q
Laundry connected to system (yes or no):
Seasonal use (yes or no): p
\vater meter readings, if available (last two (2) year usage (gpd): y�1j1rtf' Ao. J�;�j_j,SC+�i7(✓J`�4
Sump Pump (yes or nol: do 1-11,.IS fib 1-C-V D//'Q"
Last date of occvpanc) ��
COMMERCIAUINDUSTRIAL:
Type of establishment .{/A
Design slow .vARallons/day
Grease trap present. (yes or no) ,VA9
Industrial Waste Holding Tank present: (yes or no)AO
.',on-sanaary waste discharged to the Title S system: (yes or no)-d)—/)-
water meter readings, if available. .Ufa
Last date of occupancy
OTHER: (Describe)
Last date of occupancy:
GENERAL IN'FORM.A�TIO�1N
PUMPING RECORDS and source of inf mat on:`�-�'�c1 (3vrn/2 /arlk) /C
iies
System pumped as part of inspection: (yes or no)4W
If yes, volume pumped: AJ/? gallons
Reason for pumping
TYPE OF SYSTEM.
�ep(,c tank/distribution box/soil absorption system
Single cesspool
-22 Overflow cesspool
,J)/) Privy
Zid Shared system (yes or no) (if yes, anach previous inspection records, if any)
XI I/A Technology etc. Copy of up to date contract?
Other
APPR XIMATE ACE of all components, date installed (if known) and source of information:
K�6, — SA) A;) '14P6'
Sewage odors detected when arriving at the site: (yes or no),tl�d
(r•vs••d 0�/Js/f7( P•9. 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 3 Gallery Place Osterville,Mass .
Owner Frank Burns
Date of Inspection 11 /1 9/97
BUILDING SEWER:
.,oca!e on site plan)
Depth Delo- grade
Material of construction Cast iron -.4140 PVC — other (explain)
D.sLance irom pr,vale water supply well or suci,on line 'V'4
Diameter "
Comments tcond,t,on of loin v Wring, evidence of leakage. Ic.) C�
c�
r
SEPTIC TANK:l�pp9�¢ pUg
ocole on s'le plan;
L/
Dep!n t>elow grade
,••a!enal of construcl'on loncrete _metal _Fiberglass _Polyethylene _other(explatn)
16_�
II Lank is metal. 1,51 age 4/ Is age confirmed by Certificate of Compliance A'�p (Yes/No)
'/ ) / c
D,mens,Ons �b r'�`/L4/� /rLaj Al1A
SI'cge depth
O stance from top f sludge to bonom of outlet tee or baffle.
. �
Sc m !h-ckness �
Distance Irom top of scum to top of outlet tee or baHle��+Q,
D,uance from bonom of scum to bonom1 of
outlet tee for baffle �_
—ow d,mens�ons were determined i
pmmenLs
,recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet rove^.
evidence of leaka e, etc ) /
r P
"'
CREASE TRAP:,&!4�g)e_
:IoC.ale on site plan)
Deoth txlow grade A2
xaLenal of conslrucltuna1,14concreleof�IgmetalAZqiberglasso"Polyeihylenei{4other(explain)
D�mens,ons-
Scum thickness. !V
Distance from top of scum to top of outlet tee or baHle: IPA
D,sLance from bonom of scum to bonom of outlet tee or baffle: IAA
Date of lastA,
pumping �
`omments
:recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in rela!ion to outlet nve�.. s:r_:—..
.n!egnry. ev-dence of leakage, etc 1
XML
!r.v1..d 04/75/97) P.9. 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 3 Gallery Place Osterville,Mass .
Owner: Frank Burns
Date of Inspection: 11 /1 9/97
TIGHT OR HOLDING TANK:A.1Dy(Tank must be pumped prior to, or al time, of inspection)
(locate on site plan)
Depth below grader
Material of construction:ll concreteltgmetalsUffiberglassA2gPolyethylene42&other(explain)
lyfi
Dimensions: /I
C Design
it-. gallons
Design �low� gallons day
Alarm level- Alarm in working order Yes: ANC,
Date of prev'ous pumping LYA�
CommenU
(cond,t�on of inlet tee, condition of alarm and float switches, etc )
DISTRIBUTION BOX:
(locate on s.te plan)
Depth o- liquid level above outlet invert:��
Comments
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc )
a/
PUh1P CHAMBER: '('(—
(locate on site plan)
Pwmps ,r. „orking order (Yes or No)_L4
Alarms n working order (Yes or No)--d
r Comments:
Incite condition of pump chamber, condition of pumps and appuu+nenances, etc.)
(r•�r•.e 0�/75/97), P.g• 7 or 10
• . may,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 3 Gallery Place Osterville,Mcbss .
Owner: Frank Burns
Date of Inspection: 1 1 /1 9/97
SOIL ABSORPTION SYSTEM (SAS):
+locate on site plan, if possible. excavation not required, but may be approximated by non intrusive methods)
If not determined to be present, explain:
Type
leaching pits, number.
leaching chambers, number:
leaching galleries, number:
leaching.trenches, number,length:
leaching fields, number, dimension
overflow cesspool, number
Alternative system: Ad
Name of Technology: d�
Comments
(note condition of soil signs of hydraulic failure, level f ponding, condition of vegetation, etc.) _
is t i S
CE5SP00LS:
(locate on site plan)
Number and configuranon: r
Depth-(op of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer: Ag
Dimensions of cesspool:
materials of construction: 114
Indication of groundwater: /1114
inflow (cesspool must be pumped as pan of inspection)
o s ao s Wre - r 6 _.h>
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etcJ
PRIVY:
(locate on site plan)
Ma(enals of construction: Dimensions:
Depth of solids.zZ
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(r.vi..d 04/25/97) P.g. 8 of 10
U
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Propen, Address: 3 Galery Place Osterville,Mass .
O"nv Frank Burns
Date of Inspection:1 1 /1 9/9 7
SKETCH OF SEWAGE DISPOSAL SYSTEM:
-C[.;de Iles to at least two permanent references landmarks or benchmarks
Iccate all wells -thin 100 (Locate where public water Supply comes into house)
I
I
3 (�6 lle-r y
Inrt..e :r/:5/f71 P.y. 9 of 10
SUBSURFACE SEWACE DISP SYSTEM INSPECTION FORM
SYSTEM INFOI. tON (continued)
PropenYAddress: 3 Gallery Place Osterville,Mass .
Owner: Frank Burns
Date of Inspection: 1 1 /1 9/9 7
rj
Depth to Groundwater /( Feet
Please ind2ate all the methods used to determine High CroundwaW Eli.a!ion:
_ 00;amed from Des,gn Plans on record
]ZOervat,on of S,te (Abuning property, observation hole, basemcrl simp etc.)
e:ermtne it from local conditions
Check with local Board of health
_ Cneck FEM.A, Maps
Check pumping records
Check local e.ca�ators. installers
use USCS Data
Desc,oe ,r, Your own words how you established the High Crouncfwulcrflevat,on. QMust be completed)
Used Cape cod Commission Map
September 1995
Water table Contours
And
Public Water Supply
Well head Protection Areas
J.P.Macomber &Son Inc. . Installed this
septic system in 1985 . 12 Years ago. No water encounterd
at 14 ' .
lr
TOWN OF Barnstable BOARD OF HEALTH
SU!lSUIIFACF SEHA(;F DISPOSAL SYSTF,M INSPECTION FORM - PART D .- CERTIFICATION
�. �...r.•^-r••.••...--. -^.--n.r.-T•n:rrtr-i.r.rr,ra�Tr-�c•t� rn-.arnm'�'*�s�,e�+r rsrsr.rs•.t.rrsr� rsen n•.mrnr,rv-r�•r+rrm.:—rrrr—•r. —.
-TYPE OR PRINT CI.EARL)'-
PI?OPERTY INSPECTED
STREET ADDRESS 3 Gallery Place Osterville,Mass .
ASSESSORS MAP , BLOCK AND PARCEL #
OWNER' s NAME FRANK Burns
PART D - CEI?TIFICATION I
NAME OF INSPECTOR Joseph P.Macomber Jr. ,
COMPANY NAME J.P.Macomber & Seii 'Inc.
COMPANY ADDRESS Box 66 Centerville,Mass. 02632
Street Town or City Stat• LIP
COMPANY TELEPHONE ( 508 ) 775-3338 FAX ( 790 ) 1578 - ( 508 )
A
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
complete as of the time of .inspection , The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one :
Sys teui PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
healLh or Llle environment as defined in 310 CMR 16 , 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
--ems-- Sys t e m FAILED*
The inspection which I have con (lcted has found that the system fails to
Protect the 'Public health and the environment in accordance with Title
5 , 3.10 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature Date 11 /19/97
One copy of this certification must be provided to the OWNER, the BUYER
( Where applicable ) and the I30ARD OF HEAL111.
If the inspection FAILED , the owner or ` _Pa rotor shall upgrade the system
wil.l,in one year of the date of the inspection , unless allowed or required
otherwise as provided in 3.10 C�IR 15 . 305
partd . doc
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S byV 31
THE CONLMONWEALTH OF MA.SSA.CHUSETTS
DEPARTMENT OF ENNTRONM:E-i NTA L PROTECTION
BE IT KNOWN THAT
Joseph P.. Macomber, Jr.
Has satisfied the Depar-tmcnt's qualifications as required and is hereby
authorized to use the title [,
CER � i D TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15 .340 and Section 13 of Chapter 21 A of the
General Laws . Issued by The Department of Environmental Protection_
lurx 8- 1995 - ..-----__--------------- -- j ---- —
Acting [)ir .C(Of of t11c Oi �Slc�n of Witcr Pollution Control
1 ~
Fee$ 50
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Zipplitation for Migaal *pztem Con!truction Permit
Application for a Permit to Construct( )Repair( )Upgrade({)o Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot A.3Main Street Ost. owner's Name,Address and Tel.No. Frank Burns
#3 Gallery Place Osterville,Mass. #3 Gallery Place
Assessor's Map/Parcel 0 s t e r v i l l e,Mass. 02655
Installer's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3 S Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 8
Box 66 Centerville,Mass. 02632 J.P.Macomber & Son Inc.
J.P.Macomber & Son INc. Box 66 Centerville,Mass. 02632
Type of Building:
Dwelling XXNo.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( )
Other Type of Building RES No.of Persons 2 Showers( ) Cafeteria( )
Other Fixtures
Design Flow 330 gallons per day. Calculated daily flow 3 x 1 1 0 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Existing 1 000 Type of S.A.S.2-500gallon chambers
Description of Soil
Loamy sand to medium sand.
Nature of Repairs or Alterations(Answer when applicable)
)mitting and removing existing leaching it. Installing two 500
gallon chambers. pi'r1l
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 issu d by this ealth.
Signed r Date 1 2/1 /9 7
Application Approved by Date IVZ 9
Application Disapproved for the following reasons
Permit No. '7 7-6 7 7 Date Issued
---------------------------------�:------
No.— ! , `CG O -7 Fee$
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF.BARNSTABLE, MASSACHUSETTS
Zipprication for Migpool *pgtem Construction Vermit
Application for a Permit to Construct( )Repair( )Upgrade(X)p Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot N main street Os . Owner's Name,Address and Tel.No. Frank Burns
#3 Gallery Place Osterville,Mass. #3 Gallery Place
Assessor's Map/Parcel O s to rvp l l e,Mass. 02655
Installer's Name,Address,and Tel.No. 5 0 8-7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 8
Box 66 Centerville,Mass. 02632 J.P.Macomber & Son Inc.
J.P.Macomber & Son INc. �,,.�Box 66 Centerville,Mass. 02632
Type of Building:
Dwelling- XXNo.of Bedrooms 3 of Size Esq.ft. Garbage Grinder( )
Other Type of Building RES No. of Persons `2 Showers( ) Cafeteria( )
Et Other Fixtures
D�ign Flow 330 gallons per day. Calculated daily flow 3 x}1 10 gallons.
Plan Date Number of sheets Revision Date
Title '
Size.of Septic Tank Existing 1000 Type of S.A.S.2-500gallon chambers
Description of Soil
Loam# sand to medium sand.
' Nature of Repairs,or Alterations(Answer when applicable)
)mit4ing and removing existing leaching pit. Installing two 5000
gallon chambers. ,-w/Tf� qStowe-
Date last inspected:
Agreemefit: -The u�'dersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordannce,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 issu d by this arr,o alth.
`. Signed _� Date 12/1 /9 7
r Applicati n Approved by lev. 4v Date /Z Z 9'7
t Application Disapproved for the following reasons
Permit No q 7' P 7 Date Issued Z Z" 27
i -— ——————————---——--- ————————————————
rR,
THE COMMONWEALTH OF MASSACHUSETTS v�
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (XX) Upgraded( )
Abandoned( )by J.P.Macomber & Son Inc.
at # 3 Gallery Place Osterville,Mass. ( 933 Main ) has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 9 7` G J 7 Z dated � -Z— ? _T
Installer� J.P.Macomber & Son INC. Designer J.P.Macomber & Son Inc
The issuance of this ennrmit shall not be construed as a guarantee that the syste � i function as designed.
Date !,°I , J ? Inspector 1�
No. � � '�
-- ---------------------------Fee 50
THE COMMONWEALTH OF MASSACHUSETTS
z
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Mizpogar *pgtem Con.5truction Permit
Permission is hereby granted to Construct( )Repair{X)Upgrade( )Abandon( )
Systemlocatedat 3 GallewFyPtace Ostervil�le,Mass. ( 933 Main )
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:Construction must be completed within three years of the date of this ermit.
Date: Z— 2" g%7 Approved by
1
ems, tr
10/9/97
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
1, Joseph P.Macomber Jr., hereby certify that the application for disposal works
construction permit signed by me dated 12/1 /97 , concerning the
property located at 3 Gallery Place Ostervi lie,mass. meets all of the
933 Main Street.
following criteria:
There are no wetlands located within 100 feet of the proposed leaching facility
/There are no private wells within 150 feet of the proposed septic system
Y There is no increase in flow and/or change in use proposed
Y There are no variances requested or needed.
l;! If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the
proposed leaching facility will pot be located less than fourteen(14) feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) Flo
f
B)Observed Groundwater Table Elevation(according to Health Division well map)
I
SIGNED : DATE: 1 2/1 /9 7
LICE, S 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).
q:health folder:cert
I
HAII rk
P,�
�rHe
Town of Barnstable
Department of Health, Safety, and Environmental Services
BAuvec,►e Public Health Division
9eb AM
,' �� 367 Main Street, Hyannis MA 02601
CEO Mld�
Office: 508-790-6265 Thomas A. McKean, RS, CHO
FAX: 508-790-6304 Director of Public Health
Frank Burns
933 Main Street, .
Osterville, MA
ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL
CODE, TITLE 5.
The septic system owned by you located at 933 Main Street , Osterville was inspected on
November 19, 1997, by Joseph Macomber, Jr. a Massachusetts licensed septic inspector.
The inspection of your septic system showed that your system has failed under the
guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• Back of sewage into system component due to an overloaded or clogged soil
absorption system.
• Liquid depth in leaching pit is less than 6" below invert
You are directed to hire a licensed Town of Barnstable septic system installer to submit a
sketch diagram of a proposed system to the Town of Barnstable Health Division Office
(Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance
with 310 CMR 15.00, The State Environmental Code, Title 5 within(14) fourteen days of
receipt of this notice. You are also directed to bring septic system into compliance within
(60) days of receipt of this order letter.
You are further directed to maintain the system by hiring a licensed septage hauler to
pump the septic system to prevent discharge of sewage or effluent into the buildings, onto
the surface of the ground, or in to surface waters.
Any person aggrieved by any order issued by the local approval authority may appeal to
any court of competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER OF THE BOARD OF HEALTH
o as A. McKe�an, .S., C.H.O.