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0972 MAIN STREET (OST.) - Health
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OwtANT? m s "'• e 's,✓ ` '. -t 4 .`' s,,. •.s'�, x• �_ ,'' `,.;.� sue. .'F ,.. ,�-'fa ' 1' � 'z. y , ' rfi' NI" x; '�✓g��#e�. ..:�y ,,,�, j ��. -a�.,;�� �,� , � :.� �� .� �� s��,• gar `�'r�,, �t�• 'fin z 5. F , CI - '+ .:� a• �� •.;, R. `i�' - r 4 "s c sr :� i, ,��• t s'*sgtf a. a �.- bgy:�"��� p+�a` {, a i Ay -. g -v5t" NEW � '�;�� s :�` , .�� �� ,�ii� I� :+}sus .rt" ��rt »'�� �`'�'� � ��!'�� �. .r.^'� �?�' r��i•�q���`. ������" ���•.�, • f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 972 Main Street F= Property Address Tammi Hayes Owner Owner's Name information is Osterville MA 02655 March 13, 2015 required for every _- page. City/Town State Zip Code Date of Inspection �a 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 filling out forms A. General Information on the computer, use only the tab Inspector: r key to move your 1. I , cursor-do not David D. Flaherty Jr., IRS, REHS use the return Name of Inspector key. Flaherty Environmental Services Company Name - P.O. Box 81 - Company Address Yarmouth Port MA 02675 City/Town - State Zip Code 508-362-1657 SI#4713 Telephone Number License Number B. Certification I certify that l 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. l am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The systerri` ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority March,14, 2015 Inspe or's Signature 67 Date The system inspector shall submit a copy of this inspection report tothe Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater;the inspector and the system owner shall submit the report to the appropriate regional office of the DER The original should be 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. LU S t5ins•3113 Title 5 I Inspection Forth:Subsurface S ge Disposal System•Page 1 of 17 r Commonwealth of Massachusetts ~ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 972 Main Street Z Property Address Tammi Hayes a Owner Owner's Name information is required for every Osterville MA 02655 March 13, 2015 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 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 nee_ d 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 Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 L Commonwealth of Massachusetts Title 5 Official Insp ection Fo' rm ,' w Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 972 Main Street Property Address Tammi Hayes Owner Owner's Name information is Osterville MA 02655 March'13 2015 required for-every , page. Cityrrown State Zip Code Date of Inspection. B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): M ❑ Observation of sewage backup or break out or high static water level in.the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y [-],N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipes) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ 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•3113 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 ,M 972 Main Street Property Address Tammi Hayes Owner Owner's Name information is required for every Osterville MA 02655 March 13, 2015 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and`SAS and the SAS is within a Zone 1 of'a public water' supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water. supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no'other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: - You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due.to an overloaded or clogged SAS or cesspool M ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 official- Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 972 Main Street Property Address Tammi Hayes ` Owner Owner's Name information is required for every Osterville MA 02655 March 13, 2015 page. Cityrrown State Zip.Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® n The system is a cesspool serving a facility with a design flow of 2000gpd- 10,0006pd: ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or no. to each of the following, in addition to the questions in Section D. Yes No ❑ ❑. the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or...a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurfaoe Sewage Disposal system•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M ,•''y 972 Main Street Property Address Tammi Hayes Owner Owner's Name information is required for every Osterville MA 02655 March 13, 2015 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? ® 0 Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, ' dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information.for example,.a plan at the'Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 972 Main Street Property Address Tammi Hayes Owner Owner's Name information is required for every Osterville MA 02655 March 13 2015 - page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents:. 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system2(Inciude laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ =Yes ❑ No Seasonal use? ❑ Yes ® -No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? -❑ Yes ® No ' 2015 Last date of occupancy: a Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(9Pd) 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: r t5ins-3113 Title 5 Official Inspection Form: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 , 972 Main Street Property Address Tammi Hayes Owner Owner's Name information is required for every Osterville MA 02655 March 13, 2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) - Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: . gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system. ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes,attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and . maintenance contract(to be obtained from system owner) and a copy of latest inspection of the l/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3t1 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 L Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments M 972 Main Street Property Address Tammi Hayes Owner Owner's Name information is Osterville MA 02655 March 13 2015 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: 1982 per BBOH Were sewage odors detected when arriving at the site? El Yes- ® No Building Sewer(locate on site plan): • -Depth below grade: 3.5feet 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.): joints tight, venting through dwelling adequate, no evidence of leakage Septic Tank(locate on site plan): Depth below grade: feet Material of construction: Z 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 1500 gallon Dimensions: 3„ Sludge depth: t5ins•3113 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 972 Main Street Property Address Tammi Hayes Owner Owner's Name information is required for every Osterville MA . 02655 March 13, 2015 page. Cityrrown d State Zip Code. Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 6.r Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 14 How were dimensions determined? dip stick, tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): maintenance pumping should be performed every two to three years, inlet&outlet with no tees but good, tank seems structurally sound, liquid level appropriate, no evidence of leakage 4 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 Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 972 Main Street Property Address Tammi Hayes Owner Owners Name information is required for every Cisterville MA b2655 March 13, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site,plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes' ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): 4 Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 972 Main Street Property Address Tammi Hayes Owner Owner's Name information is required for every Osterville MA 02655 March 13, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert N/A Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): no dbox 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: M t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 972 Main Street Property Address Tammi Hayes Owner Owner's Name ` information is required for every Osterville MA 02655 March 13, 2015 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: (1) ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number,length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number., ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of e vegetation, etc.): (1)6'x 6' leachpit with 3' stone;located near stonewall, pit dry,no signs of hydraulic failure or breakout, vegetation typical (lawn) 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•3113 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments. M 972 Main Street Property Address Tammi Hayes Owner Owner's Name information is required for every Osterville MA . 02655 March 13, 2015 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.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System.Form.-Not for Voluntary Assessments 972 Main Street Property Address Tammi Hayes Owner Owner's Name information is required for every Osterville MA 02655 March 13, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells.within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately � I C5 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection dorm Subsurface Sewage Disposal System form Not for Voluntary.Assessments 972 Main Street Property Address Tammi Haves Owner Owner's Name information is required for every Osterville MA 02655 March 13, 2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >11 - feet - -Please indicate all methods used to determine the high ground water elevation: , ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation.hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ° ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: hand augered to 11' no groundwater encountered Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary.Assessments 972 Main Street Property Address Tammi Hayes Owner Owner's Name information is required for every Osterville t MA 02655 March 13 2015 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth,to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form a Not for Voluntary Assessments Subsurface Sewage Disposal System Form M Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6/15/2000. Inspection forms may not be altered in any way. A. Certification Important: �O When filling out 1. Property Information: IL- PY forms on the computer, use 972Main Street Osterville, MA 02655 . only the tab key Property Address to move your Tammi Hayes cursor-do not use the return Owner's Name key. 205 Prospect Street Owner's Address r� Hingham MA 02043 City/Town State Zip Code Date of Inspection: November 13, 2005 Date 2. Inspector: --� David D. Flaherty Jr., R.S. Name of Inspector Flaherty Environmental Services sA C5 Company Name ° P.O. Box 19 Company Address Wellfleet MA 0 667 Cityrrown. State Zi Code Cn m 508-362-1657 �' Telephone Number Certification Statement: I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Furth Ev on by the Local Approving Authority November 15, 2005 Inspector's Signat re Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 972 Main Street Property Address Cisterville MA 02655 City/Town State Zip Code Hayes 11/13/05 Owner's Name Date of Inspection Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described i e "Conditional Pass" section need to be replaced or repaired. The system,upon com tion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N D) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal an over 20 years old* or the septic tank(whether metal or not) is structurally unsound, ex ' its substantial infiltration or exfiltration or tank failure is imminent. System will pass ins p tion if the existing tank is replaced with a complying septic tank as approved by the B rd of Health. *A metal Sep ' tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Complia a indicating that the tank is less than 20 years old is available. ND Explai t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts y Title 5 Official Inspection Form - Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 972 Main Street Property Address Osterville MA 02655 City/Town State Zip Code Owner's Name Date of Inspection B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the di lbution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distri tion box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping mor than 4 times.a year due to broken or obstructed pipe(s). The system will pass inspection if(wi approval of the Board of Health): ❑ broken pipe(s) are re aced ❑ obstruction is re oved ND Explain: Xvaluation is Required by the Board of Health: exist which require further evaluation by the Board of Health in order to determine if is failing to protect public health, safety or the environment. will pass unless Board of Health determines in accordance with 310 CMR (b)that the system is not functioning in a manner which will protect public health, d the environment: esspool or privy is within 50 feet of a surface water sspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ,M Subsurface Sewage Disposal System Form A. Certification (cont.) 972 Main Street Property Address Osterville MA 02655 City/Town State Zip Code Hayes 11/13/05 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (cont.): 2. System will fail unless the Board of Health (and Public Water Su tier, if any) determines that the system is functioning in a manner that prote s the public health, asafety and environment: ❑ The system has a septic tank and soil absorption Sys (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface ter supply. ❑ The system has a septic tank and SAS an he SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank an AS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septi ank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water sup y well". Method used to de rmine distance: *"This system passes ' the well water analysis, performed at a DEP certified laboratory, for coliform bacteria.and olatile organic compounds indicates that the well is free from pollution from and t that facilit ye resence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided th no other failure criteria are triggered. A copy of the analysis must be attached to thi/her- t5insp.doc 3. Ot •11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 972 Main Street Property Address Osterville MA 02655 City/Town State ZipCode Hayes 11/13/05 Owners Name Date of Inspection D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS.or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Yz day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] Yes No ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 f Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form y,M A. Certification (cont.) 972 Main Street Property Address Osterville MA 02655 City/Town State Zip Code Hayes 11/13/05 Owner's Name Date of Inspection E) Large Systems: To be considered a large system the system must serve a 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 ' a f ci 'addition to the questions in Section D. YES NO ❑ ❑ the system is.within.400 feet of a surface ' king water supply ❑ ❑ the system is within 200 feet of a trib ary to a surface drinking water supply ❑ ❑ the system is located in a nitrog sensitive area (Interim Wellhead'Protection Area-IWPA) or a mapped Z ell of a public water supply well If you have answered "yes" to any question in . ction E the system is considered a significant threat, or answered "yes" in Section D above the lar a system has failed. The owner or operator of any large system considered a significant threat and Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15 04. The system owner should contact the appropriate regional office of the Department. t5insp.doc•11/2004 Title b Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form H B. Checklist 972 Main Street Property Address Osterville MA 02655 City/Town State Zip Code Hayes 11/13/05 Owner's Name Date of Inspection 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 ❑ N Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based.on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(3)(b)] t5insp.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface.Sewage Disposal System Form C. System Information 972 Main Street Property Address Osterville MA 02655 City/Town State Zip Code Hayes 11/13/05 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 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? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d '03: 14 gpd; '04: 9 ( Y 9 (gpd)): 102 gpd Sump pump? ❑ Yes ® No ' Last date of occupancy: presentDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of.design flow(seats/persons/sq:ft., e . Grease trap present? ❑ Yes ❑ No Industrial waste holding tank p sent? ❑ Yes ❑ No Non-sanitary waste disc rged to the Title 5 system? ❑ Yes ❑ No Water meter readin s, if available: Last date of o upancy/use: Date Other(d cribe): t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 I Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments. Subsurface Sewage Disposal System Form C. System Information (cont.) 972 Main Street Property Address Osterville MA ` 02655 Cityrrown State Zip Code Hayes 11/13/05 Owner's Name Date of Inspection 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? Reason for pumping: Type of System: ® Septic tank,-list iem bex soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1982 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of.Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments �M Subsurface Sewage Disposal System Form C. System Information (cont.) 972 Main Street Property Address Osterville MA 02655 City/Town State Zip Code Hayes 11/13/05 Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 3.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >30feet Comments (on condition of joints, venting, evidence of leakage, etc.): joints watertight, venting adequate, no evidence of leakage Septic Tank(locate on site plan): Depth below grade: 3 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 ❑ Yes El No certificate) Dimensions: 1000 gallon Sludge depth: 2 inches Distance from top of sludge to bottom of outlet tee or baffle 32 inches Scum thickness < 1 inch Distance from top of scum to top of outlet tee or baffle 6 inches Distance from bottom of scum to bottom of outlet tee or baffle 14 inches How were dimensions determined? sludge judge, tape measure t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments iG^M Subsurface Sewage Disposal System Form C. System Information (cont.) 972 Main Street Property Address Osterville MA 02655 City/Town State Zip Code Hayes 11/13/05 Owner's Name Date of Inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): inlet and outlets o.k., structurally sound, no evidence of leakage Grease Trap (locate on site plan): x Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fibergla ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top o outlet tee or baffle Distance from bottom of scu o bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumpin recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as relate to outlet invert, evidence of leakage, etc.): Tight or H ding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth low grade: Mat rial of construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): t5insp.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 f C Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cunt.) 972 Main Street Property Address Osterville MA 02655 City/Town State Zip Code Hayes 11/13/05 Owners Name Date of Inspection Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes No Alarm level: Alarm in workin order: ❑ Yes❑ No Date of last pumping: Da Comments (condition of alarm and float switches, etc Distribution Box (if pre/mustbned) (locate on site plan): Depth of liquid level abComments (note if box ution to outlets equal, any evidence of solids carryover, any evidence of leakage intc.): Pump Ch ber(locate on site plan): Pumps ' working order: El Yes ❑ No Ala sin working order: El Yes ❑ No t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 f Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 4fN Sey`e C. System Information (cont.) 972 Main Street Property Address Osterville MA 02655 Cityrrown State Zip Code Hayes 11/13/05 Owner's Name Date of Inspection Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): a If SAS not located, explain why: Type: ® leaching pits number: 1, 6'X 6', 3 stone ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic.failure, level of ponding, damp soil, condition of vegetation, etc.): no ponding, vegetation normal, pit dry, no sign of hydraulic failure t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 l_ • Commonwealth of Massachusetts Title 5 official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form N C. System Information (cont.) 972 Main Street Property Address Osterville MA 02655 Cityrrown State Zip Code Hayes 11/13105 Owner's Name Date of Inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site n): Materials of cons ction: Dimensions Depth of s lids Comm is (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation;/ etc.): t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 972 Main Street Property Address Osterville MA 02655 City/Town State Zip Code Hayes 11/13/05 Owner's Name Date of Inspection Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. t � 3 t5insp.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 A : Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 972 Main Street Property Address Osterville MA 02655 City/Town State Zip Code Hayes 11/13/05 Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: hand augered six.feet below bottom of SAS, no groundwater t5insp.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 i j COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION � F u m m � tl ti ti � re TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 972 MAIN ST OSTERVILLE,MA 02655 L`� �p� R�CEI�ED Owner's Name: LINDA TOUZA C/O CARLA ROY Owner's Address: BOX 466 COTUIT MA.02635 ApR 6 2d�� Date of Inspection: 4/23/01 F gARNSTAgLE 10WHEALTH DEPT Name of Inspector: (please print) JOHN GRACI Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _ Conditionally Passes _ Ne4aopy aluation by the Local Approving Authority Fa Inspector's Signature: Date: 4/23/01 The system inspector shall su 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 now of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments THE SYSTEM PASSES TITLE V INPECTION. RECOMMEND PUMPING NOW AND EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. ****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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 972 MAIN ST OSTERVILLE,MA 02655 Owner: LINDA TOUZA C/O CARLA ROY Date of Inspection: 4/23/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: s X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: THE SYSTEM PASSES TITLE V INPECTION. RECOMMEND PUMPING NOW AND EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.,If"not determined"please explain. n/a 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 Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed` _-distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health); broken pipe(s)are replaced _obstruction is removed ND explain- n/a Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A i, CERTIFICATION(continued) Property Address: 972 MAIN ST OSTERVILLE,MA 02655 Owner: LINDA TOUZA C/O CARLA ROY Date of Inspection: 4/23/01 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(l)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: , _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance n/a "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile compounds organic indicates that the well is free from pollution from that facility and the presence of ammonia g nitrogen and nitrate nitrogen is equal to or less than 3 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: n/a Z i Page of 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 972 MAIN ST OSTERVILLE,MA 02655 Owner: LINDA TOUZA C/O CARLA ROY Date of Inspection: 4/23/01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to 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 ''/z 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 Wa. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of 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. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] _ (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large 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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no 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 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large System has failed.The owner or operator of any largo system considered a significant thrmt 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. f Page 5 of II OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 972 MAIN ST OSTERVILLE,MA 02655 Owner: LINDA TOUZA C/O CARLA ROY Date of Inspection: 4/23/01 Check if the following have been done. You must indicate"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 Were any of the system components pumped out in the previous two weeks X Has the system received normal flows in the previous two week period`? X Have large volumes of water been introduced to the system recently or as part of this inspection ? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out'? X _ Were all system components,excluding the SAS, located on site? X _ 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? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 972 MAIN ST OSTERVILLE,MA 02655 Owner: LINDA TOUZA C/O CARLA ROY Date of Inspection: 4/23/01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: 0 Does residence have a garbage grinder(yes or no): YES Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use:(yes or no): YES Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM �. X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes, attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1982 Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 972 MAIN ST OSTERVILLE,MA 02655 Owner: LINDA TOUZA C/O CARLA ROY Date of Inspection: 4/23/01 BUILDING SEWER(locate on site plan) Depth below grade: 42" Materials of construction:_cast iron _40 PVC Xother(explain): 20 PVC. Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade:36" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8' 6" H 5' 7" W 4'.10"" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle:33" Scum thickness:0" 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: n/a 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 SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND. RECOMMEND PUMPING EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 972 MAIN ST OSTERVILLE,MA 02655 Owner: LINDA TOUZA C/O CARLA ROY Date of Inspection: 4/23/01 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: _(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: n/a 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.): n/a PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 972 MAIN ST OSTERVILLE,MA 02.655 Owner: LINDA TOUZA C/O CARLA ROY Date of Inspection: 4/23/01 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) AS not located explain why: If S Pa n/a Type 1000 GAL 6' X 6' leaching pits, number: n/a leaching chambers, number: n/a n/a leaching galleries, number: nla n/a leaching trenches, number, length: n/a n/a leaching fields, number: nla n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PIT ISFUNCTIONING Y.THE PIT THE TIME OF THE NSPECTION THE STAIN L NES INTHE PIT INDICATE THE WAS EMPTY AT HE LEVEL OF WATER HAS BEEN 6" TO PIPE. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a , f Page 10 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 972 MAIN ST OSTERVILLE,MA 02655 Owner: LINDA TOUZA C/O CARLA ROY Date of Inspection: 4/23/01 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. fox a o� � 3 AA 30L AQ AC 41 Page I I of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 972 MAIN ST OSTERVILLE,MA 02655 Owner: LINDA TOUZA C/O CARLA ROY Date of Inspection: 4/23/01 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 10+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS- 10+FEET S TOWN OF BARNSTABLE LOCATION �,alsTr SEWAGE # VILLAGE ASSESSOR'S MAP & LOT R I f LV INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY J,S-6 0 g�j LEACHING FACILITY:(type) ��� fA.�/' (size) 1p U Z7 NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER Fb� 84f DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED- Yes a �/ No F � � � �' � � �� `� �.A'� `` s � �` � � i , d f' _ / ��� �__ _ �° � _ J If; f NoD..Z`1.'?_ Fxs... ------- THE COMMONWEALTH-OF MASSACHUSETTS �! BOAR® F HE/A HE/A TH Appliration for Disposal Work Tonstrnrtiun 11nmit Application is hereby made for a Permit to Construct or Repair pp y ( ) p (--j'*an Individual Sewage Disposal System at, -- �Addr s ...!� ...�� ------------------•._......_. �, .. �j... :v ---------....--------..... .. � ` � l ;g ess ddr... Installer v Address ^per Type of Building Size Lot..)?J..s-ts--------•..Sq. feet �-, Dwelling—No. of Bedrooms......... .............................Expansion Attic ( ) Garbage Grinder (MO `4 Other—Type of Building a yp g ............................'No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ...................................................... ----------------- -----•--------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width......._........ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by........................................................................... Date...........,............................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ .....•-•-•--•-----••••-•-•------•--•--•.....••••----------•---------------------••••--•-----•------•......................................................... DDescription of Soil........................................................................................................................................................................ x --------------•------ --•-- U Nature of �pair A erat.i,o� —Aer when app cble _ 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 dersi ed further agrees not to place th syste in operation until a Certificate of Compliance has be n ' ed by bo of health. Signe - - ............................................ f / Dat Application Approved BY .....�,/.�......... --- e� Date Application Disapproved for the following reasons:---•-----------------------•-------------....---•------------------------------•------------•---------......-•-- ...--•--•-------------------••----------•--•-•-----------•------••-----••-•-------------•----••--•-----------------------••-•-----------------•-------------•----•-------••------------•--------------- Date PermitNo.......................................................- Issued....................................................... ate 4 �OARDXHEAZT THE COMMONWEALTH OF MASSACHUSETTS Cam.oF............... .................................... v g/i1/l/ fvrr�g�ar�a�e of ft�uut��i�anrr THIS IS TO CER I Y, That the I i�vidW Sewage Disposal *System constructed ( or" Repaired by--------- ---•----•- ..7 �vdl. sc .......... /f .............................................................. has been installed in accordance with the provisions of TI 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No... cs/.._�..y.�.. dated-............................................... THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS OARD /IDF HE!4�_T�A Le Application is hereby made for a Permit to Construct or Repair Vr�� Individual Sewage Disposal 5ystem at: Address Type of Building Size Lot-------- P.....Sq. feet Z Other Distribution box ( ) Dosing tank .( ) U N A�tt&rs Arer when app cable... ......... /---------- ........#/-�A _17 The undersigned agrees to install the aforedescribed Individual Sew�ke Disposal System in accordance with the provisions of T I'AI2 5 of the State Sanitary Code—TheAndersigned further agrees not to place th - system in operation until a Certificate of Compliance ht;as�b neued b h� bo d of health. p�ace in ;D1. ................=...... i Date Date Date Date THE COMMONWEALTH OF MASSACHUSETTS BOARD CVF H�rr( or THIS IS TO CE, T FY, That th 4d iel Sewage Disposal System constructed VK1 Repaired d. � .41.- 4------------AZ has been installed in accordance with the provisions of TIT T' 5 of The State Sanitary Co&as described in the THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. THE COMMONWEALTH OF MASSACHUSETTS ~_ ---'l' �����—�«�F—� �����c---_----- ' mw==��.---_�' _ ,,' � . ruu- ................. yernuoou�o hereby -----_--___-----__-- toConstruct ( l �r ` at �� --- ............................... Street uo shown oothe application ' for Disposal Works Construction 'A'44'of Health ----'--------' FORM /am� x�� w ���. INC.. puc�s*�� � . . ` ' 71 PLOT Vll M.11;. sl,,� doh E LA Q ,:� RCIo ISTF 2 et) l A iJTj 5v�\1 . ,re w tBAXTE �i Na 24048 ' !. SET FN D c ri F`f T 714 (S rou Wt)Ar10(,1 S flow _ �l�zcw u cony Pay TN3AV } `! � � 51•Dl3UuC -� St�'T`t�AG!L Qt'LpuIQC:MIrl.1TS � " r YU�p Y!J • Note: This drawing is an artistic Designed l0/1 1/2017 interpretation of the general Printed: 1/2/ .018 alipeaarancd of tk e design. It is IAW&on ddscftl not.meant to be an exact 'rendition., Croiuley:kit All Drawing.#: 1 i ;r I w i *' 27. 57 lug! 291' N" N M BCFW30 .kEF2D2 38a BC38R 00, a :f V. TP'' i • 1:241 3,01 i; All dimensions size designations This is an o igxal design and must Designed: 1/3/2018 given are subject to verification on not be released or copied unless . Printed: 1/3/2018 job site, and adjustment to fit job applicable fee has been paid. or job conditions: 2`020order placed. Crowley As Bu lt.lcit 7JAII Drawing #: 1 N, Scale. ;.. i �:. 120z i5 b .. _ a f n(� ' mN 42s1� ��.., �' � `. � � . .a...,r!i.!r. •V.. n.... 1 —' h — I IDB�.-`y ~—! 11 f rn - 18' i 3% ' '39 to 3s. 3.311. fie`r 9 t r.6m� sIN i ' 17,2 : ' 25 4'� 10 s; s 22,aa, s _181 cc' •.3{„�. � -39" '" _ I, Nin n00i I W183�LL W3012 W3930 N. w N N window seat/bench ' _�_ i CO _FI3D6 GET.*: BCFW39f2 mop w TZ W - �. ,� ( M C%I Wlhd W seaUb8flCh IL!, .,,.- M TEP2484WD 'TEF2484WD N o ! CO - r' m Wndow seaVbench. h x C angled ''W361224 s. 2 •1 1 5� +q +1S � j s� �$, ..,f I �1 - f 36 si 361 x-18 55,d' All dimensions _size designations t Thin is an original design. and`niust De igned 10/11/2.017` given are subject to verification on. not be released: or copied unless Printed: 1/2/2018 job site :and adjustment. to fit job, a plicable .fee'has been aid or job' J J_ p p conditions. i : ,order placed. Crowley.kit q All Drawing #: 1 No Scale.: