HomeMy WebLinkAbout0102 OLD EAST OSTERVILLE ROAD - Health 102 Old East Osterville Road
Osterville
A= 145-046
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form' Fill
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Nn I'
102 Old East Osterville Rd. �
U Property Address
Courtney Langdon
Owner Owner's Name
information is f'
Osterville Ma 02655 9-14-1.8
required for every 1
page. City/Town State Zip Code Date of'Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector Information S j.# /3 3 a_
filling out forms i
on the computer, Brett Hickey
use only the tab
key to move your Name of Inspector
cursor-do not B&B Excavation
use the return key. Company Name
374 Route 130
Company Address
Sandwich Ma 02563
City/Town State Zip Code
(508)477-0653 S113747
Telephone Number License Number
B. Certification ,
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 16.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ❑■ Passes _
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
Inspector's Ignature 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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
c Commonwealth of Massachusetts
�e Title 5 Official Inspection Form-
ii
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
102 Old East Osterville Rd.
Property Address
Courtney Langdon
Owner Owner's Name
information is Osterville Ma 02655' 9-14-18
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.'
1) 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:
The system was in working order at the time of inspection.
2) 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):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
IL ,
c� Commonwealth of Massachusetts a
�s Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
102 Old East Osterville Rd.
v Property Address
Courtney Langdon
Owner Owners Name
information is Osterville Ma 02655 9-14-18
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps%alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s).are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
3) 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.
a. 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:
t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
c Commonwealth of Massachusetts
�o Title 5 Official Inspection Form
p .
I e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
102 Old East Osterville Rd.
v
Property Address
Courtney Langdon
Owner Owner's Name
information is Osterville Ma 02655 9-14-18
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ 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
i
b. System Will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
c. Other: F '
4) 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
❑ Q Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
i5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
I e
Commonwealth of Massachusetts
�m ,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
102 Old East Osterville Rd.
L
Property Address
Courtney Langdon
Owner Owner's Name
information is Osterville Ma 02655 9-14-18
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ 0 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
❑ 0 _ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ El Any portion of the SAS, cesspool or privy is below high ground water elevation.
El El tributary
portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ O Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ 0 • 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.] .
❑ O The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ E 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.
5) 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
t questions in Section CA. -
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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
AN,
Commonwealth of Massachusetts
�- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
102 Old East Osterville Rd.
Property Address
Courtney Langdon
Owner Owner's Name
information is Osterville Ma 02655 9-14-18
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no" for each of the following for all inspections:
F
Yes No
❑ ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ E Were any of the system components pumped out in the previous two weeks?
i
❑ 0 Has the system received normal flows in the previous two week period?
El Have large volumes of water been introduced to the system recently or as part of
El this inspection?
0 ❑ Were as built plans of the system obtained and examined?.(If they were not
available note as N/A)
❑ n Was the facility or dwelling inspected for signs of sewage back up?
Q ❑ Was the site inspected for signs of break out?
0 ❑ Were all system components, excluding the SAS, located on site?
El ❑ 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:
E ❑ Existing information. For example, a plan at the Board of Health.
El Determined in the field (if any of the failure criteria related to Part C is at issue
a, El approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
102 Old East Osterville Rd.
Property Address
Courtney Langdon "
Owner Owner's Name
information is Osterville Ma 02655 9-14-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
3 3
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330/gpd
Description:
0
Number of current residents:
Does residence have a garbage grinder? ❑ Yes 0 No
Does residence have a water treatment unit? ❑ Yes Q No
i
If yes, discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes 0 No
information in this report.)
Laundry system'inspected? ❑ Yes g No
Seasonaluse? 0 Yes ❑ No
See below
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
***2016-96,000gallons 2017-50,000gallons***
-Sump pump? ❑ Yes M No
9-8-18
Last date'of occupancy: . 7. Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
102 Old East Osterville Rd.
Property Address
Courtney Langdon
Owner Owner's Name
information is Osterville Ma 02655 9-14-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
NA
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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date ,
Other(describe below):
3. Pumping Records:
Owner- date of last pump is unknown
Source of information:
Was system pumped as part of the inspection? ❑ Yes ❑M No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.R26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
c� Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
102 Old East Osterville Rd.
Property Address
Courtney Langdon
Owner Owner's Name
information is required for every Osterville Ma 02655 .9-14-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
E Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
2-24-1983 per COC
Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No
5. Building Sewer(locate on site plan):
• 21611
Depth below grade: '.. feet
Material of construction:
❑ cast iron ❑■ 40 PVC' ❑ other(explain):
Town water
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
102 Old East Osterville Rd.
Property Address
Courtney Langdon
Owner Owner's Name
information is Osterville Ma 02655 9-14-18
required for every
page. City/Town State- Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
11611
Depth below grade: feet
Material of construction:
■❑ concrete ❑metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
1
Dimensions: 000gallons
611
Sludge depth: '
30"
Distance from top of sludge to bottom of outlet tee or baffle
3"
Scum thickness
L 16"
Distance from top of scum to top of outlet tee or baffle
13"
Distance from bottom of scum to bottom of outlet tee or baffle
measured
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.):
The tank was in working order at the time of inspection. The tank is in need of pumping
at this time and should be pumped every two years for maintenance.
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
t
r
c Commonwealth of Massachusetts
�d Title 5 Official Inspection Form'
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
102 Old East Osterville Rd.
Property Address
Courtney Langdon
Owner Owner's Name
information is Osterville Ma 02655 .9-14-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan): ,
NA
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 ,
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,,structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): ,
NA '
Depth below grade:
Material of construction: A
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
L `
r
c Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments-,
.,
102 Old East Osterville Rd.
Property Address
Courtney Langdon*
Owner Owner's Name
information is Osterville Ma 02655 9-14-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
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
9. Distribution Box(if present must be opened) (locate on site plan):
orr
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.):
The d-box was in working order at the time of inspection.
' k ,
4
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
f- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
102 Old East Osterville Rd.
Lv
Property Address
Courtney Langdon
Owner Owner's Name
information is Osterville Ma 02655 9-14-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes No*
Alarms in working order: ❑ Yes No*
• V.
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
NA
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System(SAS) (locate on site plan; excavation not required):
If SAS not located, explain why:
Type:
(1 ) 6-X6-
0 leaching pits number:
❑. leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑'` leaching fields number, dimensions:
❑ overflow cesspool number:
i t ❑ innovative/alternative system
Type/name of technology:
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
f Commonwealth of Massachusetts
I , Title 5 Official Inspection Form
f Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
102 Old East Osterville Rd.
�v
Property Address
Courtney Langdon
Owner Owner's Name
information is required for every Osterville Ma 02655 9-14-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The leaching was in working order at time of inspection. The leach pit had 2' of standing
water when viewed with no evidence.of past back up.
J
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
NA
Number and configuration
I
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
�e rp Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
102 Old East Osterville Rd.
V
Property Address
Courtney Langdon
Owner Owner's Name
information is Osterville Ma 02655 9-14-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
NA
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
c Commonwealth of Massachusetts
,z Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u 102 Old East Osterville Rd.
Property Address
Courtney Langdon
Owner Owner's Name
information is Osterville Ma 02655 9-14-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. 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
Asbuilt Ground water profile
Grade W
3'
9' -
Garage
C
B 14' 12'
B1.13'
Cl-17'
A2.36' 82.38'
12' >3r
• � 13'
Ground water
t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
�- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
v
102 Old East Osterville Rd.
Property Address
Courtney Langdon
Owner Owner's Name
information is Osterville Ma 02655 9-14-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
0 Check Slope
0 Surface water
❑E Check cellar
,
■❑ Shallow wells
No GW @ 12'
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
12-9-18
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150ifeet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain: a
You must describe how you established the high ground water elevation: '
A plan on file with the Board of Health was used.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
I
Commonwealth of Massachusetts
�s Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
102 Old East Osterville Rd.
U
Property Address
Courtney Langdon
Owner Owners Name
information is Osterville Ma 02655 9-14-18
required for every -
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist r
Complete all applicable sections of this form inclusive of:
■❑ A. Inspector Information: Complete all fields in this section.
❑ B. Certification: Signed& Dated and 1, 2, 3, or 4 checked
❑� C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4(Failure Criteria)and 6(Checklist)completed <
■MI D. System Information: -
For 8: Tight/Holding Tank—Pumping contract attached
Y
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
s
t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
` Commonwealth of Massachusetts -
Title 5 Official .Ins' pection' Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments,,
yY 102 Old East Osterville Rd
Property Address
Barbara Solakian
Owner Owner's Name
information is Osteryille MA 02655 4-20-12 required for every _
page. City/Town State Zip Code Date of Inspection -
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information v
p��1Uf,tttl�t►u�p,
on the
use only tab .�• ��\tN OF MgsS9��iy
1. Inspector: '
key to move your
cursor-do not �.• JAMES •N
James D. Searsuse •;m
key.the return Name of Inspector 3* ;C40
Capewide Enterprises, LLC
�•v Company Name 4 �F
153 Commercial St.
Company Address
law
Mashpee r MA 02649 r '
Citylrown ,` State Zip Code
508477-8877 1. ` , S1623
Telephone Number License Number
B. Certification s
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 s
❑ Needs Further Evaluation by the Local Approving Authority
4-20-12
pector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority. .
****This report only describes conditions at the time of inspection and under the conditions of use .
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use. ;
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts -
' Title 5 Official, 'Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
, •'< 102 Old East Osterville Rd
Property Address
Barbara Solakian
Owner Owner's Name
information is required for every Osterville MA 02655 4-20A2
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: .t .
® 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:
13) System conditionally
Pa
sses:'
.❑ 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 t
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):
•
t5iiis•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
r
9 1 F ., • «
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'l 102 Old East Osterville Rd
Property Address f
Barbara Solakian
Owner Owner's Name
information is
required for every Osterville MA 02655 4-20-12
page. Cityrrown State Zip Code Date of Inspection
B. Certification (coot.)
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):
El
obstruction is removed El Y. El ❑ ND(Explain below):
El distribution box is leveled or replaced ❑ Y ❑r N ❑4 ND(Explain below):'
. •
❑ The system required pumping more than 4 times a.year due to broken'or.obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N.- ❑ ND (Explain below):
❑ obstruction is removed ❑.,Y• ❑ N ❑ ND (Explain below): _^
3
C). Further Evaluation is,Required by the'Board of Health:
El 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:
El Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
' Commonwealth of Massachusetts
Mime Title 5 Official 'Inspection Form, '. I,-
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°< 102 Old East Osterville Rd " {
w.
Property address
Barbara Solakian
Owner Owner's Name
information is required for every Osterville MA 02655 4-20-12
page. City/Town State Zip Code Date of Inspection
B. Certification cont.
,
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment: l
f�
❑ 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. w
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the-SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance: -
This system passes if the well water analysis, performed at a DEP certified-laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal .
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must'indicate"Yes"or"No"to each of the following for all inspections:
Yes No ,
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
i ❑ ® Discharge•or ponding of effluent to the'surface of the ground or surface_ waters
due to an overloaded or clogged SAS or cesspool
El
' ® 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-11/10 " Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
102 Old East Osterville Rd
Property Address
Barbara Solakian' ;
Owner Owner's Name
information is Osterville MA 02655. 4-20-12
required for every .
page. Cityrrown State Zip Code- Date of Inspection
B. Certification (cont.),
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high groundwater 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 r 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 tocorrect 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 m
❑ ' ❑ 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 71WPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11/10 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts .'.
Title 5 Official inspection Form,
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
.' 102 Old East Osterville Rd
Property Address r .
• P
Barbara Solakian
Owner Owner's Name
information is Osterville MA 02655 4-20-12 s
required for every '
page. Cityfrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate``yes":or"no"as to each of the following:-
Yes No w _
❑ ® 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?,
19 ❑ 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)
. 0 ❑ Was the facility or dwelling inspected for signs of sewage backup?'
® ❑ Was the site inspected for signs of break out? ,
� I
® ❑ -' 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?
. .r
® ❑ 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): - 3
DESIGN flow based on 310 CMR 15.203(for example:`110 gpd x#of bedrooms): 330
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System vPBge 6 of 17
IL
x
` Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for'Volunta Assessments
9 P Y ry -
"< 102 Old East Osterville Rd
Property Address ,
Barbara Solakian. '
Owner Owner's Name "t
information is
required for every Osterville MA .. 02655 4-20-12
page. City/Town State Zip Code Date of Inspection
D. System Information
Description: '
The system is a 1000 Gal Precast Tank D Box and Pit
0
Number of current residents:
Does residence have a garbage grinder? ® Yes ❑ ' No
Is laundry on a separate sewage system? [if yes separate inspection required],- ❑ Yes ® `No
Laundry system inspected? ` ❑ Yes ®' No
Seasonal use? ® Yes ❑ No
Water meter readings, if available last 2 ears usage 2011-84.000
9 ( Y 9 {gPd)) 2010-168,000
Detail: .
Sump pump? . ❑ Yes Z . No
Last date of occupancy:_ NA
- .Date'
Commercial/industrial Flow Conditions:
Type of Establishment: _ r
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? to Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No.
Water meter readings, if available:
t5ins•11/10 * Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System-Page 7 of 17
r
Commonwealth of Massachusetts fi
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
• 1
102 Old East Osterville Rd
Property Address
Barbara Solakian -
Owner Owner's Name '
information is Osterville MA 02655 4-20-12
required for every i
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont)
Last date of occupancy/use: Date f
S
Other(describe below): {'
r General Information
Pumping Records: a '
., NA
Source of information: ,
Was system pumped as part of the inspection? E• ❑ Yes ® ,No:
` If yes, volume pumped: gallons
How was quantity.pumped determined? ,
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool -
❑ Overflow cesspool
❑ Privy..
El Shared4system (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):
r
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.�� 102 Old East Osterville Rd
Property Address
K
Barbara Solakian ,
Owner Owner's Name
information is Ostervilte MA 02655 4-20-12
required for every State Zip Code Date of Inspection
page. Cityrrown
D. System Information (cont.) #
Approximate age of all components, date installed (if known)and source of information:
3
1983 Permit # 83-46
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
2'
Depth below grade: feet '
r 4
Material`of construction: "
❑cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line: t feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Piping is 4"sch 40 pvc j
Septic Tank(locate on site plan):
1811
Depth below grade: ,_ feet
r t
Material of construction: '
® concrete ❑metal ❑fiberglass, ❑ polyethylene ❑ other(explain)
y
{
If tank is-metal, list age: years
Is age confirmed by a Certificate of Compliance?:(attach a copy of certificate) ❑ Yes ❑ No
" 1000 Gal Precast
Dimensions:
Sludge depth: ,
t5ins•11N 0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 17
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments -
102 Old East Osterville Rd
Property Address
Barbara Solakian
Owner Owners Name
information is required for every Osterville MA 026.55 4-20-12
page, Cityrrown State Zip Code Date of Inspection
D. System Information (cont.) .
Septic Tank(cunt.)
Distance from top of sludge to bottom of outlet tee or baffle 29" ,
2"
Scum thickness
Distance from top of scum to top of outlet tee or baffle1711
;
Distance from bottom of scum to bottom of outlet tee or baffle
Tape-Asbuilt
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.):
Tank at working level,•in and outlet Baffle, Tank and covers at 18' No-sign of leakage or over loading
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction: . -
❑ concrete 0 metal E fiberglass El 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-11I10 , Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of'Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal gSystem Form Not for Voluntary Assessments
102 Old East Osterville Rd'
Property Address
Barbara Solakian .
Owner Owner's Name
information is
required for every Osterville MA 02655 4-20-12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,etc.): r
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: f '
Capacity: A` gallons
Design Flow: t
gallons per day
Alarm present: y ❑ 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
F
•
t5ins•11/10 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 -
'l 102 Old East Osterville Rd .
Property Address
Barbara Solakian
Owner Owner's Name
information is Osterville MA 02655 4-20-12
required for every a
page. CitylTown State Zip Code Date of Inspection
D. System Information (coot.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet.invert 0
, ,
4
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.): r
D Box is 16"x16",27" Below Grade 1 line out, D Box is 20"off stone drive way, Box is newwith
cover at 8" -
f
Pump amber Ch » - - • .. II
(locate on site plan):
Pumps in working order:, ❑ Yes-'
[l No
Alarms in working order: ❑ Yes 0 No
Comments(note,condition of pump chamber;condition of pumps and appurtenances, etc.):,
•
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:.
• J
t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17
S
' r •.
f
Commonwealth of Massachusetts
. Title 5 Official Inspection 'Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
102 Old East Osterville Rd
Property Address
Barbara Solakian
Owner Owner's Name
information is required for every Osterville MA 02655 4-20-12'
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
f ,
El
leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
•f T
❑ leaching fields '• number,dimensions:
F
❑ overflow cesspool number' <
El innovative/alternative system
Type/name of technology: .
Comments(note condition of soil, signs of hydraulic failure,' level of pondingi damp soil, condition of
vegetation, etc.):
Leaching is one 1000 Gal Precast Pit,-with 2+' stone Pit is 45" Below Grade w/cover at 15 Pit is
dry walls clean like new No sign of over loading,' carry over or stain line
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): e
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer _
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•11/10 y Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
14 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
' 102 Old East Osterville Rd
Property Address • • '
Barbara Solakian
Owner Owner's Name
information is required for every Osterville MA 02655 4-20-12
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Comments(note'condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): -
r
Privy(locate on site plan):, n
-Materials of construction:
Dimensions
Depth of solids r
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
- - � � • ,. � - :.a ' - '! , - ICI
} i '
&ns-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
102 Old East Osterville Rd
Property Address
Barbara Solakian ,
Owner Owner's Name ,
information is Osterville MA' 02655 4-20-12
required for every State Zip Code Date of Inspection.
page City/Town
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 .
0 drawing attach separately '
....... ...-... -
r
r "
I
'a `s
F
w
4t
y
- If _,-. .. .,. t
IF
1.
r
1
•_.:,.,_.:v__.� ......_.ram_ -�...,». _
s 4sr - 5
n. Title 5 official Inspection Forth:Subsurface Sewage Disposal System-page i5 of 17
t5ins•11110
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments'
"< 102 Old East Osterville Rd
Property Address
Barbara Solakian
Owner Owner's Name
information is required for every Osterville MA' 02655 4-20-12 ..
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope r v
❑ Surface water "
❑ Check cellar
❑ Shallow wells " b
15' No Water
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 local Board of Health explain:
❑ Checked with local excavators; installers-(attach documentation)
❑ Accessed USGS database-explain::
You must describe how you established the high ground water elevation: . '
Hand Auger 15' No Water Auger 5' Below Bottom of Pit F
d.. .. -
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
' Commonwealth of Massachusetts .
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
102 Old East Osterville Rd,
Property Address
Barbara Solakian
1 +
Owner
Owner's Name
information is required for every Osterville MA 62655 4-20-12 {
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,2 Estimated depth to high.groundwater
❑ Sketch of Sewage Disposal System either drawn on page 15 or attached inseparate file
• • ' , . _ • . F it
• #1-
r
t5ins i 11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17-
-
No. O'i�/ —`' V Fee 160
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
applitation for Bisposal *pBtem ContrUrtlon Permit
Application for a Permit to Construct( ) Repair 7w Upgrade( ) Abandon( ) ❑Complete System 'Individual Components
Location Address or Lot No. 10A ®Lp�'Z M- (4g ' Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel 45
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
CAIP~®O R00s LL<—I
iS i
Type of Building:
Dwelling No.of Bedrooms Lot Size t'3 j 44e, . 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)
r)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health
Si C Date — 13 "
Application Approved by Date r�
Application Disapproved by Date
for the following reasons
Permit No. (q �a - Date Issued 44 h 3
_R -No. / �J' `' �. ' Fee /
- THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
2pplication for Disposal *pstem Construction Permit
Application for a Permit to Construct( ) Repair(,V Upgrade( ) Abandon( ) ❑Complete System RIndividual Components
Location Address or Lot No. IqA p W Z*T 45 gyp6C I Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel 1445
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
C 5��� tab f-, �Oos L"-
Type of Building: L
Dwelling No.of Bedrooms Lot Size o3 5 Ae .agyOr Garbage Grinder( )
Other Type of Building Qgs 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)w
DNS"PL4W-E: b" 73aq
S
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Si C Date ! ,.
Application App`roved by Date r�
Application Disapproved by Date
for the following reasons
Permit No. n Date Issued
---------------------------------------- ------------- --------- ----------------------------------------------------------------------
- THE COMMONWEALTH OF MASSACHUSETTS
r-
BARNSTABLE,MASSACHUSETTS
A,) fir` ` Certificate of Compliance
1
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(1yr) Upgraded( )
Abandoned( )byl � �
at ()Lmbp M has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit NLLt),�)-0cf I dated
Installer rj.:- �[i'�7� � L L� Designer
#bedrooms Approved design flow god
The issuance of this permit shall not e construed as a guarantee that the system will funotion�as designed.
Date t C7- Inspector
No. �(a I� " 0 , I Fee D
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal 6pstem ConetCULtion 3permit
Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( )
System located at Q d(. <557jg)f V/L a V It L
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 i must ltie completed within three years of the date of thl ermit.
Date `1 1� —v--- Approv d by
LOCATION _ / SEWAGE PERMIT NO.
VILLAGE /
INSTA LLER'S NAME i ADDRESS
�• 6UILDEIt OR OWNER
DATE PERMIT ISSUED � J
DAT E COMPLIANCE ISSUED
Ad2�n v w
I
3,
� / u
,No.. • �°-- Fus.......��..............
= Lf _�•� THE COMMONWEALTH OF MASSACHUSETTS
tfaR I OZ BOARD OF HEALTH
Town.............oF....Barnstable
. ..----------------•--------.............-••••---••••-
ApplirFa#ion for Dispniial Workg Tnnitrnrtiun Vamit
Application is hereby made for a Permit to Construct ( X o e� ) an Individual Sewage Disposal
System at:
Lot..#.� ......: �Ld--•---•. .............MOM.........................................................................
Location-Address •or Lot No.
Capricorn Realty.Trust 765. Falmouth Road•,••_Hyann .................
..--- .... ...........................
Address
G ......•.................••.... .
Installer Address
d Type of Building Size Lot............................Sq. feet
aDwelling—No. of Bedrooms..............3...........................Expansion Attic ( ) Garbage Grinder ( )
04 Other—Type of Building ..ranch........... No. of persons............................ Showers (2 ) Cafeteria ( )
Q' Other fixtures ......................................................................................................................................................
<11
W Design Flow........5.5..............................gallons per person per day. Total daisy flow...................3..0,...............gallons.
WSeptic Tank—Liquid capacity1000.gallons Length_8.........._.... Width biameter................ Depth. ...8......
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter..... ............. Depth below inlet....... ........... Total leaching area...... 66.....sq. ft.
Z ( ) tank ( )
Other Distribution box DosinEl dee d e En ine e rin Date..11-2 -81
Percolation Test Results Performed by....................g.....-------.................ng. _5_-.....................
aTest Pit No. 1.�. 2.. . minutes per inch Depth of Test Pit.......1.,.... Depth to ground water21011e...enCounte —
Test Pit No. 2-BA.....minutes per inch Depth of Test Pit....N,IA....... Depth to ground water------N�A.........
e
w' ---•--•-•-•--••••--••••-•• •------•-•...............•--•-----••--........----...----•--•-----------------•-----:..-•••-......----•---.......--.•--•-
O Description of Soil _ 2 loam._&.._to..so_i1......••--
v2 '................................................... 10 u .Yellow__sand----------------------.................................................
10 _ 2 med.. white Viand/tra0� Qf grave],lnQ watex..at 12 '
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
------------------------------------------------------------------------•--••••••--•-•-------•------••--•-•--•-••--•---------•-••••••-•••-••--•-•-•-••-•--•------•••--•-••--•-•--••--•--------......-••-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iT T i,;j. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Complianc a en issued by the board of health.
. AV Date
Application Approved By.... _.... = � �
-•. Date
Application Disapprove or th ollowing reasons-----------------------------------------------------------------------------•--•-------------------------.......
...............................•-------•------•-----------•-------------------.......------------------'---------------------------•-•-•••-•--•--•....•---•--•---•••-----...----... •-•••-------.
Date
PermitNo--------------------------------------------------------- Issued_.......................................................
Date
i
140,
4 d c � c
,JUJ
.+ �• I 1 ,�C 1. �Ci
tv� \ 5Z fi �
9 41,±
f2 .101
37
s 9��
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N OF bless _
/o JOF��' r-
Onus y I oo wI D 11
LEGEND CERTIFIED PLOT FLAN
STING SPOT ELEVATION OxO
�-;t� OF h �
EXISTING CONTOUR --- O -- /;���� �A^s je,.rrz .vrv� . z�r�rid
FINISHED SPOT ELEVATION [ A
FINISHED CONTOUR 0 ----
-'
0j ORSE vs
°e No.10951 0)
APPROVED , BOARD OF HEALTH , 4 N, b 2 a
DATE AGENT SCALE, =�o" DATE 1l2 o S�
L�R�®CE EAIGl�14EERON�' �Q IN(t) FRN c
CLIENT e6,EF L- I CERTIFY THAT THE PROPOSED
:v EGISTERE REGISTI: ED JOB NO e2-"0 BUILDING SHOWN ON THIS PLAN
CIVIL LAND , CONFORMS TO THE ZONING LAWS
ENGINEER SURVEYOR DR-By'---- -_ OF 'BAR
E, "ASS.
712 M AI N STREET CH. By �l,/2•C . .:. �
NYANN i S, MASS. MEET f OF D-ATE LAND SURVEYOR
S
IV07E /F A NER T,AlE SEPTIC 7,4N.fC OR
20 FT. MI/V." i--,4 lNG p/T ARE ../"JORE T.°I A:"/ /2"�GELD I^V
/O FT. M/N. 1RAOE�_A 24 'O/AMETER .CONCR.ET� COMER.
;:. SWALL BROUGNT To EX77RA
CONGRCTE 4mPYC P/PL ,-ie,4Yy C/1 ST IRON. Co(/ER Sh'.4GL !3E USEO
MIN. P/TCN /F/N Z>R/V"=WA Y
L LG�r,. l Uyp COVERS �
. �B•OFR FT.
' 2 , MiN. CO/VCRE•TE s
s G ,4oE CO VER A C L EA N SA IV IO
4.
LIQUID LEVEL
CAST
2 LAYER
IRON P 0 v O CH MI•JG� , m v o 0 GtiF ��B+_ ��B"
~-0k MIN.P/YCN F .
° e • e s • • • • • • e •4
%4"PAR rr. 5EP7-iC TA/VlC, D 1 ST, Jr • e • . . . • , , • * WASHED S727NE
BOX- v • • 8 • r • • •.� .•e •
e • ► e • eEFFECT/VC ' • • y 34 /2
n ► • • DEPTtI • • • ' i o WA5hrED 5740
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1.
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INYP eLErYATio/vs P/ `,�.����:�-y S 4 /}"� fv'W^,f ►• • • • • • • o P/T DR EQvly
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INVERT.AT QL//LD/NG_ 9 9 n FT, 6 FI' DJAM.
INLET" SEP-r/C .Ti4NK 8, FT . L / f7. Z71A . C rl SEE TftBULATION> 4
Ot/?LET SEPTIC TANK AFT-
/NLET DJSTi�/8!/T/DN OVTLE,TDISTR/B[/7/ON
GROVA D P447ER TBL EBOX 9 SECTJON OA'
MX y z FT JNL 6T LEACHING PIT 99 o FT SENrAGE O/.�'POrS'A L S�3TEM
I-EACHIlVa ��o -rgduL�a-Tlon� �
-SCALEF
/ / - OIMENS/ON A 3 T.
DE3/5los' CRITERIA 01AM-A'5/0 I•/ j3- FT•
NV AMER OF BEDROOMS 3 D/HENS/aN C ` FT.
9 AR6A6I='D/SPOSAL. UNIT wove SOIL LOG
r0TA4. EST/MATEG. FLOW 3 3 D GAL.�DAY SOIL TEST )o/ SOIL TEST#2 SD/L. ?"EST
NUMBER pF LEACNUVG P/TS_. &V ° 'I—EL01 PATE aF SOIL TEST z �Z 1
SIDE 4,-ACHI/VG PER PIT Lg-�- S<;t FT. v _ Z ' RESULTS /V/TNESSED BY JRE
BOTTOh!I-zq /NGPERP/T 54• FT �_v-q. r--s _ PtRCOLAT/ON RATE / LEIS MIIV�INGH
TOTAL LEACH/NG AREA 2-b U sp. FT. ! P1EhC0L.AT/0N RATE A 7/11 MIN.1 JNCH
77
RBSERVEGEAC'N1,VCrARE^ V SQ. FT.
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F � o o.10951 0 _ EL DREDGE EN&IMEZR/NG CO,//YC.
'� Y tpOjSTE@��'0� •`� �� ��. a`;' L %. O` �+; 71 Z "A l-Y S T. , y Y.q�t/NIS, M.g SS.
'� ;•C4ao SUR��y o^c`615T�l�°\a ER ENCDUNTLrREO - F2^ IV CO _
NAtGRO[JNv LVA7- CL/ENT. [.� e DRTE
rt Q GRO UIV0 WATER AT ELEV. _
i j o a NO: Ut"z v U Z. SHEET OF Z
� i r
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.o...�
Appliration for Dispilli al Works Tnnstrnrtiun JIrrmit
Application is hereby made for a Permit to Construct )_.pr Repair ( ) an Individual Sewage Disposal
System at: t�/�J��
........L v ,=% i � .-,.! l !�___ !zc P_. a�_.:T.. .. .. .. ................. ..................
___........ f�l 2 2, ,l'�.. _
~~••--- Location-Address or Lot No.
:C jj?^2C tt _7 ...: �G,.7 .. `L U- - — .�_:'.._`__a mom.......................................to ...................................�
1 ner Address
:
W ......................................... - _.... 7...... .._..____ ........... .................................. ..
Installer Address
Type of Building Size Lot............................Sq. feet
U
Dwelling—No. of Bedrooms.._2......................................Expansion Attic ( ) Garbage Grinder ( )
p, Other—Type of Building _n�i r,2h............. No. of persons............................ Showers Cafeteria (i )
p' Other fixtures -----------•... --••-••--•••--• .
W Design Flow..........�.'1.............................gallons per person per day. Total daily flow.............{.?..........................gallons.
g Septic Tank—Liquid capacity!.C.)Q.Ilgallons Length 8 _�°`...... Width=ke%s_l'.. Diameter________________ Depth. '_8!1..._
W Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.1.................. Diameter......n ......... Depth below inlet......6............ Total leaching area..... 6 ..... ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by._'BI_.��.:Y`'1:�<j�__�. .....§1:r.1�?'........._. Date....1.�•-'--
..` -.
minutes per inch Depth of Test Pit... .._ Depth to ground water-qoL ne.__-encounter_
Test Pit No. 1__�W_r.____ �.:_._.__ CS
(s, Test Pit No. 2�`= :.._...minutes per inch Depth of Test Pit.1,4 Ai...._._.... Depth to ground water-__ty'i `a_____________ e
------------------------•_-----...------••-----_.........--------------•---•-....----.__--------•---•------ ---------------------------------
D Description of Soil..........0`_._ - 2 ..........�.o ?...�:_..t:n�_n�_�..
-
W 1� 12. med. 4*n} .. �r7 �-' i �' --Z°"s_ rF?! �:ac,...t° ...at. 121
.........
d2
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 A IT 2 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliancei�fias_1ve n issued by the board of health.
� r
Application Approved By. = - 1�.�E=y�• -1
Date
Application Disapprovedffor th following reasons:................................................................................................................
-••••••••••••••••••...._......••-•-•-•••-•-•-•-•••-••---•--••-••-•......•--•--••-•-•-••-•....•••••---•-•---••••-•-•-••••-••--•••••--•••---•••---•--•--•-••-----•-••-----•••......---•••---•-•......-----
Dat
r Permit No......................................................... Issued ......•-_-•r - .
-------••••--••••- ..........
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............:.. _>,
Trr#ifiratr of Toutpliana F
THIS IS TO CERTIFY .That the Indivi Sew ge sal in onstructed (!,; ) or Repaired (' )
by................................................ ''��f? • -•-•-............
..`1..-•--.. ....... •-•................................................
er
at.................... rr� e;�c.._:'.. �' � 1- ; _r, „ ----------•-
has been installed in accordance with the provisions of TI 5_of The State Sanitary Co e/a,, Kscribed in the
application for Disposal Works Construction Permit No._- __. !` ..:.................. dated.eA_d '_____.___._..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRII D AS A GUARANTEE THAT THE
SYSTEM 1AlI�G . F NCTION SATISFACTORY. �%
DATE--- . L. .. ,1........................................................ Inspector....._. ...�-----------••---------------•-------------•-----•--------•---•---
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
NO.. �:..:�.... FEE........................
i �r�a �tl 1-5aann
Permission is hereby granted -...t,r............................. •• .... ... -• -•-•••• •••••. ............................•-•--......
to Construct ( ) or Repair ( jn iv' ua r sp System
treet f/ / �� 3
as shown on the application for Disposal Works Construction Permit . o___________________ Dated__: ___ -------
+� .........--•••-- ---......-� ----------- '---------.................................
c�C ` ,r! - i
�) Board of Health
DATE...............--••-•---•-----`----••-�------•-----••-----•----•-•............... i
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS -(