HomeMy WebLinkAbout0211 OLDHAM ROAD - Health 211 ,OLDHAM R.D., OSTERVILLE. '
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No. � Fee 7�'
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:—�
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
2pplicatlon for Misposal *pstpm Construction Permit
Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System individual Components
Location Address or Lot No. Z\k C M Ick (�' 0 Owne 's Name Add ess,and el.No. `_r• �D• Z
Assessor's Map/Parcel ��SG� X v v
Installer's am ddress,and\Tel.N . ` Designer's Name,Address,and Tel.No.
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A_nn Z9
Type of Buildin f
Dwelling No.of Bedrooms 1• Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow providedA/htgpd
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) P rs Q�( r`Q
Date last inspected:
Agreement: �J l
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.
Signe Date
Application Approved by A-51Date
Application Disapproved by Date
for the following reasons
Permit No. 7ATU� 241-, Date Issued f
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No. � t/� =, , � • Fee 7
" THE COMMONWEALTH'OF'MASSACHUSETTSz Entered in computer: ='E�
PUBLIC'HEALTH DIVISION-- TOWN OF BARNSTABLE, MASSACHUSETTS Yes p�
Of# lication for Misposar *pstem Construction Permit C
Application for a Permit to Construct O Repair(Upgrade O Abandon( ) ❑Complete System Individual Components
Location Address o '(AL� Oer'so Js Name,Add ess,and Tel.No. i.(' ZZ '
Ir
Assessor's Map/Parcel < ,
Installer's Name ddress,and Tel:N . Designer's Name,Address,and Tel.No.
c, k rras�K, „�c��a yap,u�,
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Type of Building:
a, Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( . ) Cafeteria( )
Other Fixtures
/Design Flow(min.required) N gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
z,. Title
" '`w,• �� a Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date'last inspected:
f -TM Agreement
r �
The,undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
A'accordarice 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 Healt o;;=
Signed� ��'' Date
Application Approved by Date �.
Application Disapproved by Date
> i for the following reasons
Permit
t o. ;-7 Date Issued
- - -'
THE COMMONWEALTH OF MASSACHUSETTS
"ry BARNSTABLE,MASSACHUSETTS
f; Certificate of Compliance
1,
THIS IS TO CERTIFY,that the On-site Sewage Disposal system,Constructed( y ) Repaired( Vj' Upgraded( )
Abandoned( )by
at \ has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 1 -?Z ated t 1
k Installer 5,f-cg r,< Designer t•
bedrooms }!�f A 1 Approved design fl�o , gpd
The issuance of this pe it shall not be consttrued as a guarantee that the system wil`( nct/�n./as des ed.
Date i ( Inspector
:.
No. - Fee
THE COMMONWEALTH OF MASSACHUSETTS NIS
,.
bb PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS „
'
V Misposat 6pstem Construction J)Prnut -
Permission is hereby granted to'Construct( ) Repair(V-5" Upgrade( ) Abandon(: )
System located at ��
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 s"pecial conditions.
f .
Provided:Constrju�cti n 7ust
Z be completed within three years of the date of this permit.
Date (� . ( "�, "Approved by
TOWN OF BARNSTABLE
LOCATION 211 Oldham RoaD SEWAGE #
v- 1 GH Osterville ASSESSOR'S MAP & LOT__
INSPECT&PHONE NO. J,P, 'Macomber & Son, Inc='
SEPTIC TANK CAPACITY 1000 gal
LEACHING FACILITY: (type) Pit (size) 10 010 gal
NO. OF BEDROOMS
BUILDER OR OWNER Charlene Clifford
I
PERMITDATE: COMPLIANCE DATE:
I
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 le c Z9 ,
ili Feet
Furnished byd
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or
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=1l fE—� TOWN OF B S ABLE'
LOCATION OR>2.( Oe SEWAGE # 2-0 "G
G
VILLAGE �aLZ' '�' ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY �®
LEACHING FACILITY: (type) (size)
r+
NO. OF BEDROOMS
BUILDER OR OWNER ► -
PERMTTDATE: - COMPLIANCE DATE: s
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by "' 5
"qq o - rasp po,
Ascw,
LOCATION SEWAGE PERMIT NO.
VILLAGE
INSTALLER'S NAME j (R�SS
3UIL0EIII OR OWNER
DA T E PERMIT ISSUED
DATE ' COMPLIANCE ISSUED
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Commonwealth of Massachusetts
.. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
211 Oldham ---
Property Address
Derek&Mary Lynch _ ----
Owner Owner's Name
information is Osterville Ma 02655 6/3/2021
required for every State Zip Code Date of Inspection
page. Citylrown
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 4r(SLj
filling out forms
on the computer,
use only the tab Sean M. Jones
key to move your Name of Inspector
cursor-do not S.M.Jones Title V Septic Inspection _
use the return Company Name
key.
74 Beldan Lane -
Company Address
Centerville Ma 02632
IL AV CityTTown State Zip Code
> 774-248-4850 smjonestitle5@gmail.com, SI4522
sear@smjonestitle5.com 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 15.000); 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
6/3/2021
Inspector's Signature Date
The system inspector ha mit 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.
15insp.doc•rev.7/26/2018 Title 5 official inspection Form:Subsurface sewage Disposal System•Page 1 of 1s
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
211 Oldham
Property Address
Derek&Mary Lynch _
Owner Owner's Name
information is Osterville Ma 02655 6/3/2021
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:
Z 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 property located at 211 Oldham Rd Osterville is served by a Title V septic system consisting of a
1000 gallon septic tank, distribution box and a precast leach pit. Although the system was found to
be in proper working condition at the time of inspection this report does not guarantee future
performance under similar or increased usage.
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.M&201 B Title 5 Official Inspection Form:Sul>surraoe Sewage Disposal System•Page 2 of 16
I
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
211 Oldham ---
Property Address
Derek&Mary Lynch
Owner Owner's Name
information is Osterville Ma 02655 6/3/2021
required for every State Zip Code Date of inspection
page Citylrown
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 pipes)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
t 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:
Mnsp.doc-my.71AMI8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of IS
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
211 Oldham
Property Address
Derek& Mary Lynch
Owner Owner's Name
information is required for every Osterville Ma 02655 6/3/2021
page. Cityfrown 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
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:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
El ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
211 Oldham
Property Address
Derek_&_Mary Lynch
Owner Owner's Name
information is Osterville Ma 02655 6/3/2021
required for every —
page. CitylTown State Zip Code Date of Inspection
C. Inspection Summary (cost.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
ElLiquid depth in cesspool is less than 6" below invert or available volume is less
than %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 i.s 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 water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis,performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
The system is a cesspool serving a facility with a design flow of 2000 gpd-
El ® 10,000 gpd.
❑ ® 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
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 supply11 .
❑ the system is located in a nitrogen sensitive area(interim Wellhead Protection
Area—IWPA)or a mapped Zone 11 of a public water supply well
t5hsp doe,rev.7/2612018 Tole 5 Official Inspection Form:Subsurface Sewage oisposet System-Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
211 Oldham w.
Property Address
Derek& Mary Lynch _
Owner Owner's Name
information is Osterville Ma 02655 6/3/2021
required for every State Zip Code Date of Inspection
page. Citylrown
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:
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?
® El Were as built plans of the system obtained and examined? (if they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
t5insp.doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6of18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
211 Oldham
Property Address
Derek&Mary Lynch
Owner Owners Name
information is Osterville Ma 02655 6/3/2021
required for every
page. Citylrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
f'
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
330 gpd
Description:
4
Number of current residents:
1 Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
!Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): —
Detail:
Sump pump? ❑ Yes ® No
current
Last date of occupancy: Date
k
i
i t5insp doc rev 7f2612018 Title 5 Official Inspection Form:Subsurface sewage Disposal system•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
t Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w 211 Oldham
Property Address
Derek& Mary lynch
Owner Owner's Name
information is Osterville Ma 02655 6/3/2021
required for every
page. City/town state Zip Code Date of Inspection
D. System Information (cont.)
2. CommerciaUlndustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
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:
Source of information: Tank pumped for inspection
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1000
gallons
How was quantity pumped determined? size of tank
Reason for pumping: routine maintenance _
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
211 Oldham
Property Address
Derek& Mary Lynch --
Owner Owner's Name
information is Osterville Ma 02655 6/3/2021
required for every cityrrown State Zip Code Date of Inspection
page.
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box,soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the 1/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:
original system installed 1981
Were sewage odors detected when arriving at the site? - ❑ Yes ® No
5. Building Sewer(locate on site plan):
1.5
Depth below grade: feet
Material of construction:
❑cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints,venting,evidence of leakage,etc.):
Joints in good condition, no leakage,vented through roof.
t5insp.doc-rev.7126=18
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
211Oldham
Property Address
Derek&Mary Lynch
Owner Owner's Name
information is Osterville Ma 02655 6/3/2021
required for every State Zip Code Date of Inspection
page. City/Town
D. System Information (cont.)
6. Septic Tank(locate on site plan):
1
Depth below grade: feet J
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
1000 gallons
Dimensions:
5"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
3'
2"
Scum thickness
7"
Distance from top of scum to top of outlet tee or baffle
10"
Distance from bottom of scum to bottom of outlet tee or baffle --
Opened covers and took
How were dimensions determined? measurements
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 was pumped for inspection and should be done again every 2 years for proper maintenance.
Water level was even with outlet inlet and was structurally sound.
t5insp doe.rev>'!WO18 Title 5 ofrrcial Inspection Form:Subsurface Sewage Disposal System•Page 10 of 16
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,oil
211 Oldham
Property Address
Derek& Mary Lynch -
Owner Owner's Name
information is Osterville _ Ma 02655 6/3/2021
required for every City/Town state Zip Code Date of Inspection
page.
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction-.
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness _.
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle -
Date of last pumping: Date
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):
Depth below grade:.
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
t
t5irtsp.doc•rev.7/26/2018
Title 5 official Inspection form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
211 Oldham
Property Address
Derek&Ma!y Lynch - -
Owner Owner's Name
information is Osterville Ma 02655 6/3/2021
required for every City/Town State Zip Code Date of Inspection
page.
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):
Depth of liquid level above outlet invert 01.
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.):
Distribution box was replaced for inspection permit#2021-203
tSarsp tlx•rev.72612018 TNIe 5 01'fiCIaI inspection Form:Subsurface Sewage Disposal System•Page 12 of 1
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form ,
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
211 Oldham
Property Address
Derek&Mary Lynch
Owner Owner's Name
information is Osterville _Ma _02655 6/3/2021
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 ❑ Not
Alarms in working order. ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order,system is a conditional pass.
11. Soil Absorption System(SAS)(locate on site plan,excavation not required):
If SAS not located, explain why:
Type:
1 I
® leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number.
innovative/alternative system
Type/name of technology:
t
t5insp roc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 13 of 18
Commonwealth of Massachusetts
l . Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
211 Oldham
Property Address
Derek&May Lynch _ -...-
Owner Owner's Name
information is Osterville Ma 02655 6/3/2021
required for every CitylTown State Zip Code Date of Inspection
page.
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.):
precast leach pit was video inspected and found with standing water within 2'of inlet and no signs of
past overloading.
12. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer .__.......
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-row.1/26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
`J 211 _Oldham
Property Address
Derek 8 Mary L nor ch! __ --
Owner Owner's Name
information is Osterville Ma 02655 6/3/2021
required for every
State Zip Code Date of Inspection
page. Cityrrown
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction: —
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
f
}
y t5insp doc•rev 7/26l2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of le
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
211 Oldham
Property Address
Derek& Mary Lynch
Owner Owners Name
information is Osterville Ma 02655 6/3/2021
required for every — State Zip Code Date of Inspection
page. Citylrown
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
Zia ,-Ax—
Al Z 7
(3 't
?
A2 3�
,37
t5insp doc•rev.726MI8 Title s official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
I
„ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
211 Oldham
Property Address
Derek&Mary Lynch_
Owner Owners Name
information is Osterville Ma 02656 6/3/2021
required for every
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
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
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:
Groundwater was established by accessing town of Barnstable groundwater contour maps.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5insp.doc•rev.V2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 17 of 18 -
i
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
211 Oldham _. -
Property Address
Derek& Mary Lynch --
Owner Owner's Name
information is Osterville Ma 02655 6/3/2021
required for every ---- --
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
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 ,
® D. System Information:
For 8:Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/2812018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
TOWN,OF BARNSTABLE
LOCATION 0\8\,C_tn CZ SEWAGE# U 1 V
VILLAGE ASSESSOR'S MAP&PARCEL ,
IR&TALLER'.S NAME&PHONE NO. SCo " r-, 7VVaen�L S-D Z pad-(
SEPTIC TANK CAPACITY k\-
LEACHING FACILITY.(type) (size)
NO.OF BEDROOMS
OWNER
PERMIT DATE:__'l.� COMPLIANCE DATE: 2
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility A Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) / Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
: :FURNISHED BY� 1'�
x � N
o �
41 so
��x x
DATE;_ 7/13/00---
VI ti. a
PROPERTY ADDRESS ----------------
_V211_oldham Road______ I RECEIVE®
Osterville
------------------------ JUL 5 2000
On the above date, I Inspected the septic system at t eT�� Hi� rs.
This system conslsts of the following;
1 . 1 -1 000 gallon septic tank
2. 1 -distribution box
3 . 1 -1000 gallon leaching pit
Based on my Inspectlon, I certify the following oonditlonc
4 . This is a title five septic system. ( 78 Code )
5. The septic system is in proper working order
, at the present time. _
6 . Waste water is 47" below the invert of the leaching
pit.
SIGNATURE.„
N a m e ;_,��3.�.K9Ssmktr-->LT-----_—_
Company.-� oae-h_P - Hacomber_& Son , Inc ,
Address:- Box 66 —___
__Centerville Na ,_02632-0066
Phone;___ S08_77S_3938_------
THIS CERTIFICATION ooES NOT CONSTITUTI3 A OVARANTY OR WARRANTY
JOSEPH P, MACOMBER & SON, INC,
Tanki•C�s:pools•L�achfl�lds
Pumped L Installed
Town Sewer Conneotlons
P,O,' Box 6 .3J3 �t3o77, M 02632.0066
775 4
J U L 2 5 2000
• � sue, FD�yr;p=BARNSTABI� �.
HEALTH DEPL
i
COMMONWEALTH OF MASSACHUSETTS
1Vj EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292.6600
TRUDY CORE
Secretary
ARGEO PAUL CELLUCCI _ DAVM B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
PropertyAddrsss:211 Oldham Road Name of Owner Charlene Clifford
Osterville AddrassofOwnw:65 ciark LaH—e
Data of hspecdon: �1 Waltham, Ma. 02451
Norm at Inspector: (Pteaao"Jose h P. Macomber Jr.
I am a DEP approved systam inspector pursuant to Section 16.340 of This 6(310 CMR 16.000)
cot.,0 yName: Joseph P. Macomber & Son nc.
Mary Address: Ko xbb, Cen erville, Ma. 0 2 6 3 2-0 0 6 6
Telephone Ni rnber: b—3 3 3
CERTIFiCAMN $TATEMFM
certify that I have personally inspected the towage disposal system at this address and that the Information reported below Is true, accurate
and complete as of the dme of inspection. The Inspection was performed based on my training and experience In the proper function and
maintenance of on-site so wage disposal systems. The system:
N I Passes
Conditionally Posses
_ Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: Data:
The System Inspector all submit a copy of this Inspection report to the Approving Authority (Board of Health or DEP)whNn thirty (30) days of
completing this Inspe don. It the system Is a shared system or has a design flow of 10,000 gpd or greater,the Inspector and the system owner
shall submit the report to the appropriate regional office of the Department of}Ertvironmentsl Pratection. The original should'be sent to Vw
system owner and copies sent to the buyer, If applicable, and the approving authority.
NOTES AND COMMENTS
revised 9/2/98 Page IofII
" Printed on Recycled Paper
f
SU93URfAC9 SEWAGE DISPOSAL IYF"M INSPECTION FOiW
. PART A
t ! CETYViCAMN (OorrdAU44t
ftopwTy Ad,",: 211 Oldham Road, Osterville
Owrw-, Charlene Clifford
Dww of hap.otson: 7/1 3/0 0
►iSMC=N SUTAMAxYt cr,.ck a e, C, oa o
A'.�/SYSTE7,�i IA35F3J �
I hays not found ►ny Informadon wNch Indicates that any of the Wuto cor4t:10 s described In 310 CMA 14,303 ex.4%. Any talk
crtur(a not sysJustod us Indlcoted below,
CO k[JrtFNT3:
s. SYS7Y7d CONDMONA.UY?ASSES: '
A0 One w mao system sompononu sa daaaribod In the •Coed tIwW Pass' soodon nood to be replaced o+ropairod. Tho system. wp
complotion of the repl000ment w repair, as approved by the Dowd of Health, wW peas,
tnmcete yes no, w not doterrrJnod(Y, N. w ND). Doacribo b"s of detwn4mdwt In all Wtwtoes. If 'not dotarrt Ir**d', explain why rwt.
The oepdc tank le moW, unless the owner w opwotw has provided the system Inwpoetw whh a oopy of a Cardltuto 0
Compllsnce (anoched) lndlcsdno that the tank was kwtallod wl%Nn twenty(20) yaws pdw to Ow date of tt» tnapocvon
the septic tank, whothor or not meteJ, Is sreoked, ewewrally unsound, shows wbetandal tnftivadon w asNvedon. w ,
Wluro U Imminont. The system wW psas Inapocdon If the exJ#dnp sopds tank Is replecod whh a oornplytnp septic tans
approved by the lowd of Hsa)th.
Sewage bockup or breakout of Nph stado water love)observed In the dlsv(budon box Is due to broken w obiVvctsd pip
or duo to a broken, ooided or uneven dl#VIW%Jon box. The system wW peas inspo"On If(with approval of VW Board of
HaaJth).
Woken pipe(#) we replaced
obowcdon Is removed
d)evlWdon box Is levelled w replaced
LThe syv%om rsquirod pumphirrnory 0%an'fota-0mes•"ardue to broitenw vb.trvotod pip*(•)• The vyvum werysar^
Irtepectlon If (with opp(oval of the board of Health),
broken pipe(#) uo replaced
ob#trvcdon Is removed
revised 9/2/99 fti<<3orlr
SUBSURFACE SEWAGE DISPOSAL SYSTEM WS(tECT10N rr-OR!<A
PART A
CERTIFICATION fcondnued)
propwTyAd&*": 211 Oldham Road, Osterville
own«: Charlene Clifford
Dave of V apecrd—: 7/1 3/0 0
C. FURTHER EVALUAT)ON IS REQUIRED BY THE BOARD OF HEALTH:
44 Condrdons exist which require further evaluation by the Board of Health In order to determine If the system Is f4ng to protect the
public health, safety and the environment.
1) SYSTVA WILL PASS UNLESS BOARD OF HEALTH DETER1dWES W ACCORDANCE WITH 310 CUR 16.303(1)(b)THAT THE SYSTEIW
IS NOT FUNCTIONING IN A MANNER WHICH.WILL.PROX CT THE PUBLIC UMTKAND SAFETY AND THE 81108mmEh ia--
Cesspool or privy Is within 60 feet of surface water
d[(j Cesspool or privy Is within 60 feet of a bordering vegetated wetland or a salt marsh.
Z) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETFRJr WIES THAT THE SYSTBA IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
' The system has a septic tank and toll absorption system (SAS)and the SAS Is within 10o fast of a surface water supply or
tributary to a surface water supply-
The system has a septic tank and soil absorption system and the SAS Is within a Zone I of a public wets+ supply well.
The system has a septic tank and soil absorption system and the SAS Is within 60 feet of a private water supply weU.
( The system has a septic tank and soli absorption system and the SAS Is Isas than 100 feet but 60 feet or mae from a
private water supply well, urtleas a well water onalyals for coliform bacteria and volatile organic compounds Indcataa that th o
well Is free hom pollution from that facility and the presence of smmoNs nitrogen and nluate N)vogen Is equal to or less
than 6 ppm. Method used to determine distance 414 (approximation not valid).-
3) OTHER
IV
ool
revised 9/2/98 Page 3of11
f
SUBSURFACE SEWAGE DISPOSAL SYSTE)A WSPEC-nON FORM
PART A �. .,
CEAT'IMAT10N (corrdmadi
PropaRy Address: 211 Oldham Road, Osterville
owner: Charlene Clifford
Dante of yNPection: 7/1 3/0 0 .
D. SYSTEM FAILS:
You must Indicate either 'Yes' or 'No' to each of the following:
failure
1 have det rils dthat oneb r more of
The he fo lo}MHcalth should conditions
be co described l
ntacted to determine will correct the necessary to cor the Wlur'
ed
determination Yes No / BflSor-cees>aool. y' `
Backup o#eewage IRw f+clllty�er'�tt�mmisona^t,due�to an overloaded crcie99�
Discharge or ponding of etfluent to the surface of the ground or surface waters due to an overloaded or dogged SAS or
cesspool
� Static liquid level In th distribution b9x above outlet Invert due to an overloaded or clogged SAS or cesspool.
� I I s,th+n 8' belowinvert or available volume is less than 112 day flow.
Liquid depth In t+aapea
Required pumping more than 4 times In the last Yost NOT due to clogged or obstructed pipe(0.
Number of times pumped 0•.
Any portion of the Soil Absorption System, cesspool or privy Is below the high groundwater elevation.
Any portion of a cesspool or privy Is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy Is-within a Zone I of a public wall.
Any portion of a cesspool or privy Is within 60 feet of a private water supply.wall,
Any po
rtion of a cesspool or privy Is less then 100 feet but groats(then 6o test from a private water supply won with no
o be
.tiacceptable water quality analysis.olitorm bacteria, volatile organiacof the well mpounds,has been�mmonlaanalyzed nitrogen�and nluate nitlogen.ach copy of well water analysis or
E, LARGE SYSTEM FAILS: '
You must Indicate either "Yes" or "No" to each of the following:
The following criteria apply to large systems In addition to the criteria above:
100 The system ae facility with a design flow of
because one or000 morepol the foliod or owingrconditJon ezlsge System) and t;the system Is a significant threat to F
health and safety and
Yes Nc
the system Is within 400 lest of a surface drinking water supply
_ 1C •w�Y....
the system•i►within 200 f++t d tute(y to a au(faoa�rirsklrsq w+i«
_N the system Is located In a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a pu
water supply well)
The owner or operator of any such system shall upgrade the system In accordance with 310 CMR 16.304(2). Pleats consult the local (00
office of the Department for further Info(Jnstion. -
revised 9/2/98
Peer 4 or l l
I
SUBSURFACE SEWAGE DISPOSAL SYSTEW INSPECTION FORM
t PART B
CHECKLIST
PropertyAd&*": 211 Oldham Road, Osterville
Owner: Charlene Clifford
Dau of Ingot : 7/1 3/0 0
Check If the following have been done: You must Indicate either 'Yes' or 'No' as to each of the following:
Yes No
—;el Pumping Information was provided by the owner, occupant, or Board of Health.
Nona of the systemcompoaants kawbaan pwr►pad4va4RJsaatZwo•woa1saawdtba7ystam h"j;a"q0c*, ioq"Doad AON
rates during that period. Large volumes of water have not been introduced Into the system recently or as pan of this
Inspection.
As built plans have been obtained and exeminod. Note If they are not available with N/A.
_ The facility or dwelling was Inspected for signs of sewage backup.
The system does not receive non•sanJtary or Industrial waste flow.
_ The eke was Inspected for signs of breakout.
All system components,4kluding the Soil Absorption System,'have been located on the site.
_ r
_ The septic tank manholes were uncovered, opened, and the Interior of the septic tank was Inspected for condition of balls
or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The site and location of the Soli Absorption System orr the alto has been determined based on:
Existing Information. For example, Plan at B.O.H.
_ Determined In the field(If any of the failure criteria related to Part C is at Issuo,approximation of distance Is unacceptatwo)
116.30213IIb1)
The facility owttar tand.or +s,Jf dlttarsat froctiwscaar),wata,pta�idad,wtSh lnfotutatioacn r►+A rt-r..
^L^ ^f
SubSurf ace Disposal Systems.
.t
revised 9/2/98 Ngc3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART C `
SYSTEM WFORMATION
PropertyAd&*": 211 Oldham Road, Osterville
owner.: Charlene Clifford
Dou of Vwpecton: 7/1 3/0 0
FLOW CONDMONS
RESIDENTIAL:
Design flow:_uQ g.p.d./bedro m:
Number of bedrooms d •lyre Number of bedrooms (actual):j
Total DESIGN flow
Number of cuffn resldents:
Garbage grinder(yes or no):
Laundry(separate system) ( or n�o _•; If yes, sopacats1nspaction.required
Uundrysystem inspected orno) -' 1998=82 000 als..=224 :66 G P.D
Seasonal use (yes or no):_
g
Water meter readings,If available (last two year's usage(gpd):`I1 9 9 9=1 1 2�0 0 0 as 1 G_=3 0 6_ 8 5 G.P.D.
Sump Pump (yes or no): A0
Last date of occupancy:=L-1!h
r,OMMERCIAUW DVSTRUIL:
Typo of establishment:
Design flow: d IBased on 15.203)
Basis of design flow
Graeae trap present: (yes or no)•1/_
Industrial West# Holding Tank present: (yes or no)AY
Non•sartitary waste discharged to the Title 6 systeyes or no)"
Water motor readings,If available: Vol
Last date of occupancy:
OTHER:(Describe)
Lsst date of occupancy:
' GENERAL INFORMATION
PUMPWG REC ROS and soulc4 of Information:
46r,,
System pumped as part of Inspection: (yes or no)! �
if yes, volume pumped: gallons
Reason for pumping:
TYPE 0 SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
/irt Overflow cesspool
T'C Privy
Shared system(yes or no) (11 yes, attach previous Inspection records,If any)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank _Copy of DEP Approval
Other /
APPROXIMATE AGE of all components, date Inotelledilf known)-end sourer o,44v fomtstl n:ilk
Sewage odors detected when arriving at the site. (yes or no)
revised. 9/2/98 Page 6of 11
I
SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM
r PART C ,
SYSTEM INFORMATION(contirwed)
Prop"Ad&*": 211 Oldham Road, Osterville
own«: Charlene Clifford
Dou of Frsspecdon: 7/1 3/0 0
BUILDING SEWER:
(Locate on site plan)
Depth below grade: /+-31, ��
Material of construction:_cast Iron L 9D PVCother (explain)
Distance tro,,jj//private water supply well or suction line /dam
Diameter
Comments: (condition of Joints, venting, evidence of Isakaga,�tc.l
Joints
le
ager
TANK Q
Syc;t-am 1� ,o
S t- --e rg:OH'a Ouse yPn
EPTIC V
(louts on site plan)
d
Depth below grader
Material of construction:/concrQtW4-bmst&I4/ Fiberglass.(/QPolyethyleneA&other(explain)
If tank is fnetal, Ills/t age_ ls.age.confvmed by Certificate of Compliance (Yes/No)
Dimensions:
Sludge depth: ./tip _•
Distance from to sludge to bottom of outlet tee or bsfflr.Z&&0L'
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:2&Akl—
Distance from bottom of scum to botto of outlet tV or baffle. .Te�/
Mow dimensions were determined:
Comments:
(recommendation for pumping, condition of inlet and outlet ties or-baffles, depth of liquid level In relation to outlet invert, structursHotegrity.
evidence of leakage, etc.) ' PUMP the se
Inlet & outlet tee a an is s ru
and shows
GREASE TRAP:
(locate on site plan)
Depth below grade:A-0
Material of construction:4,&�oncrets i�?nstaV4;OFiberg(sssy�Polyethyleno other(explain)
110
Dimensions: 41
Scum thickness:
Distance from top of scum to top of outlet tee or batfle:-Aid .
Distance from bottom of scum to bottom of outlet tee or.bstilr.��
Date of Iasi pumping:
Comments:
(recommendation for pumping, condition of Inlet and'outist tees or baffles, depth of liquid level in relation to outlet Invert, structural Integrity,
evidence of leakage, etc.)
rease trap i
revised 9/2/98 Paee7orll
I
I
SUBSURFACE SEWAGE OLSPOSAL SYSTEM INSPECTION FORJM
r �
PART C '
SYSTEM INFORMAMN (cortdrr»�)
PropwtyA6&o": 211 Oldham Road, Osterville
O-wrow: Charlene Clifford
D ou of tia�: 7/1 3/0 0
TIGHT OR MOLDING TANX/A&-([Tank must be pumped prior to, or •t time of, Inspecdon)
(locate on she plan)
Depth below grade 4)h
M+tsrtal of con+vuctlon: concrete,Ameta{ L4 Fib srpla+s&Polyethylene42ath+r(expl+ln)
Dlmen+lons:�'
Capacity: gallon+
Design flow==1 t♦allona/day
'
Alarm present
Alarm level: Alarm h��orklnq order:Yea/�� No
44
Dote of previous pumping:
Comments:
lconoitfon of INet tee, condltlon of alarm and float switches, etc.)
77oldingarp not pragant -
OtSTRISUnON BOX:�-
(locate on site plan)
Depth of liquid level above outlet Invert:
Comments:
tnote If level and distribution Is equal, oAdenoe of solid+carryover, dunce pl eakoge Into or out of box, etc.)
Distribu Igo evidence of solids
1 ence O ea age i ri o nr ntif- of f-ha hns�
PUMP CW1M8fMA: et[,
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms In working order (Yes of NO)�
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
UmD C ;;mhpr J c n-+- ^r-aseRt
revised -9/2/98 hilt Iofli
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C ! '
SYSTEM INFORMATION(continued)
Property Address: 211 Oldham Road, Osterville
Ownw: Charlene Clifford
Darte of{nap.ction: 7/1 3/0 0
SOIL ABSORPTION SYSTEM(SAS): ' 41"N /)�-.
(locate on site plan, If possible; excavation not required,location may be approximated by nondntruslve methods)
If not located, explain:
Type:
leaching pits, number:-
leaching chambers, number: d
leaching galleries, number:=
leaching trenches, number, length:
leaching flelds, number, dimenslonr.
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, dampp soil, condition of vegetation, etc.)
Loam s No signs of h r
on ina of s are dry. Vegetation ; g nnrmal
CESSPOOLS:
(locate on site plan) _.
Number and configuration:
Depth-top of liquid to inset Invert: ,4
Depth o1 solids layer: _
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
indication of groundwater:
Inflow (cesspool must be pumped as part of Inspection)
eSSp001 g arp not -i ragAni-
Commenu:
(note condition of soil, signs of hydraulic fallure, level of ponding,condition of,vegetat)on, etc.)
-Cesspools are not pragant
PpivY:dd&"C-
(locate on site plan)
Materials of construction: /U� Dimensions:
Depth of solids: I&
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation;etc.)
rive is not preRprit
y
revised 9/2/98 page 9orIi
SUI3URFACi IIWAOI DLSFOSAL$YiTDd MKCTION FORA
FAAT C
SYITDA WFORJdATIdN(ooertSr*i+•aJ
v,op.M Ad&a": 211 Oldham Road, Osterville
0WrW: Charlene Clifford
offuc+Vap•'d— 7/13/00
SKkTCH Of SEWAGE DtSPOSAL SYSTEM:
IncJude I, to of lees,two pormanont reference landmuks or bsnchmuks
locsto all wells wl%Nn 100' ILocoto whore public weter supply comes Into house)
r ,
��l OI�NQM RD. 051,
, -
y� f
'
0
revised 9/2/98 >�rloerll
SUBSURFACE SEWAGE DLSP93AL SY3TIDA INSPECTION FORM
PART C 5 .
s SYSTEAA pFORMATION ( " ) f
PropertyAddrs"; 211 Oldham Road, Osterville,
Oww: Charlene Clifford
Deu of I%&P*C` M: 7/1 3/0 0
NRCS Report name
Soil Type_
Typical depth to groundwater
USCS Date wabsite visited
Observation Wails checked
Groundwater depth: Shallow Moderate Deep _
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Ettimated Depth to Groundwater/tr/ Feet
Pisase Indicate all the methods used to determine High Groundwater ElevatJon:
_ Obtained hom Design Plans on record
hole, basemeat SUMP etc.)
bserved Site (Abutting property observation
Determined from local conditions
Chocked with local Board of health
Checked FEMA Maps
Chocked pumping records
Checked local excavator$, Installers
Used USOS Data
Describe how you established the High Groundwater Elevation. (him be completed)
Used water contours Map.
Gahrety & Miller Model
12/16/94
Y
revised 9/2/98 Page iiofII
I
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'I'UWN OF BARNSTABLE BOARD OF HEALTH
SUI)SURFACR SFWAOF, DISPOSAL ,SYSTEM INSPECTION FORM -' PART D •- CERTIFICATION
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-TYPO OA PAINT CI.LAILY-
PROPERTY INSPECTED
STREET ADDRESS
211 Oldham Road, Osterville
ASSESSORS MAP , BLOCK AND PARCEL #
OWNER' S NAME Charlene• Clifford
PART' D - CERTIFICATION
NAME OF INSPECTOR Joseph P. Macomber Jr,
COMPANY NAME Joseph P. Macomber &'' Son, Inc.
COMPANY ADDRESS Box 66 Centerville MA. 02632-0066
Street Tovn or City State LIP
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( ) -
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposa`1 system nt
�recoinmendat* lons
his nddress and that the information reported is true , accurate , and
omplete as of the time of ,inspection . The inspection was performed and any
regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one .
System PASSED
The inspection which I have conducted. has not found any information
Which indicates that the system fails to adequately protect public
health or, the environment as defined in 310 CMR 16 , 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILED
The inspection which I have con 'acted has found that the system fails to
protect the })ublic health and the environment in accordance with Title
5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signatur Date
.�
ne copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the BOARD OF KEAL'I'll,
• If the inspection FAILED, thb owner or operator shall upgrade ' the eyetem
Within one ,year of the date of the inspection , unless allowed or required
otherwise as provided in 3.10 CMR 16 . 306 .
partd . doc