HomeMy WebLinkAbout0061 NEWPORT LANE - Health 61}}Now" ,
..alb 1 Z ; k9 4�
4* X -V" 'l!'r�•
y OsterviIle ' e:< w ;.j, �� •�.
R A d,,P166' 025: �r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' '
61 Newport Lane `
Property Address ;, y
Michael Cosentino
Owner Owner's Name Wit.
information is z
required for every Osterville MA 02655 5-5-18 0
page. City/Town State Zip Code Date of Inspection '=
wa
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 q ,�ptuulmgp��
on the computer, ' 3 0 ! \``���� _jH-0FAfgs,1/14�
use only the tab 1. Inspector: �`�� • ''��'��'�
key to move your p�'r '•.yG
r
cursor-do not James D.Sears z JAMES •: "
use the return key. Name of Inspector
Capewide Enterprises % �'•. ^ o:
Company Name
153 Commercial Street %,FrJ5l INSIp�G``\`���
Company Address
Mashpee MA 02649
City/Town State Zip Code
508-477-8877 S 1623
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. I am a DEP approved system inspector pursuant to Section 16.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
5-8-18
Iq ector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original 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.
l5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
61 Newport Lane
Property Address
Michael Cosentino
Owner Owner's Name
information isequired or every Osterville
MA 02655 5-5-18
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:
The system is three old c.pools w/oran a bur e & vc pipeing.
I
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.doc-rev.6/16 Title 5 Official Inspection Form: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
61 Newport Lane
Property Address
Michael Cosentino
Owner Owner's Name
information is required for every Osterville MA 02655 5-5-18
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.):
❑ 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):
i
❑ 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.doc•rev.6116 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
. 61 Newport Lane
Property Address
Michael Cosentino
Owner Owner's Name
information is required for every Osterville MA 02655 5-5-18
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 tributa
ry ryto a surface wa
ter 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 aseptic 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:
b
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
A/A ❑ ❑ 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
l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
m Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u 61 Newport Lane
Property Address
Michael Cosentino
Owner Owner's Name
information is required for every Osterville MA 02655 5-5-18
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ®. Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CM 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�10 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
61 Newport Lane
Property Address
Michael Cosentino
Owner Owner's Name
information is required for every Cisterville MA 02655 5-5-18
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 manholes uncovered, opened, and the interior
inspected for the condition of the UllfAMM 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): NA Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
l Title 5 Official , Inspection Form
F Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
61 Newport Lane
u
Property Address
Michael Cosentino
Owner Owner's Name
information is required for every Osterville MA 02655 5-5-18
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Three block c. pool's w/oran a burge & pvc pipein .
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection. El Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)): 2016-44,000Gals
Detail: 2017-45,000Gal's
Sump pump? ❑ Yes ® No
Last date of occupancy: NA
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc-rev.6/16 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
61 Newport Lane
Property Address
Michael Cosentino
Owner Owner's Name
information is required for every Osterville MA 02655 5-5-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
1
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
® > cesspool
® Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
c Commonwealth of Massachusetts
l Title 5 Official Inspection Form
r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a
M 61 Newport Lane
u
Property Address
Michael Cosentino
Owner Owner's Name
information is required for every Osterville MA 02655 5-5-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
NA
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 31feet
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.):
Orange Burge pipeing and 4" PVC SCH -40.
Septic Tank(locate on site plan):
Depth below grade: t
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:
Sludge depth:
t5ins.doc•rev.6116 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
61 Newport Lane
Property Address
Michael Cosentino
Owner Owner's Name
information is required for every Osterville MA 02655 5-5-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
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
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
61 Newport Lane
Property Address
Michael Cosentino
Owner Owner's Name
information is required for every Osteryille MA 02655 5-5-18
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
I
t5ins.doc•rev.6116 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
61 Newport Lane
�V
Property Address
Michael Cosentino
Owner Owner's Name
information is required for every Osterville MA 02655 5-5-18
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
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.):
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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form; Not for Voluntary Assessments
61 Newport Lane
Property Address
Michael Cosentino
Owner Owner's Name
information isequired for every
Osteryille MA 02655 5-5-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
® overflow cesspool number: 2
❑ 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.):
Leaching is two block c pool's. Cover's at 8" below grade, dry w/no.sign of over loading T deep.
Y
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration 1.
Depth —top of liquid to inlet invert Dry
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
7'
Materials of construction Block
Indication of groundwater inflow ❑ Yes ® No
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
1 Title 5 Official Inspection Form
to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
61 Newport Lane
�V
Property Address
Michael Cosentino
Owner Owner's Name
information is
Osterville MA 02 - -required for every 655 5 5 18
page. City/Town State Zip Code Date of Inspection
D. System Information (cost.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Main Block C. Pool T deep w/cover at 8" dry.
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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
TOWN OF BARNSTABLE
LOCATION e-W p b Er JAAj, SEWAGE#
VILLAGE O STery& ASSESSOR'S MAP&PARCEL
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY . CQ,S5t3M1
LEACHING FACILITY:(type) a- C¢,Ss�pG��s (size)
NO. OF BEDROOMS y
OWNER I'�AJCr1
PERMIT DATE: COMPLIANCE DATE:
Separation Distance 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
N
a 3a iq
3 yT 28
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
61 Newport Lane
Property Address
Michael Cosentino
Owner Owner's Name
information is required for every Osterville MA 02655 5-5-18
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
l5ins.doc•rev.6/16 Title 5 Official Inspection Form: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
�u 61 Newport Lane
Property Address
Michael Cosentino
Owner Owner's Name
information is required for every Osterville MA 02655 5-5-18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
N�
Estimated depth t high ground water: 12'+
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:
Ck site and area. No G.W. problem seen. Bottom of over flow at 7' below grade.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev,6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Y Title 5 Official Inspection Form .
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
61 Newport Lane
Property Address
Michael Cosentino
Owner Owner's Name
information is required for every Osterville MA 02655 5-5-18
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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
TOWN OF BARNSTABLE
LOCATION n e_W pp�'f' IA6& SEWAGE#
"A VILLAGEO STe(vik ASSESSOR'S MAP&PARCEL IGG' a
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY ct,ZPM)
LEACHING FACILITY:(type) a' C¢,Ssp W b (size)
NO.-OF BEDROOMS y
OWNER ��AJer1
PERMIT DATE: COMPLIANCE DATE:
Separation Distance 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 T/1S_�
A
,A f3 a 3
a 3a iq
� 3 y8 ay
TOWN OF BARNSTABLE
LOCATION SEWAGE# Z D/B —/18
VILLAGE ASSESSOR'S MAP&PARCEL 25
alb Id
INSTALLER'S NAME&PHONE NO. CaeIw11)c 6nl , y)) -rd77
SEPTIC TANK CAPACITY
LEACHING FACILITY. (type) (size)
NO.OF BEDROOMS ct�%Inc�e L-onts cr1(-1 '
OWNER ;u l A C oS C-N n^/o
PERMIT DATE: Lt -LS - l 8 COMPLIANCE DATE: S 4/
Separation Distance 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
FURNISHEDBY G4k-WIDE �Y1Iq2t��-s A
�.z = 32. CRk R�
zL '
g� L
3
-3 A Z.li `
No. ^/ Fee v
or—
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
0(ppfication for 30isposal .pstem Construction permit
Application for a Permit to Construct( ) Repair(A Upgrade( ) Abandon( ) ❑Complete System ndividual Components
Location Address or Lot No. (01 (Q C-7(,v 7 0A_T L.V Owner's Name,Address,anti Tel. (No. e
Ia'ti�r4�'C. CoSEcl00 .7�ec.4 j,¢TTa
Assessor's Map/Parcel �-� I -,4LW1 pi:; N (Ai- ,4"
Installer.'s Name,Address,and Tel.No. 08-4't7--271 Designer's Name,Address,and Tel.No.
C�Dcw�a� �•t�zP�cs� tJ 14
CS ��C1 Sr S
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 B d of He lth. B j
Si ed
Application Approved by X Date
Application Disapproved by Date
for the following reasons
Permit No.C i---� a� Date Issued
---------------------------------------------------------------------------------------------------------------------------------------
- No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in compute
PUBLIC HEALTH DIVISIO1 4OWN OF BARNSTABLE,-MASSACHUSETTS Yes
Rpplicatioii for disposal Opstetn Construction VPrinit
Application for a Permit to Construct( ) Repair(A Upgrade(" )Abandon( ) ❑Completq.System . [ Individual Components
Location Address or Lot No. p O er's Name,Address,and Tel.No. t.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. �-q1'T .2"al-1 Designer's Name,Address,and Tel.No.
6XP
153 <:JAW.0 t"-C[ S-r
Type of Building:. }k
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
r.. . Nature of Repairs or Alterations(Answer when applicable) j,J 9 �crpa {r
Date last inspected:
Agreement:
n.. The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions-of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Sign Date c -
b 5
Application Approved by �_ h Date
Application Disapproved by Date
zfor the following reasons
Permit No.C �tS`" —1 .� Date Issued / lb-!! /'1
---------------
THE COMMONWEALTH OF MASSACHUSETTS
�. BARNSTABLE,MASSACHUSETTS --
Certificate of Compliance
THIS IS TO CERTIFY that the On-site Sewage Disposal system Constructed( ) Repaired(X Upgraded( )
Abandoned( )by
at f IUFt.IJJ�U�Z L.4.�c J �`1 S-7— has been constructed in accordance f
with the provisions of Title 5 and the for Disposal System Construction Permit Noc;b/i�_-/dated Ll es�/
Installer CA
`r�l Designer
#bedrooms Approued.design flow gpd
The issuance of this permit shall of be onstrued as a guarantee that the system will 6n ^ esi ed. ;
Date Inspector
- -- --- ----------- ------------- ----- -------- -------------------------------------------
No. C 7"/�^
Fee
THE COMMONWEALTH OF MASSACHUSETTS
� {`Q PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal 6psteni Construction J)Prmit
Permission is hereby granted to Construct( ) Repair as(x) Upgrade( ) Abandon( )
System located at �- uj(�o gzc , LA,tJ o 9 T"'t-_Fx_Y l!4.A'
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 completed)yithin three years of the date of this permit. —• .
Date Approved b .�
s �
i
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 61 Newport Lane
Osterville, MA 02655 L
Owner's Name: Sally Haven ��
Owner's Address: A
Date of Inspection: . November 10, 2006
Name of Inspector: (Please Print) James M. Ford
Company Name:. James M. Ford. �-
Mailing Address: P.O.Box 49 Ny
Osterville,MA 02655-0049
Telephone Number: (508) 862-9400
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the inrmation repgrted`a
below is true,accurate and complete as of the time of the inspection. The inspection was perform4-'based on r*
p �..
training and experience in,the proper function and maintenance of on site sewage disposal systems. I� m a DEg 'r-n
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
N e s Further Evaluation by the Local Approving Authority
it
g
Inspector's Signature: Date: November 13, 2006
The system inspector shall sub it 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..
Notes and Comments
**"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.
Title 5 Inspection Form 6/15/2000 page I
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 61 Newport Lane
Osterville, MA
Owner: Sall
v Haven
Date of Inspection: November 10, 2006
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 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.
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.
ND explain:
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:
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:
2
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 61.Newport Lane
Osterville, MA .
Owner: Sally Haven
Date of Inspection: November 10, 2006
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
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 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.
3. Other-
3
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 61 Newport Lane
Osterville. MA
Owner: Sally Haven
Date of Inspection: November 10, 2006
D. System Failure Criteria applicable to all systems:
You must indicate either"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'/z day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public 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:]
No (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 System:
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
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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 61 Newport Lane
Osterville• MA
Owner: Sally Haven
Date of Inspection: November 10, 2006
Check if the following have been done: You must indicate"yes"or"no"as to each of the following:
Yes No
✓ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ _ Has.the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ _ Was the site inspected for signs of break out?
✓ _ Were all system components,excluding the SAS,located on site?
✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes No
✓ _ 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)]. .
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 61 Newport Lane
Osterville, MA
Owner: Sally Haven
Date of Inspection: November 10. 2066
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): n/a Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: 1
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently Occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Pumped 2 years ago-per owner
Was system pumped as part of the inspection(yes or 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)
Tight Tank Attach a copy of the DEP approval ,
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Date of installation unknown
Were sewage odors detected when arriving at the site(yes or no): No
6
r
Page 7 of 11
OFFICIAL INSPECTIO
N,FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 61 Newport Lane
Osterville. MA.
Owner: Sally Haven
Date of Inspection: _November 10. 2006
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron 40 PVC _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan) (Cesspool acting as a septic tank)
Depth below grade: To grade
Material of construction: concrete _metal _fiberglass _polyethylene
✓ other(explain) Cesspool block
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 5'W x 6'T x 8'bottom to grade
Sludge depth: --
Distance from top of sludge to bottom of outlet tee or baffle: --
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: --
Distance from bottom of scum to bottom of outlet tee or baffles
How were dimensions detennined: Measuring stick
Comments(on pumping recommendations,inlet andputlet tee or baffle condition, structural integrity,liquid levels
as related to outlet invert, evidence of leakage,etc.):
No outlet tee was present. The cover was to Qrade.
GREASE TRAP: None (locate on site plan)
Depth below grade:
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:
Comments(on pumping recommendations,'inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARYASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 61 Newport Lane
Osterville. MA
Owner: Sally Haven
Date of Inspection: November 10, 2006
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grader
Material of construction: -_concrete ''_metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Commments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: None (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids canyover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 61 Newport Lane
Osterville, MA
Owner: Sally Haven
Date of Inspection: November 10, 2006.
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
✓ overflow cesspool,number: 2
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.):
One overflow cesspool 02)was 5'W x 6'T x 8'bottom to Qrade and had 6'of 1Lquid on the bottom Liquid was up to the outlet
ape. The cover was to grade. The other overflow 03)was 5'W x 6'T x 8'bottom to grade and had 6".of liquid on the bottom
The scum line was at the same level. The cover was to trade There did not appear to be any Sign of failure
CESSPOOLS: None (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 or no):
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: None (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Coirunents(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 61 Newport Lane
Osterville, MA
Owner: Sally Haven
Date of Inspection: November 40, 2006
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.
i-- —----- :.-------- _ ----
A�FlLk B
a► IG 3
a
3
10
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 61 Newport Lane
Osterville, MA
Owner: Sally Haven
Date of Inspection: November 10, 2006
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 30+/- feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet.of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS.database-explain:
You must describe how you established the high ground water elevation:
Using Barnstable topographic and water contours maps the maps were showing approximately 30'+1-to Around water at this
site.
This report has been prepared only for the septic system and components described herein. This septic system has been
inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will
function properly in the future. There have been no warranties or guarantees, either expressed, written or implied,
relating to the septic system; the inspection, this report and/or any components of the septic system which have not
been located and inspected.
11