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HomeMy WebLinkAbout1381 MAIN STREET (OST.) - Health 1381 MAIN'9 i STERVILLE r 0 0 TOWN OF BARNSTABLE LOCATION ztC 00,'" SEWAGE # VILLAGE �� �� ^� A�SSSSESS S MAP & LOT enn NAME&PHONE NO �� //�� /�• ��� SEPT >cG�L'IC TANK CAPACITY 1AW �,*,, ��- CP LEACHING FACILITY: (type) 10,06 P '(s )10� NO. OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation.Di stance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by k +o Jc- O". F TOWN OF BARNSTABL E L0CATI0N j �I_h'_J�_� �._ _._S WAGE #� _ VILLAGE �T�/��i!/� ASSESSOR'S MAP & LOT//7 - ®?d INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY�d LEACHING PACILITY:(type)_ NO. OF BEDROOMS _snn PRIVATE WELL- OR PUBLIC WATER . BUILDER OR OWNER- R-6 b7- W 5,PL/,t=/j DATE PERMIT ISSUED:_��/�C ,� tf _"_,oz, -----� DATE COMPLIANCE ISSUED;_ VARIANCE GRANTED: Yes _� No ���� .. w.- j � No. I Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftpliLAtion for Mispo8AY 6pstem Cunstruttion permit Application for a Permit to Construct( ) Repair(A Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 1321 en Az'h S`. C S TM-1 Owner's Name,Address,and Tel.No. l.O ti' 1 6 b nn /� Assessor's Map/Parcel h 0-7 0 1� CX 1`�o&►4 , A-I_ 5 Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. CAP&w;ka evf _ n-S c3 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 Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of He h. Signe Date �p I �'0 13 Application Approved by Date 1. Application Disapproved by Date for the following reasons Permit No. 3 Date Issued ( � 1 / 3r � i �,. No. � - Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVIISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2ppli(Ation for Misposal 0pstem Construction Permit Application for a Permit to Construct( ) Repair ) Upgrade( ,)+ Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No:(3$1 M o0r,'his 0 51 K"11� Owner's Name,Address,and Tel.No. ( Wr Assessor's Map/Parcel i � p� I00 p Installer's Name Address and Tel.No. Designer's Name,Address and Tel.No. y �r Type of Building: Dwelling No.of Bedrooms Lot Size -_ sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) y Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. w Description of Soil r� Nature of Repairs or Alterations(Answer when applicable) 14 -2 0 No -,3 oti AMA L� 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 Heath. Signe Date (0 Application Approved by Date to Application Disapproved by Date for the following reasons Permit No. >' Date Issued - - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )by (� 0-W at ?J g r►%-q',H 51_ o 511 E0.%.,' %1— has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. l j` 3 a-C?-Jdated Installer C�� J-P'% �1f)' LLL Designer #bedrooms 1 Approved design flow / gpd/' The issuance of this pe it shall not construed as a guarantee that the system will f2)ioniaass dessig)ned.d. Date //� 1 Inspector f i�'!/ l 17t ---------------------------i----------------------------------------- ----------------------------------------------- No. /�'G 13 Fee d— , THE COMMONWEALTH OF MASSACHUSETTS / PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair(K) Upgrade( ) Abandon( ) System located at ► '3 1 �Nt A�� S7: D 5'f'E 12 �- l Y and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be co'pleted within three years of the date of this permit. Date l Approved by Commonwealth of Massachusetts Title 5 Official Inspection Form ram. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1381 Main Street Property Address Claire Murray Owner Owner's Name information is required for every Osterville MA 02655 5-21-13 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 ```����� OF rgss�,��� on the computer, ���� •••'°' !I z,� use only the tab 1. Inspector. o- • yc key to move your � � t JAMES R, cursor-do not James D.Sears `o. :-4= use the return a, S€AFS key. Name of Inspector *: ; ,� Z CapewideEnterprises,LLC s�i'••�F�TIF��°:��2 1 Company Name rp� ,6 I N SpSGp��``�\` 153 Commercial Street ►..tutor Company Address Mashpee MA 02649 Cityrrown State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: M1 ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority . /n�2.di 5-21-13 Ins is 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 DFP. The original should be sent to the system owner and copies sent to the buyer,ifzappheablet;ari oproving authority: ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection".not address how the system will perform in the future under the same or different conditions of usiZ A VW � 4 � 02'1 t5ins•3/13 Title 5 Official Inspection ortn. uhsurface Sewage Disposal System•Page 1 of 17 { Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i. yr< 1381 Main Street Property Address Claire Murray Owner Owner's Name information is Osterville MA 02655 5-21-13 required for every page. Cityrrown State Zip Code Date of Inspedion 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: Conn. Pass, D Box not level. All flow going to one pit. Box is 10"xl0 plastic. Wall caving in. Need to replace D Box w/cement Box. Pipeing in and out of box SCH 20 PVC. Need to replace w/SCH 40 PVC Tank inlet cover under old brick patio Both tank covers need to be raised. B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the,following statements. If not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3113 Title 5 official fnspeofion Forth:Subsurface Sewage Disposal System•Page 2 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .' 1381 Main Street Property Address .Claire Murray Owner Owner's Name information is required for every Osterville MA 02655 5-21-13 page. Citylrown State Zip Code Date of Inspection B. Certification (cunt.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ® distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): D Box is 10"x10"-40" Below grade. D Box is plastic,wall caveing in. Two line's out. Need to replace D Box ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below).. ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning In a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments- °< 1381 Main Street Property Address Claire Murray Owner Owner's Name information is required for every Osterville MA 02655 5-21-13 page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded I ❑ ® or clogged SAS or cesspool ❑ ® Liquid depth in mapM is less than 6"below invert or available volume is less than'Y2 day flow fiT t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 17 j Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1381 Main Street Property Address Claire Murray Owner Owner's Name information is required for every Osterville MA 02655 5-21-13 page. cityrrown State Zip Code Date of Inspection B. Certification (cunt.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. El ® 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 11 of'a public water supply well v 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•3/13 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 r , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1381 Main Street Property Address Claire Murray Owner Owner's Name information is required for every Ostefyille MA 02655 5-21-13 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they 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? ® El information 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. ® El approximation 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): NA Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 550 t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1381 Main Street Property Address Claire Murray Owner Owner's Name information is Osterville MA 02655 5-21-13 required for every page. City/town state Zip Code Date of Inspection D. System Information Description: The system is a1500 Gal.tank DBox and two pits. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 2011-165,000GaI2012-45,000Gal's Detail: Sump pump? ❑ Yes ® No Present Last date of occupancy: Date Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft.,etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3f13 Title 5 OMdal Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 t Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °yt 1381 Main Street Property Address Claire Murray Owner Owner's Name information is required for every Osterville MA 02655 5-21-13 page. CitylTown State Zip Code Date of Inspection D. System Information (cunt.). Last date of occupancy/use: Date Other(describe below): , General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® 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/Altemative 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts - Title 5 official Inspection Form Subsurface Sewage Disp osal System Form-No r 9 P Y t for Voluntary Assessments M 1381 Main Street Property Address Claire Murray Owner Owner's Name information is required for every Osterville MA 02655 5-2T-13 page. cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components, date installed(if known)and source of information: 1983 Permit #.82-553 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 41" Depth below grade: 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 to and from Box 4" PVC SCH 20 Pipeing should be replaced w/4"pvc sch 40 Septic Tank(locate on site plan): Depth below grade: 31"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: 1,500 Gal. Precast 4" Sludge depth: t5ins•3113 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1381 Main Street Property Address Claire Murray ` Owner Owner's Name information is required for every Osterville MA 02655 - 5-21-13 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-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 Woutlet baffle. Tank and out let cover at 31" below grade. Inlet cover under old brick patio. Tank covers need to be raised. Grease Trap(locate on site plan) Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1381 Main Street Property Address Claire Murray Owner Owner's Name information is required for every Osterville MA_ 02655 5-21-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons - Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1381 Main Street Property Address Claire Murray Owner owner's Name information is required for every Cisterville MA 02655 5-21-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box, etc,): D Box is 10"x10%40" below grade. D Box is plastic,wall's caving in. Two line's out..Need to replace D Box 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. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1381 Main Street Property Address Claire Murray Owner Owner's Name information is required for every Cisterville MA 02655 5-21-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cost.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is two precast pits. Pit 1 and cover at 39"below grade. Camera out from D Box. 17-18"from inlet line to water level. Pit 2 and cover at 26"below grade dry wall's clean. Note: All of flow going to pit#1 Due to D Box and pipeing. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 't 1381 Main Street Property Address Claire Murray Owner Owner's Name information is required for every Osterville MA 02655 5-21-13 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, , etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 OtBdal inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts ITTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1381 Main Street Property Address Claire Murray Owner Owner's Name information is required for every Osterville MA 02655 5-21-13 page. Cityrrown State Zip Code Date of Inspedion D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building" Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately a 43 tetc k, I A 1 PAT© _� _ l _ 42 I got 13 13 L- _ _ ° - / 3) ' . 3 y- t5ins-3113 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1381 Main Street Property Address Claire Murray Owner Owner's Name information is required for every Osterville MA 02655 5-21-13 • page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells N0 Estimated depth toFigh ground water: ��t+ Please indicate all methods used to determine the high groundwater elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: G W off past report 20'+ bottom of Pit at 9'+ bottom of Pit at 11'+above g.w. depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Tft 5 official h spection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments y< 1381 Main Street Property Address Claire Murray Owner Owner's Name information is Osterville MA 02655 5-21-13 required for every 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 a t5ins 3/13 Tige Official p 5 Oal Ins ectfon Foam:Subsurface Sewage Disposal System•Page 17 of 17 • t Commonwealth of Massachusetts Title 5 Official Inspection Farm a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1381 Main Street Property Address Claire Murray Owner Owner's Name information is required for every Ostetyille MA 02655 '05102/13 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 I cursor-do not Michael Kellett g use the return Name of Inspector key. Aardvark Environmental Inspections my Company Name PO Box 896 �I Company Address East Dennis MA 02641 City/rown State Zip Code - 508-385-7608 SI 3742 Telephone Number Vicense Number B. Certification I certify that I have personalty inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15A00).The system: ® Passes q❑ Conditionally Passes - ❑ Fak, � O ❑ Needs Further Evaluation by the local Approving Authority r w 05/05/13 �< Inspector's Signature d Date 51. The system inspector shall submit a copy of this inspection report to the Approvi g Author%(Bop of Health or DEP)within 30 days of completing this inspection.If the system is a shared sy em 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•11/10 Trite 50fficial Inspection Form:SegeDisposal System•Page 1 of 17 • T Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1381 Main Street Property Address Claire Murray Owner Owner's Name information is required for every Osterville MA 02655 1 05/02/13 page. Cityrrown State Zip Code EWe of Inspection B. Certification (coat.) Inspection Summary:Check A,B,C,D or E/ahvays complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. 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 eAttration ortank 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. l ' *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins-11/10 l Title 5Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 ems.: Y Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1381 Main Street Property Address Claire Murray Owner Owner's Name information is required for every Osterville MA 02655 05/02/13 page. Citylrown state Zip Code Date of Inspection B. Certification (font.) B) System Conditionally Passes(cont.): ❑ 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): 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•11/1 C. Tie 5 of iar Inspection Form.Subsurface Sewage Disposal System•Page 3 of 17 I Commonwealth of Massachusetts 93 Title 5 Official Inspection Form UW.,, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1381 Main Street Property Address Claire Murray Owner Owners Name information is required for every Osterville MA 02655 05/02/13 page. Cityrrown state Zip Code Date of Inspection B. Certification (cunt.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has aseptic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well'". Method used to determine distance: *"This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool ❑. ® Uquid depth in cesspool is less than 6"below invert or available volume is less than 1/.day flow t5ins•11/10 We5Official Inspection Form.Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1381 Main Street Property Address Claire Murray Owner Owner's Name information is required for every Osterville MA 02655 05/02/13 page, City1rown state Zip Code Date of Inspection B. Certification (cons) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. El ® 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 ebst 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 faded 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 1381 Main Street Property Address Claire Murray Owner Owner's Name information is required for every Osterville MA 02655 05/02/13 page. Cityrrown state Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner,occupant,or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?Of 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): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 550 t5ins-11/10 Title 5Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1381 Main Street Property Address Claire Murray Owner Owner's Name information is required for every Osterville MA 02655 05/02/13 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 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? t ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings,if available(Cast 2 years usage(gpd)): Detail ` Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft.,etc): Grease•trap present? ❑ Yes '❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Tide 5 system? ❑ Yes ❑ No Water meter readings,if available: t5ins-11/10 Tie 5Official inspection Forth:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1381 Main Street Property Address Claire Murray Owner Owners(dame information is required for every Osterville MA 02655 05/02/13 page" Cityrrown state Zip Code Mate of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: - " gallons How was quantity pumped determined? r� o Reason for pumping: Type of System: ® Septic tank,distribution box,soil absorption system ❑ Single cesspool c ❑ Overflow cesspool410 e 'R ❑ Privy ❑ Shared system(yes or no)(f yes,attach previous inspection records,if any) ❑ Innovative/Aftemative 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 VA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Titte 5Ofrciat Inspection Form:Subsurrace Sewage Deposal System•Page 8 of 17Y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1381 Main Street Property Address Claire Murray Owner Owner's Name information is required for every Osteryille MA 02655 05/02/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components,date installed(if known)and source of information: 12/06/82 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3.6 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.): Septic Tank(locate on site plan): Depth below grade: 2.8 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: 1,500 gal Sludge depth: 4" , t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1381 Main Street Property Address Claire Murray Owner Owner's(dame information is required for every Osterville MA 02655 05/02/13 page. Citylrown State Zits Code Date of Inspection D. System Information (cunt.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? measured Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc): The tank was sound and tight with tees in place and liquid at outlet invert. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑metal El fiberglass © polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-11/10 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1381 Main Street Property Address Claire Murray r Owner . Owner's Name information is required for every Osterville MA 02655 05/02/13 page. Citytrown State Zip Code Date of Inspection D. System Information (coat.) Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc): E Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc): Attach copy of current pumping contract(required).Is copy attached? ❑ Yes ❑ No t5ins-11/10 _ Title 5 ClI icial inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1381 Main Street Property Address Claire Murray Owner Owner's Name information is required for every Osterville MA 02555 05/02/13 page. Cityfrown State Zip Code Date of Inspection D. System Information (font.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert even Comments(note if box is level and distribution to outlets equal,airy evidence of solids carryover,any evidence of leakage into or out of box,etc.): The box was level and tight with no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Soil Absorption System(SAS) (locate on site plan,excavation not required): If SAS not located,explain why: t5ins-11/10 Titte5 CMial trrspecbm Forth:Subsuftce Sewage Disposal System-Page 12 of 17 L ' l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forrn-Notfor Voluntary Assessments. �< 1381 Main Street Property Address ' Claire Murray A Owner Owner's Name , information is required for every Osterville MA 02655 05/02/13 page. Citylrown State Zip Code Date of Inspection . D. System Information (cont.) Type: ® leaching pits 2 _ number: ❑ leaching chambers number: ; 3 ❑ leaching galleries' number: ❑ leaching trenches number,length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: . ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): This system has two 6'x6'precast pit surrounded by a foot of stone.There was 24"between th inlet invert and the liquid. Cesspools(cesspool must be pumped as part of inspecfion)(locate on site plan): Number and configuration ; Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction, Indication of groundwater inflow .:'. ❑ Yes. ❑ No t5ins-11/10 Title 5 official inspection Form:Subsurface Sewage DNxml System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1381 Main Street Property Address Claire Murray Owner Owner's Name information is required for every Osterville MA 02655 05/02/13 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.): 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.): l t5ins•11/10.. Tine 5 Official inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 1 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1381 Main Street Property Address Claire Murray Owner Owner's Name information is required for every Osteryille MA 02655 05/02/13 page. Citylrown State Zip Code Date of inspection D. System Information (cunt:) 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 43 , rear 35 47 32 34 51 26 60 t5ins-11/10 Idle 5 Ofrtcial Inspection Fomr Subsurface sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1381 Main Street Property Address Claire Murray Owner Owner's Name information is required for every Osterville MA 02655 05/02/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to,high ground water: 20.0 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 hale 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: USGS Maps show an elevation of over 20.0 feet I / 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 Commonweafth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments • 1381 Main Street Property Address Claire Murray Owner Owner's Flame information is required for every Osterville MA 02655 05/02/13 page. Citylrown 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 t t5ins•11/10 Td1e 5 C ffxial Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 i 1' 1_OL .00� D s .; sr oo BOR'I'OLOTTI CONSTRUCTION, INC. ��, 45 INDUSTRY ROAD, MARSTONS MILI.,S, MA 02648' 508-771-9399 508 428-892G 'FAX: 508-428-9399: 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: knl Z&L& Date Of Inspection Inspector's Name• Owner's Name and Address: CERTIFICATION STATEMENT: I Certify that 1 have personally Inspected the Sewage Disposal System at this address and that the informa- tion reported below is true,accurate and complete as of the time of Inspection. The Inspection was perfornr-. ed based on my Training and Experience'in the Proper-Function and Maintenance of On-Site Sewage Dis- posal Systems.Th system: v 4 4 E Passes " Conditional) ses Needs F er vain t' yjhiLocal Approving Authority Inspector's Signature Date:_ The System Inspector shall submit a copy of this Inspection Report to the Approving Authority with Thirty (30) Days of completing this Inspection. If the System is a Shared System or has a Design Flow of 10,000 gpd or greater,the Inspector and the System Owner shall submit the Report to the appropriate Regional Office of , the Department of Environmental Protection. The Original should.be sent to the System Owner and copies sent to the Buyer,if applicable and the Approving Authority. INSPECTION SUMMARY: A) SYST PASSES: 1 have not found any information which indicates that the System violates'any of the fail- ure criteria as defined in 310,CMR 15.303. Any Failure Criteria not evaluated are indi- cated below. B) SYSTEM CONDITIONALLY PASSES: One or more System Components need to be Replaced or Repaired. The System,upon completion of the Replacement or Repair;Passes Inspection. Indicate yes,nor,or not determined (Y,N,OR ND). Describe bases of determination in all instances. if"not determined",explain why not. The Septic Tank is Metal,Cracked,Structurally Unsound,shows Substantial Infiltration or exfil tration,or Tank Failure is imminent. The System will Pass Inspection if Existing Septic Tank is Replaced with a conforming Septic Tank as Approved by the Board Of Health. Sewage Backup or Breakout or High Static Water Level observed in the Distribution Box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven Distribution Box. The System will pass Inspection if(With Approval of the Board Of Health): SUBSURFAC'E.KWAGE DISPOSAL:SYSTEM ,INSPECTION FORM PART A CERTIFICATION (cogtiuued) Broken pipe(s)replaced Obstruction is removed Distribution Box is leveled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). The System will pass inspection if(with approval of'The Board Of Health): Broken pipe(s)are replaced' "-`-Obstruction is renioved. C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board Of Health in order to determine if' the System is failing to protect the.Public Health,Safety and the Environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HELATH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or Privy is within 50 Feet of a Surface Water Cesspoolor Privy is within 50 Feet of a bordering Vegetated Wetland or a Salt Marsh. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(ANU PUBLIC WATER SUPPLIER,IF APPROPRIATE).DETERMINES.THAT THE SYSTEM IS,FUNCTION- AN I­11N.A MANNER THAT PROTECTS THE PUBLIGHEALTH AND SAFETY AND THE ENVIRONMENT.The system has a'Septic•Tank and Soil Absorption System and is within 100 Feet.to a Surface Water Supply or Tributary to a Surface Water Supply. 'The System has a Septic Tank and Soil Absorption System and is with a'Zone.I of a Public Water Supply Well. The System has a Septic'Tank and Soil Absorption System and is within 50 Feet of a Private Water Supply Well. The System has a Septic Tank and Soil Absorption.System and is less than 100 Feet but 50 Feet or more from a Private Water Supply Well, unless a Well Water Analysis for coliform bacteria and volatile organic comp ounds ow�ds indicates that the Well is from pollution from P on P � the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 54PPm• D)SYSTEM FAILS: have determined that the System violates one or more of the following Failure Criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overload or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clog ged SAS or cesspool.,, gg .. . ,. . , Static liquid level.in the distribution,box above outlet inillvert due;to,an overloaded or clog- ged SAS or cesspool t1C n >.k a #ly t'. r Ligmd depth m cesspool.is less Than 6"belowFinvert or available volume is less than 1/2 d,aflow. „ � .. _ Y . . Required,pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped 2 - RSIIBSURFACE��SEWAGE DISPOSAL" SYS'I`EM 'INSI'EC'I'IUN 'FORM PART A " CERTIFICATION (continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a Public Well. Any portion of a cesspool or privy is within 50 Feet of a private water supply well. Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet-from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to,the criteria above: The design flow of a system is,10,000 ggd or greater,(Large System)and the system is a significant threat to public health and safety.and the environment because:one or more of the following r l'ondltions exist .. r .: sz•c -_.., r• c`,. i i. +�.� t. ' I he system is within 400'Feet of'a surface drinking water supply . . ; :• .F Tlie system`iswithin 200 Eeet'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 mappe -,>,n . s ' • • d Zone 11 of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 315 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.B CHECKLIST Check if the following have been done: ' Pumping information was requested of the owner,occupant,and Board of Health., f None of the system components have been pumped for'atleast two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. __kZAs-built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up: •V• The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. "e y` ' t'•.aQ ' zAII'system components;'excluding the Soil Absorption System;have been located on site.. _ The septic tank manholes were uncovered,opened,acid the Interior of the septic tank was in spected'for'conditionof baffles or tees;material of construction,dimensions,depth of liquid, depth of sludge,depth of scum," I/ The size and location of the Soil Absorption System on the site has been determined based oil existing information or approximated by non-intrusive methods. - 3 - fi t �'''' ' t' °''SUBSURFACE`SEWAGEb'llISPOSAL 'SYS I EM INSPECTION FORM PART B CHECKLIST(continued) _.ZThe facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL: Design Flow:560 gallons Number of Bedroons: C _Number of'Current Resid is Garbage Grinder:_ Laundry Connected To System: Seasonal Use:f Water Meter Readings,if ilable: Last Date of Occupancy:WAaZ COMMERCIALANDUSTRIAL - , Type of Establishment:" . . ._ •. Design,Flow: r- _ gallons/day'Grease Trap"Present. (yes Industrial-Waste HoldingTank-Present: _._�.. :,._... _._...__.. Non=SanitaryWaste Discharged To The-Title V System: --- Water Meter Readings,if Available: - Last Date of Occupancy: OTHER: (Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS-any source of iniformation: � w System Pumped as part of inspection: f yes,v me pumped: gallons Reason for Pumping: TYP"F SYSTEM: Septic'1'ank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy ' Shared System(If yes,-attach previous inspection records,if any) Other(explain): ROXIMATE AGE of-all components,date installed (if_know and-source'of information:' ju Sewilge odors detected when-arriving at the site:- -4- SUBSURFACE: SEWAGE•DISPOSAL,,SYSTEM4INSPECTION .FORM PART C GENERAL JNFORMATION (continued) t SEPTIC TANK. ry:, Depth below grade: Material of Construction: ✓ concrete metal FRP Other (explain) Dimensions: Sludge Depth: /J�� Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: 2-2 Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,,conditioin of inlet and outlet to s or baffles,depth of liqui level r in relation to ou et invert,structural integrity,evidence of leakage,etc.) 9 (I(, �• GREASE TRAPl� Depth Below Grade: Material of Construction: concrete metal FRP Other .(explain): Dimensions• Scum Thickness: 'Distance from top of scum to top of outlet tee or baffle: Comments:(recomnendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural nftegr�ty,evidence,of leakage,etc:) TIGHT OR HOLDING TANK: Depth Below Grade: Material of Construction: concrete metal FRP Other (explain): Dimensions:. Capacity: gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: Depth of liquid level above outlet invert: Comments: (not level and distribution is a ual,evid ice of sol'ds carryover,evidedce f leaks a into or 0 of box,etc.) . �ZILI` PCIMP CHAMBER u_ Pump is m working order x Conunentsc (note condition of pump'chamber,cond�hou of pumps hod appui:enances,etc) t F .T? - 5 - SUBSURFACE SEWAGE,DISPOSAL,SVS'1'11,M INSI•E('TION FORM PART C SYSTEM INFORMATION(continued) SOIL ABSORPTION SYSTEM(SAS): (Locate on site plan,if possible; excavation not required,but may be approximately by non-intrusive methods) If not determined to be present,explain: Type Leaching pits,number: Leaching chambers,number: Leaching galleries,number: Leacahing trenches,number,length: Leaching fields,.number,dimensions: Overflow cesspool,number: Co unents: (note conidtion of soi signs of hydraulic failure level f ponding, ondition of vegetation,etc.) �- 00 , 14 , CESSPOOLS; Number..and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: De th of scum la er::' , Dimensions of Cesspool: P, Y P Y P Materials of construction:-> '+ Indication of groundwater: Inflow(cesspool must be pumped as part of inspection)_ Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) PRIVY: Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hyddraulic failure,level of ponding,condition of vegetation, etc.) 1 - 6 - C SUBSURFACE SEWAGE:DISPOSAL SYSTEM 'INSPN('rTION°1 FORM PART C SYSTEM INFORMATION(6)ntinuetl) SKETCI1 OF SEWAGE DISPOSAL. SYSTEM: Include ties to atleast two permanent references,landmarks or henchmarks.� Locate all wells within 100 Feet. - w - ry - - �._. __. .___ ___.._.. [a i .-. i;f'3•sr iv'a4,'d tt _ .. _•k• h.�wi� ��`b _.. a,tt ✓1: #i'!' �c:k a?, - a r I , •i. —. ._. _' _____..._., ..... __.�C` #Jr ..;fD. u dr k,�i €# � S O9• I'Y a�.r x >.€- i 1 rl t DEPTH TO GROUNDWATER: / Depth to groundwater: f 9 Feet Method of Determination or Approximation: U , 7 _ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 1381 MAIN ST. OSTERVILLE Name of Owner CAROL SMITH Address of Owner: BOX 1022 OSTERVILLE MA.02665 Date of Inspection: 6/17199 /d Name of Inspector:(Please Print)JOHN GRACI I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: n/a Mailing Address: n/a 3 �99 Telephone Number: n/a T 9 B try tH0FpI' f CERTIFICATION STATEMENT a�y` I certify that I have personally inspected the sewage disposal system at this address and that the information reported,below,isdtrue,ac rate and complete as of the time of inspection.The inspection was performed based on my training and experience in the propenfutl ltzn.artd� maintenance of on-site sewage disposal systems.The system: X Passes The Inpection Is based on criteria defined in Title V _ Conditionally Passes code 310 CMR 15.303.My findings are of how the system Is _ Needs Further Eval a n By the Local Approving Authority performing at the time of the Inspection.My inspection does Fails not Imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. Inspector's Signature: Date:6/17/99 The System Inspector shall ubmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection. f the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. revised 9/2/98 ', Page 1 of 11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1381 MAIN ST.OSTERVILLE Owner: CAROL SMITH Date of Inspection:6/17/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: n(a One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. Wa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or. the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. n1a Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced n/a The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2198 Page 2 of 11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1381 MAIN ST.OSTERVILLE Owner: CAROL SMITH Date of Inspection:6/17/99 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a ` private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nla_(approximation not valid). 3) OTHER n/A revised 9/2/98 Page 3 of 11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1381 MAIN ST.OSTERVILLE Owner: CAROL SMITH Date of Inspection:6/17/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped n/a. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,.volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) , The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. 3 revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1381 MAIN ST.OSTERVILLE Owner: CAROL SMITH Date of Inspection:6/17/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [1 5.302(3)(b)1 X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98' Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1381 MAIN ST.OSTERVILLE Owner: CAROL SMITH Date of Inspection:6/17/99 FLOW CONDITIONS RESIDENTIAL: Design flow:3UQ g.p.d./bedroom Number of bedrooms(design): 5 Number of bedrooms(actual):$ Total DESIGN flow: U& Number of current residents:4 Garbage grinder(yes or no):YES Laundry(separate system)(yes or no): No If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no):M Water meter readings,if available(last two year's usage(gpd): nLa Sump Pump(yes or no): N_Q Last date of occupancy: nLa COMMERCIAL/INDUSTRIAL Type of establishment: nLa Design flow: n&gpd(Based on 15.203) Basis of design flow: nLa Grease trap present:(yes or no):�LQ Industrial Waste Holding Tank present:(yes or no): NQ Non-sanitary waste discharged to the Title 5 system:(yes or no):NO Water meter readings.if available:nLa Last date of occupancy: n& OTHER: (Describe) nla Last date of occupancy: n& GENERAL INFORMATION PUMPING RECORDS and source of information: 1995 BY BORTOLOTTI System pumped as part of inspection:(yes or no):DLO If yes,volume pumped nLa_ gallons Reason for pumping: nLa TYPE OF SYSTEM XSeptic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: nLa APPROXIMATE AGE of all components,date installed(if known)and source of information: THE SYSTEM IS APPROXIMATELY 15 YEARS OLD. Sewage odors detected when arriving at the site:(yes or no): DLO -revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1381 MAIN ST.OSTERVILLE Owner: CAROL SMITH Date of Inspection:6/17/99 BUILDING SEWER: (Locate on site plan) Depth below grade: aLC Material of construction:_ cast iron _40 PVC X other(explain) Distance from private water supply well or suction line: TOWN Diameter: Wa Comments: (condition of joints,venting,evidence of leakage,etc.) n& SEPTIC TANK: X (locate on site plan) Depth below grade: X Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) n& If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): MQ n(a Dimensions: L R'6"H 6'7"W 4'M Sludge depth: 2_ Distance from top of sludge to bottom of outlet tee or baffle: 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: ME How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND,RECOMMEND PUMPING SYSTEM EVERY TWO YEARS FOR PROPER MAINTENANCE, GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) n(a Dimensions: n& Scum thickness: Wa Distance from top of scum to top of outlet tee or baffle:-n& Distance from bottom of scum to bottom of outlet tee or baffle n& Date of last pumping: WA Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) DLa revised 9/2/98 , Page 7 of 11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1381 MAIN ST.OSTERVILLE Owner: CAROL SMITH Date of Inspection:6/17199 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n& Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene other(explain) n& Dimensions: nLa Capacity: nLa gallons Design Flow: n& gallons/day Alarm present: NO Alarm level:jiLa- Alarm in working order:Yes_No_ NQ Date of previous pumping: nLa Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nLa DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:LIQUID LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) DISTRIBUTION BOX IS STRUCTURALLY SOUND, SYSTEM IS FUNCTIONING PROPERLY PUMP CHAMBER: MQ (locate on site plan) Pumps in working order:(Yes or No): MQ Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) n& revised 9/2/98 Page 8 of 11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1381 MAIN ST.OSTERVILLE Owner: CAROL SMITH Date of Inspection:6/17/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: Type: leaching pits,number: 2-1000 GALLON LEACH PIT leaching chambers,number: 11La leaching galleries,number: 1]La leaching trenches,number,length: nLa leaching fields,number,dimensions: nLa overflow cesspool,number: nLa Alternative system: nLa Name of Technology: _n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PITS ARE FUNCTIONING PROPERLY TH RE IS NO SIGNS OF FAILURE, CESSPOOLS: _ (locate on site plan) Number and configuration: n& Depth-top of liquid to inlet invert: nta Depth of solids layer: nLa Depth of scum layer. nta Dimensions of cesspool: nta Materials of construction: WA Indication of groundwater: Wa inflow(cesspool must be pumped as part of inspection)n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nLa PRIVY: _ (locate on site plan) Materials of construction:ala Dimensions:Wa Depth of solids: nta Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n[a revised 9/2/98 Page 9 of 11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1381 MAIN ST.OSTERVILLE Owner: CAROL SMITH Date of Inspection:6/17/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house), n/a tCIL / Vh�%0 G l� IQ O NA q ✓ q5 �c,4�� 0� 33 k &1)3 �6 - y 9C P revised 9/2/98 Page 10 of 11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1381 MAIN ST..OSTERVILLE Owner: CAROL SMITH Date of Inspection:6/17/99 NRCS Report name: n/a Soil Type: n& Typical depth to groundwater: nta USGS Date website visited: nLa ; Observation Wells checked: NO Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: - Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions _ Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS AND VISUAL-12+FEET revised 9/2/98 Page 11 of 11 No.---. sz2: S_., Fim$.... ........ tAE COMMONWEALTH OF MASSACHUSETTS j BOAR® OF HEALTH Q,b 4 )..[.O.1AL.�........ oF...�.A�- z`r�-�r`1 rgfiration for Bi-spooa1 orkii (futwuttstion rratit a Application is hereby made for a Permit to Construct (V) or Repair ( } an Individual Sewage Disposal L System at:e 1 Location-Address or It No. r� _.. A_? Eisz............... ........................_GP..fJ-4�$ `� ............ .1.:.............-- Owner Address FWj ...............................-.Jos.1-.�AVVN c---------------------------------- .......................... . . . ......................................................... Installer Address Q Type of Building Size Lot--- ....Sq. feet Dwelling—No. of Bedrooms..............S..........................Expansion Attic ( ) Garbage Grinder ( ) Other—T e 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 capacitylS _gallons Length................ Width---------------- Diameter................ Depth................ x Disposal Trench—No-------- - ----- Width_-.._r__........... Total Length.................... Total leaching area....................sq. ft. ,. ______ Diameter.._.__...__-___- Depth below inlet.._..... 4? .G..0..s ft. � Seepage Pit No........ __ p � _._.____ Total leaching area _ q. Z Other Distribution box (✓) Dosijj& tank ( ) Percolation Test Results Performed by XXTM_±.aVS.....k.AW 05..F .. Date_._....9-y2-------------=-----_-. Test Pit No. 1.....1�....minutes per inch Depth of Test Pit........1:1.-.... Depth to ground water..__"'................ Test Pit No. 2......:�-....minutes per inch Depth of Test Pit.......LZ...... Depth to ground water------- ............. p+' ............................................................... •--•-------------------------... ------------------------- •-------------------------------- ODescription of Soil........................................................... r••--•--•--•••--•--••---------•-------•-•-----•--•------•••-•-••--•--------•-----------••----•-•--------- x W ------------------------------------------------------------------------------------------------------------------------------------•---------------------------------------••....••-•..........•-•-- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ------------------------------------------•--•-----------------------•---------------.........----••----•-....---------------------------------------•-----------------------------------............... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System•in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signe...................... ice. " ,. -------•---••••----------- ............ • `� -----. ..__.Application Approved By.....--- ?�. ate Application Disapproved for the following reasons:................................................................................................................ ......................................_.......................................................................................................................................... ...................... Date PermitNo......................................................... Issued-....................................................... Date No..... �? . .' 3 F�$..... .f............... . . THE COMMONWEALTH OF MASSACHUSETTS •� �.. BOARD OF HEALTH - OF.... .�����-.( T '. �� 1..................................... Appliratiou for Uhipvii al Works Tougtrurtiou rumit Application is hereby made for a Permit to Construct O or Repair ( ) an Individual Sewage. Disposal System at: p 9 MAP & Location-Address or Lot No. _ ................... ......Z.....:-Ate .1 -s� `= '-----•-------• ........... 60 v o.r: _...I.------•-----a........................................ Oy�w,n�er Address ...............................L1..1Cl.l.Z:.lJi_A..C---- ------------------------------- ........................... .........-...-..---.....-•------------•------••-^-^----- Installer Address Type of Building Size Lot..... (�f"Z{.. ...Sq. feet � Dwelling—No.,of Bedrooms...............S_.........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building _`__________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures __________ __________________ _ ----•--------------.----••-•••••••-•------•---•--•--------•---•-•----•---------------------._..........-......._... W Design Flow.................S, 5_._..____..._ =Vllons per person per day. Total daily flow..__._.__._____._.._`E'.�'�____._____gallons. WSeptic Tank—Liquid capacity_l(. 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__.4_2a.sq. ft. Z Other Distribution box .( 4 Dosing,tank ( ) _ '-' Percolation Test Results Performed by._�`a__AXTL k.4_0`j _.._., :.-�_Q�` �1.__ _. Date___.____f_::.L.::��-..__..__. Test Pit No. 1.......--___minutes per inch Depth of Test Pit______-_f_.2-... Depth to ground water_____".:............... fT Test Pit No. 2.......Z_-':_.minutes per inch Depth of Test Pit........l_Z..... Depth to ground water........_` ............. RS ------.----•---------•-•-•-•---------------------------------------------------••------•-•--•-•-•---......................................................... 0 Description of Soil---- .......................:..............•-•--•--•--•--... .....---•--•-------------------------•---------------•---------------- ............................... ........... ... :_ .EY1.V.�1t1 ��A� ::: v -------------------------------••---••-------------- W -----•------------------------------------------------------------------------------------------------------------------------------------------------------•-------•-------------•--------------------- U Nature of Repairs or Alterations—Answer when applicable................_............................................................................... -•------------------•-----------•---•-----.._.._...-----•--•------------•--•---•---•--•----------------------•----------------------•--•-----------------------------------------------•-------....----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI:- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed.......a..t,..... - & .. ................................... -/� .v4'"._,�-�-o' Da e Application Approved B Application Disapproved for the following reasons:.............................................................................................................. ..............................•----------•-----------•---•---.......--••-----------._...•--••-------...-•---------------•----------------------------•-•---•-•---•-.................................... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ; ..........Towi. ...........OF..................( f24!71................................................. Trrtifiratr of. Touts haurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( ) bY ..�--tt V- 1MI�C'--•-•---••--••-•------ Installer at---------------��`-----I-5�------•-----.�t 5 �1=,-----.��>_(,I ` -----��`�.........�,c� 4�---...-----._.....---•-----•---•---•--•-------------------- has been installed in accordance with the provisions of T T r 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No...............2_-SI2........... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE/CONSTRU AS A GUARANTEE THAT THE SYSTEM V�i���FUNCTION SATISFACTORY.DATE.. /./....11T.. Inspecto -•---- THE COMMONWEALTH OF MASSACHUSETTS {' BOARD OF HEALTH . t �` 1"l0. 'l��3LIS ...............o.( ...............O F...........: ................................. FEE..... ................. Disposal Workii Tottofrtiott rrutit Permission is hereby granted.......... ---------•-••-•---------•------------•---------------•---..._....----•-----.............I........_.. to Construct or Repair ( J an Individual Sewage Disposal System Street as shown on the al for Disposal Works Construction Permit No_________________ _ Dated_._______ �._____.____._____........ DATE_ /pp.i/catio � •____________________•___-._••__ Board of Health FORM 1255 HOBBS & WARREN. INC., PUBLISHERS \ t 6300�1 � n � � r w N c1t C N O O HSE.NO.1381 b 26.24' LOT 100 N N 1.52ACRES N O � PROPOSED FARMERS PORCH 00 13 p0 � 13,2� O Cc) W Cn � ��C� o_ •o, M O 0 �o q0 15 A� —— ti6 45 I I I� IM I z I � � to W I oI I I 139.85, N 76.38,02 W '7certify that the dwellingshownon PLOT PLAN OF LAND this plan is as it actually exists on the LOCATED IN ground and that it conf� Cti tie town of Barnstablezoningrgtlations4ar W COTUIT,MASS. yard setbacks, PREPARED FOR CLAIRE MURRAY `! t DATE:FEB. 13,2002 SCALE: 1"=40' date.Feb.13,200X,' CAPE & ISLANDS ENGINEERING flood zone c anon`li�z�rdj `� " main st1381 , : :- MASHPEE,MASS. r , I •. 2e?noJ E.i6T I3 to R:% !' �=F I -. \ r 511.J ca_E JrCCa• o. 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