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HomeMy WebLinkAbout0245 NORTH BAY ROAD - Health 245 North Bay Road Osterville i1 �A` 072 201 _ Commonwealth of Massachusetts Title 5 Official'. Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M a 245 North Bay Road Property Address 3; ' Vincen &Annette O' Reilly ± Owner Owner's Name ! ' information is required for every Osterville MA 02655 4/10/14 page. City(rown it State Zip Code Date of Inspection ii 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 (�I on the computer, �1 use only the tab 1. Inspector: key to move your cursor-do not James Ford use the return Name of Inspector key. r� Company Name P.O. Box 49 s; Company Address �t } Osterville MA 02655 City/Town State Zip Code 508-862-9400 S12482 Telephone Number f { 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. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: d ; ® Passes ❑ Conditionally Passes ❑ Fails Needs Further v uation by the Local Approving Authority t I 4/14/14 Inspec 's Signature i Date The. ys m inspector shall submit a copy of this inspection report to the Approving Authority(Board of He or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 i od 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. s ° ****This report only describesf,i,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 cont,itions of use. s11 [ t5ins•3113 Title 5 Official Inspe enrm: urface Sewage Disposal System•Page 1 of 17 L . i; Commonwealth of Massachusetts w Title 5 Official' Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 �,M r 245 North Bay Road Property Address Vincen &Annette O' Reilly �: .. Owner Owners Name !'• information is Osterville `f F MA 02655 4/10/14 required for every �' page. City/Town State Zip Code Date of Inspection B. Certification (cont.) . Inspection Summary:.Check A,B,C,D or E/always complete all of Section D i A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or ip 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: ' } 5 B) System Conditionally Passes: t; I ❑ 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 substantipl 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 111.❑ ND (Explain below): f• ' f t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of W e u Commonwealth &Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ,r` 3 wM 245 North Bay Road Property Address y Vincen &Annette O' Reilly Owner Owners Name information is required for every Osterville MA 02655 . 4/10/14 page. City/Town State Zi Code -D ate ate of inspection- B. Certification (cont.) ❑ Pump Chamber um s/alarms not operational.P P ., System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): Vw ❑ Observation of sewage'�backup or breakout or high static water level in the distribution box due to broken or obstructedipi,pe(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)i eireplaced _ ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution bo ,is'leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): �e 1; � I }i ii ❑ 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): EJ 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 enviro :,nt: �, El Cesspool or envy is,within 50 feet of a surface water ❑ Cesspool or priVy;is.within 50 feet of a bordering vegetated wetland or a salt marsh i:. t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 p �, t Commonwealth of Massachusetts . Title 5 Official) !Inspection Form Subsurface Sewage Disposal;System Form Not for Voluntary Assessments M ,• 245 North Bay Road 1 Property Address Vincen &Annette O' Reilly Owner Owners Name information is every Osterville R re wired for eve ' MA 02655 4/10/14 page. CitylTown ;:, State Zip Code Date of Inspection B. Certification (cont.)t° 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: r ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet.of:a surf,ace.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. iI ❑ The system has a:.septictank 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 r p esence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provd8d that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 1, 3. Other: f s D) System Failure Criteria A0plicable to All Systems: 9 You must indicate"Yes" 6r,"No"to each of the following for all inspections: Yes No ❑ ® Backwp}of sewage into facility or system component due to overloaded or clogged:SAS or cesspool ; ❑ ®n 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 Y2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I; Commonwealth of Massachusetts Title 5 Officiallnspection Form Subsurface Sewage Disposappi System Form- Not for Voluntary Assessments 245 North Bay Road Property Address Vincen &Annette O' Reilly Owner Owners Name information is required for every Osterville MA 02655 4/10/14 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: ortion of the SAS, cesspool or privy is.below high ground water elevation. El ® Any p ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ®, Any: ortion of a cesspool or privy.is within a Zone 1 of a public well. ❑ JK. , Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Z. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from aiprivate 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 anmo.nia 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 6�6em is a cesspool serving a facility with a design flow of 2000gpd- 10,0dOgpd. ❑ ® 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 syste. ner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To.be cqnijidered 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. I, 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 1-1 IWPA)or a mapped Zone II of a public water supply well i. If you have answered "yes'toy any question in Section E the system is considered a significant threat, or answered"yes" in Sectido.'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 3,10:CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i 4 t; I. . Commonwealth of Mas .sachusetts Title 5 Officia'I, inspection Form ,,f Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 245 North Bay Road Property Address Vincen &Annette O'.Reilly.. Owner Owners Name information is required for every Osterville MA 02655 4/10/14 page. Cityrrown ;;'. State Zip Code Date of Inspection C. Checklist ` I Check if the following havedt;een 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 i, ❑ ® Were "Onj of the system components pumped out in the previous two we eks. ❑ ® Has theisystem received normal flows in the previous two week period? i E ® 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 th`e site inspected for signs of break out? ; ® ❑ Were aIC system components, excluding the SAS, located on site? h,1i ® ❑ 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 si a 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. f t ® ❑ Deterrilined 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)] a , t D. System Information' Residential Flow Conditions: Number of bedrooms (desi n): 5 Number of bedrooms (actual): 5 DESIGN flow based on 31 `rCMR 15.203 for exam le: 110 gpd x#of bedrooms : 550 t5ins•3/13 i I Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 tl • i s t I ', a Commonwealth of Mas*�chusetts Title 5 Officia,[ Inspection Form Subsurface Sewage Disposa''i System Form-Not for Voluntary Assessments I. ; .t 245 North Bay Road Property Address Vincen &Annette O' Reilly Owner Owners Name information is required for every Osterville }l MA 02655 4/10/14 page. City/Town State Zip Code Date of Inspection D. System Informatiolna Description: Number of current residents:';; Does residence have a gar grinder? grinder? El Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection information in this`report.) t `' El Yes ® No Laundry system inspected?, ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: unavailable Sump pump? s 1 r p ❑ Yes ® No Last date of occupancy: ; t Date Commercial/Industrial.Flow'Conditions: Type.of Establishment: Design flow(based on 31'0 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/p,e'rsons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank'r' sent? El Yes ❑ No i Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 ygtl Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 i Commonwealth of Massachusetts u Title 5 Offici [inspection Form Subsurface Sewage Disposal.system Form-Not for Voluntary Assessments °M 245 North Bav Road , Property Address f' Vincen &Annette O' Reilly Owner Owners Name information is required for every Osterville MA 02655 ' 4/10/14 page. City/Town State Zip Code Date of Inspection- D. System Informati®n'~(cont.) Last date of occupancy/use: Date Other(describe below): '" b 4 r ;. .' General Information Pumping Records: Source of information: unavailable Was system pumped as part-of the inspection? El Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ` ® Septic tanki;distribution box, soil absorption system ❑ Single cesspool ❑ Overflow c�'sspool ❑ 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): 4 ' 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 E: Commonwealth of Mas*, usetts Title 5 Official ,Inspection Form Subsurface Sewage Disposat System Form -Not for Voluntary Assessments 245 North Bay Road { Property Address Vincen &Annette O' Reillyt Owner Owner's Name information is si ' required for every Osterville MA 02655 4/10/14 page. CitylTown ?; State Zip Code Date of Inspection D. System Informatioln (cont.) Approximate age of all components, date installed (if known)and source of information: installed in 1987 Were sewage odors detectedpwhen arriving at the site? ❑ Yes Z No Building Sewer(locate on-site plan): l � Depth below grade: feet Material of construction: ; a: ❑ cast iron ® 40!'PV'C ❑ other(explain): r; Distance from private waterr supply well or suction line: feet Comments (on condition of joints,.venting, evidence of leakage, etc.): I; F : Septic Tank(locate on sitel;olan); Depth below grader41 feet 0 Material of construction: >r. • �rl ® concrete ❑ metal ❑fiberglass ❑-polyethylene ❑ other(explain) i. i i; h. ti h If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gals. H-20 t: Sludge depth: F 2„ , i; t5ins•3/13 & Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 6 li Commonwealth of Mass'adhusetts Title 5 Official+ Inspection Form Subsurface Sewage Disposal:system Form -Not for Voluntary Assessments 7 M 245 North Bay Road ,i Property Address Vincen &Annette O' Reilly. ` Owner Ow ners Name information is s required for every Osterville E; MA 02655 4/10/14 page. Cit /Town Y �� `� ; State Zip Code Date of Inspection D. System Informatidt) (cont.) ., 4 ' Septic Tank (cont.) Distance from top of sludge fb bottom of outlet tee or baffle 29" Scum thickness - ...+f 2" n s Distance from top of scum to top of outlet tee or baffle Err y 12" Distance from bottom of scy''fn to bottom of outlet tee or baffle How were dimensions deteirMined? measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to od�jet invert, evidence of leakage, etc.): The tees were present. The'liquid was even with the outlet Steels covers were to grade. I; Grease Trap(locate on site;plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal; ❑fiberglass ❑ polyethylene ❑ other(explain): N/a i Dimensions: I; Scum thickness Distance from top of scum to tdp of outlet tee or baffle Distance from bottom of scum:to bottom of outlet tee or baffle Date of last pumping: << i.; Date l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 g t . Commonwealth of Massachusetts Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 245 North Bay Road t Property Address r Vincen &Annette O' Reilly a `: Owner Owners Name information is r required for every Osterville MA 02655 4/10/14 page. City/Town :,. State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping reooirmendations, 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 El other(explain): N/a ;i Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No ;r Date of last pumping: t Date Comments(condition of ala,rm and float switches, etc.): it l e I Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 �i Commonwealth of Massachusetts Title 5 Officia I. Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM ,•'•y 245 North Bay Road Property Address Vincen &Annette O' Reilly Owner Owner's Name information is required for every Osterville 3 MA 02655 4/10/14 page. City/Town a - State Zip Code Date of Inspection D. System Informati6n: (cont.) Distribution Box if resentrnu( p st be opened)(locate on sit e plan): Depth of liquid level above outlet invert even Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or`ouf of box, etc.): The D-box was normal. !f . r ft • a � Pump Chamber(locate on;site plan): Pumps in working order: ; El Yes ❑ No' Alarms in working order: ❑ Yes ❑ No' Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): i tl . F If pumps or alarms are no)i,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: ; i +, r G; t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 f Commonwealth of Maspachusetts Title 5 Officia ,, Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ;l �M A,•'' 245 North Bay Road Property Address Vincen &Annette O' Reilly Owner Owner's Name information is required for every Osterville MA 02655 4/10/14 page. Cityrrown !i ": State Zip Code' Date of Inspection D. System Information (cont.) Type: d ❑ leaching pitg,'r, number: ❑ leaching chambers number: ri 9-4x4 galleys ® leaching galleries number: 38'x8' ❑ leaching trehohes number, length: ❑ leaching fielLds; number, dimensions: ❑, _ overflow cesspool number: ❑ innovative/alternative system r ' Type/name Fof'technology: Comments (note condition eof.soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 9f, The galleys were dry and clean.There was no signs of failure. A camera was used for the inspection r 4 :`t f Cesspools (cesspool must be.pumped as part of inspection) (locate on site plan): Number and configuration f' N/a Depth—top of liquid to inlet rv,ert Depth of solids layer e. Depth of scum layer F' Dimensions of cesspool Materials of construction q� i . Indication of groundwater iiaflow El Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 • Commonwealth of Masg4chusetts v Title 5 Official' Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments I ,M 245 North Bay Road Property Address Vincen &Annette O' Reilly , Owner Owner's Name information is required for every Osterville MA 02655 4/10/14 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.): u Privy(locate on site plan):, Materials of construction: Dimensions Depth of solids { f 1 Comments (note condition:91 soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/a y t •: i; s _ t • ff ,r: f� t , I R r; 1� t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 1 8� N, • °� Commonwealth of Massachusetts Title 5 Offici�°I, Inspection Form Subsurface Sewage Disposal.System Form-Not for Voluntary Assessments i, . . 245 North Bay r ,M y Road it Property Address t, i Vincen &Annette O' Reilly I " Owner Owners Name information is required for every Osterville MA 02655 4/10/14 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 wit hin 100 feet. Locate where public water supply 6hters the building.,Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached sepatately J • ,' rli o a �,. 31.9 3 96 O t 89 s f' t5ins•3113 I. f Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 f Commonwealth of Massachusetts Title 5 Officiaa Inspection Form Subsurface Sewage Disposal:System Form -Not for Voluntary Assessments ' f. I' 245 North Bay Road Property Address r Vincen &Annette O' Reilly Er Owner Owners Name information is required for every Osterville i , MA 02655 4/10/14 page. City/Town State Zip Code Date of Inspection D. System Informatio'n' (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar " ❑ Shallow wells . Estimated depth to high ground water: 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 Iocal Board of Health-explain: Using topo and water contours maps ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USCjS database-explain: You must describe how you established'the high ground water elevation: Design plans show water at 25'. y , Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r. it i Commonwealth of Massachusetts i Title 5 Official' Inspection Form Subsurface Sewage Disposa) System Form -Not for Voluntary Assessments 1.. wM }'245 North Ba � y Road Property Address Vincen &Annette O' Reilly " Wj'• Owner Owner's Name information is Osterville K' MA 02655 4/10/14 required for every it page. Cityrrown I; i State Zip Code Date of inspection E. Report Completeness Checklist ® Inspection Summary:A, 13,C, D, or E checked 4 ® Inspection Summary D;(System Failure Criteria Applicable to All Systems)completed ® .System Information— Esjimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i i I I' Ir !' i. i. Tj lip 1 t F �f i i t li II , 1. t` �• a o Mrs•3113 9 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 li 1 I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF,ENVIRONMENTAL PROTECTION TITLES OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION (7 - O� -' UO Property Address: 245 North Bay Road Osterville. MA•02655 Owner's Name: Patricia Miller Owner's Address: Date of Inspection:. March 15, 2007 Same of Inspector: (Please Print) James M Ford Company Name: James M Ford Mailing Address: P.O.Box 49 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 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 systeinst I am`a-DEP �s approved system inspector pursuant to Section 15.340.of Title•5(310 CMR 15.000). The system: ✓_ Passes Conditionally Passes , N. Further Evaluation by the.Local Approving Authority F I 1 Inspector's Signature: Date: March 21, 2007 The system inspector shall su n t a copy of lisinspeciion report to the Approving Authority(Board of Health or DEP)within 30 days of comple mg 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 Coimnents. ****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 1 t Page 2 of.11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 245 North Bay Road Osterville, MA Owner: Patricia Miller Date of Inspection: March 15, 2007 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 enfiltration 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 breakout or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken;settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced 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: 245 North Bay Road Osterville, MA Owner: — Patricia Miller' Date of Inspection: , March 15. 2007 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 l 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 am monia 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: _ 245 North Bav Road Osterville MA Owner: Patricia Miller Date of Inspection: March 15, 2007 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'oravailable 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.] No .(Yes/No)The system fails. I have detennined that one or more of the above failure criteria exist as described in 3:10 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 I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: . 245 North Bav Road Osterville, MA Owner: Patricia Miller Date of Inspection: March 15, 2007 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 backup? ✓ 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(arid 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(ifany of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)J. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 245 North Bav Road Osterville, MA. Owner: Patricia Miller Date of Inspection: March 15, 2007 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 5 Number of bedrooms(actual): 5 DE SIGN flow based on 31 0 CMR 15.203 (for example: 110 gpd x#of bedrooms):. 550 Number of current residents: 0 Does residence have a garbage grinder(yes,or no): n/a 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: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR, 1.5.203): 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: i OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Septic tank was dumped after inspection for maintenance Was system pumped as part of the inspection(yes or no): Yes 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: Installed on avg. 1987 Were,sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 245 North Bav Road Osterville, MA Owner: Patricia Miller Date of Inspection:. March 15, 2007 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) Depth below grade: 4' Material of construction: ✓ concrete _metal —fiberglass - ` _other(explain) If tank is metal list age: Is age confirmed by.a Certificate of Compliance(yes or no): (attach.a.copy of certificate) Dimensions: 1500 gal. (H-20) Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 10 Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet.tee or baffler 10" How were dimensions determined: - Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.). Cement tees here present. The liquid level was even with the outlet invert There did not appear to be any si ns of leakage. The tank was puniped after inspection. 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 VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 245 North Bav Road Osterville, MA Owner: Patricia Miller Date of Inspection: March 15, 2007 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no Alarm level: Alarm in working order(yes or no;. Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present.must be opened)(locate on site plan) Depth of liquid level above outlet invert:. ` Even Comments(note if box is level.and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box, etc.): The D-box was level. No solids were Present. The cover was 10"below. 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 I Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 245 North Bav Road Osterville, MA Owner: Patricia Miller Date of Inspection: March 1 S.2007 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type . Teaching pits,number: leaching chambers,nuinber: ✓ leaching galleries,number: _9-4'x4'galleries-38'x 8'per as-built card 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.): Galleries were dry. There did not appear to be any signs of failure The bottom to Qrade was 9'6"A camera was used for the inspection. 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: Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc:): t 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: . 245 North Bay Road Osterville, MA Owner: Patricia Miller Date.of Inspection: March 15, 2007 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. . N ovs� ,. .A: r e o.►T' r------ ----.� a .9 O 3 q (9 �a 0 � 3 - 10 Page I 1 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 245 North Bav Road Osterville, MA Owner: Patricia Miller Date of Inspection: March 15, 2007 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25 feet Please indicate indicate (check)all methods used to determine the hi round water high g elevation. Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting properly/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: Using Barnstable topographic and water contours maps the maps were showing approximately 25'+7 to groundwater at this site. This report has been prepared only for the septic system and components described herein. This septic p system has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will fiinction 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 e COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION AVED ' 0 4. 2003 TOVVI\Uf STABLE TLE 5 HEALTH uEPT. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A. CERTIFICATION Property Address: 245 North Bay Road Osterville, MA 02655 Owner's Name: Tom Rvan MAP Owner's Address: PARCEL Date of Inspection: June 6, 2003 LOT ; Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 OwerviUe.MA 026SS-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 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 Needs Further Evaluation by the Local Approving Authority LiFa Inspector's Signature: Date: June 6. 2003 The system inspector shall sub rt 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 1 Page 2 of I F OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFAC E SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued)' Property Address: 245 North Bay Road Ostervft MA Owner: Tom Rvan Date of Inspection: June 6, 2003 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 l I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 245 North Bay Road Ostervft MA Owner: Tom Ryan Date of Inspection: June 6 2003 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 15303 1 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 I 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 I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 245 North Bay Road Osterville, MA Owner: Tom Ryan Date of Inspection: - June 6. 2003 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 ''/2 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. ✓ An n Y 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 I of a public well. ✓ Any portion of a cesspool or.privy is within 50 feet of a private water supply well. . ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 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 descai'bed 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"nor 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 I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 245 North Bay Road Osterville, MA Owner: Tom Rvan Date of Inspection: June 6, 2003 Check if the following have been done: You mast 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: 245 North Bay Road Osterville, MA Owner: Tom Rvan Date of Inspection: June 6, 2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): S Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): SSO Number of current residents: n/a Does residence have a garbage grinder(yes or no): n/a 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): No Water meter readings,if available(last 2 years usage(gpd)): 2002-305,000 2001-383,000 gals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15203): 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 Sauce of information: Never mopped-Der treatment plant Was system pumped as part of the inspection(yes or no): 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: Approx. 1987 Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of I l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION (continued) Property Address: 245 North Bay Road Osterville, MA Owner: Tom Ryan Date of Inspection: June 6, 2003 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance frown private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC T - ANK: ✓ (locate on site plan) Depth below grade: 4' Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of. certificate) Dimensions: 1500 gal. (H-20) Sludge depth: -2" Distance from top of sludge to bottom of outlet tee or,baffle: 30" Scum thickness: 8" } 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: 10 How were dimensions determined: _ .Measuring stick m r! Coments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc..): Tees mere present. The liquid level was even with the outlet invert, There were no signs ofleakage Steel covers were to grade Recommend pumping. 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 P Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 245 North Bay Road Oste_rville, MA Owner: Tom Ryan Date of Inspection: June 6, 2003 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-box was level and clean. No solids were present There were no signs of backuD or failwe from the leach field The cover was 10"below grade. 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 f Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 245 North Bay Road Osterville MA Owner: Tom Ryan Date of]inspection: June 6 2003 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: 9-4'x 4'Qalleries-38'x 8'-per as built card leading trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Typetname of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): The galleries were located but not dug up There wAere no signs of failure. The bottom to grade was 9'6" 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: Comments(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: 245 North Bay Road Osterville AM Owner: _ Tom Ryan Date of Inspection: June 6. 2003 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. F�OvS� Q l 57.E 4m 1 a 3 q(a �a y 99 Is � � 3 � 1 10 Page I 1 of 11 OFFICIAL INSPECTION FORM - NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 245 North Bay Road Osterville, MA Owner: Tom Ryan Date of Inspection: June 6, 2003' SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 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: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using the Barnstable to noQraphic man and the Water Contours man The mans are showing 25'+/ to groundwater at This site. This report has been prepared and the system 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 system, the inspection andlor this report. t 11 OWN OF BARNSTABLE kllol - orl / qy 669 1` SEWAGE # "VILLAGE O S'7 ary, ASSESSOR'S MAP & LOT Q1a—90/ INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: .(type) yXy 64110-IS (size) '3trX NO. OF BEDROOMS BUILDER OR OWNER 7r✓1 I�YA/1 PERMITDATE: 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 leac ng facility) 1 Feet Furnished by �^S/�CaiOn T �OrC L N oust, a i y F9 -7 s TTT . a � 3 1 erf TO CBLPTABLE -A aLOCATION Of OR SEWAGE # V V lJ VILLAGEC3 STD' R N,5 ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO.('. -"SEPTIC'TANK CAPACITY .SOCK I f1 'oZ� lw 0 LEACHING FACILITY:(type) �fY size) 3�8 _ NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER 4 t'r' IC BUILDER OR OWNER DATE PERMIT ISSUED: 4M DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No s� Aig) w I d, ,7tj G411 I� i b i G. /36 IV do W f No..��..�._. � ! � � � FnB 7T.��...... THE COMMONWEALTfi OF MASSACHUSETTS BOARD OF HEALTH �a �A................oF..:... e4 N, ............................. App ration for Bispos l Works Tnm6nrtiun ramit Application is hereby made for a Permit to Construct (k or Repair ( ) an Individual Sewage Disposal System at: .... 9..2 .ski ... a 4.�.S fz -(t .. . -�....................•-----• -� .................................... Location- ress or Lot No. ...................... - . ............................ ..........._............................------ O ner Address .................C­ ..................................... .................................................................................................. Installer Address Type of Building Size Lot.M_.1,_12).(A�'_._Sq. f t V Dwelling—No. of Bedrooms.._____.____________________________Expansion Attic (�� Garbage Grinder �c 4 Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other_fixtures .................................. W Design Flow............ t.��..._..___.gallons per person per day. Total daily flow-----------. .?.._J�.........................gallons. WSeptic hk—L�quid capacity 1 gallons LengthkQ:: `'... Width 5_'k".. Diameter---_____-_�-.. Depth.�___.0`.r x Disposa�—l�o Width g Total Length Total leaching area... �?` l� sq. ft. Seepage Pit No..................... Diameter.................... DeLh below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box qo& Dosin tank e ~' Percolation Test Results Performed by.b,�K _�V r.�_N.�...................... Date...:----__.R? ........... aTest Pit No. 1. ?.......minutes per inch Depth of Test Pit---A.d.......... Depth to ground water_ _ Test Pit No. 2. ....minutes per inch Depth of Test Pit...lQ:.5-..... Depth to ground water---------------_------ 04 1-�944- •-•-•-....------•---•............. :. .................•-•-••••••-••••........-•-----•--------•-•----.........-----••--..............= 0 Description of Soil........�`�--. ..-"�----.l oA.vwg _�vqq, 2=--10 �M C V CL� ... U C}4= Q..Z_-_1,° !�i,z1 i' �! .......7. �O, .-k" _�ct7 _. / 1�_........ W ----------------------------------------------------------------------------------------------------------------- ----------------------------------•-...---...------------..._..-----•----.__.--------- UNature of Repairs or Alterations—Answer when applicable................................................................................................ . ---------------------------------------------•--•---...._...........---............._.............••-••------••---------------------....---........................------.................-----......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by the board of health. WDate Sign -- ....... /Application Approved �y_.......� .5 ........... ... ... 1.0. 7 Application Disapproved for the following reasons:.. . ...... ... . .. ............. ........................................................... ............................................. ----------------•----------------•---•---------------•-••----------------------------------•------------------------ --------•--- Date Permit No................................T �P.9. Issued............ l . . D No.— ...........Fzz .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......\.0-v4kx-----------***"OF A. ............................. ApPration for Disposal loorks Tonstrurtion Vrrmit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: O0- k'/ I �i -0 ... ......................Lc.) ... . �s......................... .. .............. .................... Location-Oress or Lot No. 4o_ ...................... ...... .....�71a1!............................. ...........I....................................................................................... Owner Address ................. Installed Address Size Lot- -- --------- q. pe Type of Building s S f t U on Attic Q\10 Dwelling—No. of Bedrooms.......�?..................................Expansion Garbage Grinder'�,F' Other—Type of Building ............................ No. of persons............................ Showers Cafeteria P-4 Other fixtures . < ,g7 0----------------------------------------------------------------------------------------------------------------------------------------------- Design Flow.......__...55 1 �� ...............gallons per person per day. Total daily flow--------e_?Z >.........................gallons. ............ ............ 1:4 Septic Tank—Liquid capacity��K.P.gallons Length%Q'.-f,'.'... Widthf,5'..A'..... Diameter---:7-:-:-'--- Depth_:)..-.,a_'.' Disposal h—N o......... .......... Width__.8............ Total Length.._.5�.b........ Total leaching area..5:5� ....sq. ft. Seepage Pit No..................... Diameter................... Depth below inlet.................... Total leaching area...................sq. f t. z Other Distribution box We� DosN tank, Percolation Test Results Performed ...........0.......... Date.... > ........... Test Pit No. ......_..minutes per inch Depth of Test Pit... .......... Depth to ground water. K oc-3�k -Eiu-CQ"J-j Test Pit No. 2.t •-.......minutes per inch Depth of Test ...... Depth to ground water........................ 'J�V_j ........................I.....................................0 Description of Soil......L?------ 'A--\, ...........A.,................... . .—.k 0 .. ..7............. ...... I ht�_- . ............... ................. --------------------- . .... ...... L. ....0. �..V. A....k" .0. ----- ---------- ........................................................................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable................................................................................................ 0............................................0......................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TLITIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...........i.......................................................................... .......................... Dat .... ......... -.7------ -- ----- - -- /1/..0 ---------------- Application Approved-Fy Da e Application Disapproved for the following reasons:..L. ... ....h .....I................................................. ..............................................6tZZ:�..................................................................................I........................................................... Date r-7 IL ( - Permit No. ............. SS1116CL ........................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................OF..................................................................................... Trrtffiratr of Toutpliaurr THIS�JS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired by--------------211� LA�.............. .............................................................................................................................................. 1 N 1 �4 Installer at............�_Oj............ .........� .............................. c.4r;:z ......... ..........S ..... ............... with d d in the has been installed in accordance the provisions of TITIE 5 of The State Sanitary, code. as e,cri e application for Disposal Works Construction Permit No.....__ ..... dated_____________ __ °���.._._...._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUAR!A' , 1E THAT E SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.............0...................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. ..........M..".... .... t 9 ..........OF............... Io......................... FEE...................... Disposal orho T-FaInstrudion 'pautit Permission is hereby granted........ ............................................................................................ ............. ...........L—/"7,"' to Construct or Repair an Individual Sewage Disposal System_ at No........... ....... ...... d sL ........ t.............................� . Ec......)G4'—r ............................ Street ..... ...... as shown on the application for Disposal Works Construction Permit N(T K2. Dated......i...bJ__2125.."_7.... ................... ...... ------------------------------------------ --------Board of Health DATE............. .......................... 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